Residency · Residency · General Surgery

Parastomal and Hiatal Hernia

Overview

Parastomal hernia is the most common complication of stoma creation, occurring in 30 to 50% of colostomies and 5 to 20% of ileostomies. Hiatal hernia involves herniation of abdominal contents through the esophageal hiatus of the diaphragm and is encountered by general surgeons in both elective foregut surgery and emergent presentations. This topic covers prevention strategies, repair options, and the principles of fundoplication for symptomatic hiatal hernias.

Parastomal Hernia

Epidemiology

The incidence of parastomal hernia is 30 to 50% for end colostomies and 5 to 20% for ileostomies, with loop stomas having higher rates than end stomas. Many are asymptomatic, with approximately one-third becoming clinically significant. Risk factors include obesity, malnutrition, steroid use, COPD (chronic cough), poor stoma site selection, and incisional hernia at other sites.

Prevention

Stoma site selection is critical. Preoperative marking by an enterostomal therapist ensures placement through the rectus muscle (transrectus approach) rather than lateral to it. The site should avoid prior incisions, bony prominences, skin folds, and the belt line, providing a flat skin surface adequate for appliance seal.

Prophylactic mesh at stoma creation has been demonstrated by the PREVENT trial, STOMAMESH trial, and multiple meta-analyses to reduce parastomal hernia rates. Mesh is placed in the sublay/retrorectus position around the stoma trephine using synthetic (lightweight polypropylene) or biologic mesh. This does not increase stoma-related complications including infection, stenosis, or mesh erosion. Despite the evidence, adoption remains inconsistent.

Classification and Indications for Repair

The European Hernia Society classifies parastomal hernias as Type I (small, less than 5 cm, asymptomatic), Type II (small, symptomatic), Type III (large, greater than 5 cm, symptomatic), and Type IV (associated with other abdominal wall hernias). Repair is indicated for symptomatic hernias causing pain, difficulty with appliance management, or skin breakdown; for complications including incarceration, obstruction, or strangulation; for cosmetic deformity affecting quality of life; and when stoma reversal with concurrent abdominal wall reconstruction is being considered.

Repair Options

Local (parastomal) repair involves direct fascial repair around the stoma but carries a high recurrence rate of 50 to 70%. Mesh can be placed around the stoma using either the Sugarbaker or keyhole technique.

The Sugarbaker technique places mesh intraperitoneally covering the defect with the bowel lateralized under the mesh, sutured circumferentially to the abdominal wall with overlap. It can be performed laparoscopically and achieves a recurrence rate of 10 to 15%.

The keyhole technique places mesh with a central aperture through which the bowel passes. It has higher recurrence than the Sugarbaker technique (15 to 30%) due to mesh contraction around the keyhole.

Stoma relocation moves the stoma to a new site with repair of the old parastomal hernia site. However, the recurrence rate at the new stoma site is 30 to 50% -- the hernia follows the patient -- making this a suboptimal standalone solution.

The combined approach (retrorectus/TAR with stoma revision) provides definitive abdominal wall reconstruction with retrorectus mesh and stoma revision. It achieves the lowest recurrence rates for complex parastomal hernias and can incorporate a modified Sugarbaker within the retrorectus repair.

Hiatal Hernia

Anatomy of the Esophageal Hiatus

The esophageal hiatus is an opening in the right crus of the diaphragm (both crura arising from the right crus in most patients). The phrenoesophageal ligament (membrane) attaches the esophagus to the hiatal margin and attenuates with age. Normal structures traversing the hiatus include the esophagus, the anterior and posterior vagus nerves, and esophageal branches of the left gastric vessels.

Classification

Type I (sliding hiatal hernia) accounts for 95% of cases and involves upward migration of the gastroesophageal junction through the hiatus. It is the most common type and is associated with GERD. Type II (true paraesophageal) is the least common type, in which the GE junction remains in its normal position but the gastric fundus herniates alongside the esophagus. Type III (mixed) combines features of Types I and II, with both the GE junction and fundus herniated, and represents the most common "paraesophageal" hernia encountered clinically. Type IV involves herniation of additional organs (colon, spleen, omentum, small bowel) through a large diaphragmatic defect.

Clinical Presentation

Type I hernias present with GERD symptoms (heartburn, regurgitation, dysphagia) and are often asymptomatic. Paraesophageal hernias (Types II through IV) present with dysphagia, early satiety, postprandial fullness, chest pain (which may mimic cardiac disease), iron deficiency anemia from Cameron erosions at the diaphragmatic hiatus, and respiratory symptoms from aspiration or mediastinal compression. The acute emergency presentation of paraesophageal hernia is gastric volvulus (organoaxial or mesenteroaxial) with incarceration, obstruction, or strangulation and perforation.

Diagnostic Workup

The upper GI series (barium swallow) is the best study to characterize hiatal hernia type and anatomy and demonstrates organoaxial volvulus. Upper endoscopy (EGD) evaluates for esophagitis, Barrett esophagus, Cameron erosions, and gastric pathology. High-resolution manometry assesses esophageal motility and guides the choice of fundoplication (Nissen versus partial). pH testing (Bravo or impedance-pH) documents pathologic acid reflux and is essential when symptoms are atypical or prior to antireflux surgery. CT chest/abdomen evaluates hernia anatomy and identifies complications such as volvulus and ischemia.

Management

Type I hiatal hernia with GERD is initially managed medically with PPI therapy and lifestyle modifications (weight loss, head-of-bed elevation, avoiding late meals). Surgical indications include refractory symptoms despite optimal medical therapy, non-compliance with medications, desire to discontinue lifelong PPI, and complications such as stricture or Barrett with dysplasia.

Paraesophageal hernias (Types II through IV) warrant surgical repair when symptomatic. Asymptomatic paraesophageal hernias are more controversial; observation is acceptable in elderly or high-risk patients, as the acute incarceration risk is approximately 1% per year. Acute gastric volvulus is a surgical emergency requiring decompression with a nasogastric tube and emergent surgery.

Surgical Technique

The laparoscopic approach is the standard of care for paraesophageal hernia repair. The key steps are: complete reduction of herniated stomach, omentum, and other organs from the mediastinum; circumferential dissection and excision of the hernia sac (which reduces recurrence); esophageal mobilization to achieve adequate intra-abdominal esophageal length of 2 to 3 cm or more without tension (if a short esophagus is present, a Collis gastroplasty creates a neoesophagus using a gastric wedge); posterior crural closure with interrupted permanent sutures; and fundoplication, which is almost always added to prevent postoperative reflux. A Nissen (360-degree) fundoplication is standard for patients with normal motility; a Toupet (270-degree posterior partial) is used for impaired motility or after a failed Nissen; and a Dor (180-degree anterior partial) is used after Heller myotomy.

Mesh reinforcement of the crural closure remains controversial. Some studies show reduced radiographic recurrence with mesh, but concerns about mesh-related dysphagia, erosion, and stricture persist. If mesh is used, biologic or biosynthetic material is preferred over synthetic, placed as reinforcement rather than a bridge. Anterior gastropexy is optional, and routine gastrostomy tube placement is not recommended.

Emergency Presentation: Gastric Volvulus

The Borchardt triad -- epigastric pain or distension, retching with inability to vomit, and inability to pass a nasogastric tube -- indicates gastric volvulus. The two types are organoaxial (the most common, in which the stomach rotates along its long axis) and mesenteroaxial (rotation along the short axis). The risk of gastric ischemia, necrosis, and perforation is significant. Management involves emergent NGT decompression (if possible) followed by urgent surgical repair. If ischemia or necrosis is found, gastric resection may be required.

<image>Classification diagram of hiatal hernias showing four types: Type I (sliding) with upward migration of the GE junction, Type II (true paraesophageal) with herniation of the fundus alongside a normally positioned GE junction, Type III (mixed) with both GE junction and fundus herniated, and Type IV with additional organs (colon, omentum) herniated through the hiatus. Show each type in a sagittal cross-section of the diaphragm and esophageal hiatus with clear anatomical labels.</image>

<image>Surgical illustration of laparoscopic paraesophageal hernia repair showing the key steps: (1) reduction of herniated stomach from the mediastinum, (2) excision of the hernia sac, (3) posterior crural closure with interrupted sutures, and (4) Nissen fundoplication with the fundus wrapped 360 degrees around the distal esophagus. Show the completed repair with adequate intra-abdominal esophageal length and the fundoplication secured above the closed crura.</image>

<image>Comparison diagram of parastomal hernia repair techniques: (1) Sugarbaker technique showing intraperitoneal mesh with the bowel lateralized under the mesh, (2) Keyhole technique showing mesh with a central aperture for the bowel, and (3) Retrorectus repair with mesh placed in the sublay position incorporating the stoma. Label mesh position, bowel orientation, and fixation points for each technique.</image>

Clinical Pearls

Parastomal hernia is the most common complication of stoma creation, and prophylactic mesh placement at the time of stoma creation reduces its incidence and should be considered in all permanent stomas. Stoma relocation alone for parastomal hernia has a 30 to 50% recurrence rate at the new site -- the hernia follows the patient. The Sugarbaker technique (lateralizing the bowel under the mesh) has lower recurrence rates than the keyhole technique for parastomal hernia repair. Most "paraesophageal" hernias are actually Type III (mixed) with both the GE junction and fundus herniated. The Borchardt triad (pain, retching without vomiting, inability to pass NGT) indicates gastric volvulus and constitutes a surgical emergency. Adequate intra-abdominal esophageal length of 2 to 3 cm or more is essential for a durable hiatal hernia repair; a Collis gastroplasty should be performed for true short esophagus. Mesh reinforcement of crural closure remains controversial, and if used, biologic or biosynthetic mesh is preferred to minimize erosion and dysphagia. Cameron erosions (linear gastric erosions at the diaphragmatic hiatus) are an underrecognized cause of iron deficiency anemia in patients with large hiatal hernias.

References

• Antoniou SA, Agresta F, Garcia Alamino JM, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia. 2018;22(1):183-198.
• Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. J Am Coll Surg. 2006;202(4):598-604.
• Jobe BA, Richter JE, Hoppo T, et al. Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel. J Am Coll Surg. 2013;217(4):586-597.
• Lambrecht JR, Larsen SG, Reiertsen O, Viste A, Norderval S. Prophylactic mesh at end-colostomy construction reduces the rate of parastomal hernia: a meta-analysis. Hernia. 2015;19(1):73-80.

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