Recognising and preventing a parastomal hernia

Key facts at a glance

• The parastomal hernia is the most common late complication after stoma surgery
• With a colostomy the risk is 18 to 40%, with an ileostomy 9 to 22%
• One study halved the incidence through a prevention programme: from 28% to 14%
• A support belt does not cure a hernia – it only supports and must be fitted
• The biggest lever is in your hands: lifting, weight, posture, abdominal muscles

A hernia next to the stoma develops gradually and is often only noticed when the appliance no longer holds. This article shows what causes it – and what has been shown to help prevent it.

How a parastomal hernia develops

When the stoma is created, the abdominal wall is cut through. A weak spot remains there. A hernia develops when the balance is no longer right:

“The intra-abdominal pressure is too great in relation to the strength of the abdominal wall.”

The gap in the area where the stoma passes through widens, and parts of the bowel push through. If the abdominal muscles are poorly trained, they can offer little resistance to the pressure.

How common it is

The figures vary between 20 and 80 percent depending on the study – a wide range, because not every hernia is diagnosed. Broken down by type of stoma:

• Stoma of the large intestine (colostomy): 18 to 40 percent
• Stoma of the small intestine (ileostomy): 9 to 22 percent

The risk factors

Some cannot be changed, many can:

Not modifiable: age, connective tissue weakness, wound healing disorders or infections after surgery, a surgically oversized opening.

Modifiable: obesity, diabetes, too early and too heavy strain on the abdominal wall, weak abdominal muscles, strong weight gain, chronic cough and COPD, poor general and nutritional condition, smoking and alcohol.

Most of these factors weaken the tissue and prevent the scar from healing properly and the stoma from growing cleanly into the abdominal wall.

What has been shown to help

An Irish study introduced a prevention programme and compared the incidence over three years:

• Year 1, without programme: 28 percent developed a hernia
• Year 2, with programme: 14 percent
• Year 3: 17 percent – with 7 percent of this group stating they had not adhered to it

The programme comprises seven points:

1. healthy lifestyle
2. no heavy lifting in the first three to twelve months after surgery
3. body weight in the range of a BMI of 20 to 25
4. ongoing, targeted stabilisation of the abdominal and core muscles once the wound has healed
5. good, upright posture at all times
6. wearing a fitted stoma support belt
7. supporting the abdomen when coughing, in the first months

Point 7 sounds minor and is not: coughing drives intra-abdominal pressure up abruptly. The flat hand placed on the stoma before the cough comes – in the first months this is one of the most effective habits of all.

What a support belt does – and what it does not

“The stoma support belt cannot cure a hernia, but only give a certain support to the outer abdominal wall.”

Two things follow from this. First, a belt is no substitute for the other six points. Second: fitting must be done by a stoma care nurse. A poorly fitting belt can press, slip and disrupt the appliance.

If a hernia already exists, the abdominal contour changes – and with it the fit of the baseplate. The appliance should therefore be checked regularly and refitted if necessary, otherwise leaks occur.

When surgery is performed

Not every hernia has to be operated on. Surgery is considered when

• the bowel in the hernia sac is constricted,
• the blood supply is impaired and reduced perfusion threatens,
• the hernia is very large.

The source also notes: not every pronounced hernia can be treated surgically – risk and benefit must be carefully weighed.

Warning signs

Seek medical advice if

• a bulge appears next to the stoma, especially when standing or straining
• the appliance suddenly holds less well than usual
• pain occurs or the output stops
• the bulge can no longer be pushed back – this is an emergency

Frequently asked questions

May I do sport with a stoma?

Yes, with good judgement. The specialist article gives as a guide value: at first no more than five, later no more than ten kilograms – better to lift several times than once heavily, which stabilises the muscles. Targeted core stabilisation after the wound has healed is expressly part of prevention, not its opposite.

When may I lift again?

Heavy lifting should be avoided in the first three to twelve months. Your treatment team will clarify the exact timing.

Can I get the belt on prescription?

Stoma support belts are medical aids and can in principle be prescribed. How the supply process works is explained in our article on medical aids on prescription.

Does a hernia go away again?

No. Prevention is therefore more effective than any later measure.

Your next step

We stock ostomy belts and accessories from Coloplast, Dansac and Hollister as well as the matching appliances. Fitting a support belt, however, belongs in professional hands – speak to your stoma care nurse for this.

Sources

• Parastomal hernia prevention through exercises of the abdominal and core muscles, Fachgesellschaft Stoma, Kontinenz und Wunde e.V. (in German)
• Information on ostomy care, Deutsche ILCO e.V. (in German)