Reversal of Hartmann’s procedure: still a complicated operation

Parastomal hernia following formation of an ileostomy or colostomy is common. This article reviews the incidence of hernia, the technical factors related to the construction of the stoma that may influence the incidence, and the success of the different methods of repair. A literature search using the Medline database was performed to locate English language articles on parastomal hernia. Further articles were obtained from the references cited in the literature initially reviewed. Parastomal hernia affects 1.8-28.3 per cent of end ileostomies, and 0-6.2 per cent of loop ileostomies. Following colostomy formation, the rates are 4.0-48.1 and 0-30.8 per cent respectively. Site of stoma formation (through or lateral to rectus abdominis), trephine size, fascial fixation and closure of lateral space are not proven to affect the incidence of hernia. The role of extraperitoneal stoma construction is uncertain. Mesh repair gives a lower rate of recurrence (0-33.3 per cent) than direct tissue repair (46-100 per cent) or stoma relocation (0-76.2 per cent). The incidence of parastomal hernia is between 0 and 48.1 per cent, depending on the type of stoma and length of follow-up. No technical factors related to the construction of the stoma have been shown to prevent herniation. If repair is required, a prosthetic mesh technique should be considered. Further randomized clinical trials (particularly of extraperitoneal stoma construction) are needed. Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Case series suggest that laparoscopic peritoneal lavage might be a promising alternative to sigmoidectomy in patients with perforated diverticulitis. We aimed to assess the superiority of laparoscopic lavage compared with sigmoidectomy in patients with purulent perforated diverticulitis, with respect to overall long-term morbidity and mortality.

The incidence of incisional hernias at the site of stoma closure is surprisingly unclear. A review of the current literature was undertaken to determine how commonly this complication may occur and to assess the quality of evidence available. A systematic review was performed to identify studies reporting the incidence of incisional hernia after closure of an ileostomy or colostomy. Studies including children ( 10% of the total number were trauma patients were excluded. Thirty-four studies provided outcomes for 2,729 closed stomas. Median follow-up time was 36 months but was only described in seven studies. Closure of loop ileostomies was the most commonly performed procedure (48%). The overall reported hernia rate was 7%, but with a wide range among studies (0-48%). Most studies based their hernia rates on retrospective clinical findings only. A separate analysis of three studies that were specifically designed to assess for stoma site hernias found the clinical hernia rate to be 30% (28/93) and the combined clinical/radiological hernia rate to be 35% (33/93). From 11 studies reporting reoperation rates, 51% of patients who developed a hernia required a surgical repair (34/66). There was a lower risk of hernia following reversal of ileostomy versus colostomy (odds ratio 0.28, 95% confidence interval 0.12-0.65). One in three patients may develop a hernia after stoma closure, and around half of hernias that are detected require repair. Risk of hernia is greater after colostomy closure than after ileostomy closure. Clinical measures to reduce the development of these hernias warrant consideration.