Non-Operative Management, Nursing Care
Depending on the presentation and symptoms of the parastomal hernia, the stoma care nurse has various options to relieve patients’ symptoms. A single intervention can address multiple symptoms, while multiple interventions might be needed for a single symptom [11].
Support garment: Is the most frequently used approach that can manage symptoms such as bearing down, poor wear time of appliances, dragging sensation, altered bodily appearance, irregular stool and fear of being physically active. They provide compression, reduce protrusion and may improve comfort and security. Support garments come in various forms (with or without a hole for the stoma) and compression levels, including belts, briefs, tubes and sportswear. To choose the right garment, the nurse assesses patient expectations, symptoms, lifestyle and comorbidities [12, 13]. Standard garments are preferred while bespoke ones are more rigid and expensive [12, 13]. Practical testing, tailored information, and follow-up are key enablers of belt adherence [12]. The stoma care nurse is aware of the risk of garments inducing symptoms such as pressure ulcers, leakage and skin irritation [11]. Garments may not be a solution if the parastomal hernia is irreducible due to the risk of pressure ulcers [11, 12].
Management of ostomy products: Nurses address issues such as poor wear time, skin problems, and leakage by adjusting patients’ appliances [11]. Stoma care nurses regularly remeasure the stoma as its size, height and shape change with a parastomal hernia. Over time, the bulge may enlarge and alter shape, stretching the skin, making it thin and fragile. For the patient, the pouching procedure may become increasingly complex [4, 14], necessitating the use of accessories and a change of stoma product. Nurses often instruct patients on new fitting procedures and the use of a mirror due to impaired visibility of the stoma.
Irrigation and Regulation of stool: Irrigation difficulties, diarrhoea, constipation and irregular stool may come with the hernia [4, 11]. Thus, stoma care nurses assess the patient’s diet and functional output, advise about dietary and fluid regulation and proper exercise, and prescribe bulk laxatives or stool softeners. Some patients may continue to irrigate their colostomy while others are advised to stop if the water can no longer pass in or out [11].
Nursing care also concerns disguise and intimacy, helping patients find ways to hide the bulge. Other elements of nursing care include providing information and education on physical activity, offering advice and education on how to assess signs and symptoms of strangulation and delivering psychological support and education on how to live with the parastomal hernia [11]. Stoma care nurses offer follow-up and reassessment, align care with the primary sector and ensure involvement of the surgeon when needed.
Operative Management
Surgical repair remains technically challenging and is associated with recurrence rates of up to 30%–50%, as well as high risk for severe complications [15]. However, if non-operative management proves insufficient and the patient’s symptoms and impaired quality of life are deemed to outweigh the risk for surgery, a repair should be offered. A suggested algorithm, based on current literature and expert opinion, for the surgical management of parastomal hernias is outlined in Figure 1B [2, 16–19]. Patients with parastomal hernias are very heterogeneous, and most often the surgical approach must be tailored to the individual patient to align expectations and to achieve the best possible result. Thus, although a mesh-reinforced repair is considered the gold standard to avoid recurrences, there are situations where sutured repair may be the best option.
Certain conditions demand operative intervention: Incarceration, strangulation and obstructions are life-threatening conditions that need emergent surgery. In those situations, less is more, and the focus should be to save the patient, and often, a sutured repair of the defect is enough. A more durable mesh repair can be planned later.
Fortunately, 90 percent of patients undergo surgery in an elective setting. Those patients are characterised mainly by feeling socially restricted, lifestyle limitations, severe pain, intermittent obstruction and stoma dysfunction such as poor appliance fit, frequent leakage, or prolapse that cannot be managed conservatively.
Since many patients will have recurrence, and especially young patients are likely to undergo another repair in the future, the best way to treat parastomal hernias is to do stoma reversal. For many patients, this could be a viable option [6]. If stoma reversal is impossible, it is important that the surgical strategy does not unnecessarily compromise any future operations. For the same reasons, stoma relocation, where the stoma is relocated to another abdominal quadrant, combined with hernia repair, should be considered as the last option [6]. This is because a high number of those patients will end up with a new parastomal hernia as well as a hernia recurrence at the previous stoma site [20, 21].
Another aspect to consider is the patients problem. The treatment of a patient with a bulge and leakage may not necessarily be the same as the treatment for a patient with symptoms of incarceration.
The patients body shape should also be considered. For instance, many patients may benefit from resection of excessive skin. However, almost all patients will continue to have an altered body shape after surgery, and many patients may end up with a retracted stoma that may provide skin and leakage problems.
In most situations, a synthetic mesh is preferred. Although there is no existing evidence, it is suggested to consider absorbable synthetic or biologic meshes and to avoid intraperitoneal mesh positions in patients with a history of fistulating Crohn’s disease.
When deciding on elective surgery, it is important to aim for minimally invasive surgery and address patient-related risk factors to reduce the risk of complications. Prehabilitation, such as weight loss, smoking cessation and optimal treatment of other co-morbidities, is often required to obtain safe surgery.