Lowering the incidence of stomal herniation: further follow up of the lateral rectus abdominis positioned stoma

A pilot single‐centre randomized trial assessing the safety and efficacy of lateral pararectus abdominis compared with transrectus abdominis muscle stoma placement in patients with temporary loop ileostomies: the PATRASTOM trial

“…Assuming that preserving the integrity of the rectus abdominis muscle is the key to preventing parastomal herniation, Stephenson et al . introduced a new surgical technique of stoma formation, LRAPS, which showed herniation rates of 5% (3/62) and 10% (4/41) at 1 and 2 years of follow‐up, respectively . The authors argued that transrectal stoma formation weakens the abdominal wall by destroying the integrity and function of the rectus abdominis muscle thus leading to an increased risk of parastomal herniation.…”

“…Using the SAS procedure PROC POWER it was determined that at least 54 patients would be required to detect a difference of 30% in parastomal herniation based on the assumption of a 5% and a 35% incidence in the lateral pararectal and transrectal groups, respectively, with equal group sizes, at a 5% significance level and 80% power. This sample size was estimated taking into account loss to follow‐up and other potential reasons for postoperative exclusions, so 60 patients were to be randomized.…”

“…There is only very limited evidence from nine retrospective cohort studies on whether the positioning of the stoma in relation to the rectus abdominis muscle has an impact on the incidence of parastomal herniation . A recent prospective cohort study using a lateral rectus abdominis positioned stoma (LRAPS) demonstrated a significantly lower incidence of parastomal herniation compared with standard techniques from other recent audits .…”

The persistent challenge of parastomal herniation: a review of the literature and future developments

“…Others have, however, not confirmed these findings . Furthermore, Stephenson and colleagues reported a 10% parastomal herniation rate at a median follow up of 23 (19–29) months when the stoma was positioned lateral to the rectus abdominis in 41 patients . Splitting and excessive stretching of the rectus fibres is likely to weaken the muscle which may be an important factor accounting for the high incidence of herniation.…”

Stoma siting and the ‘arcuate line’ of Douglas: might it be of relevance to later herniation?

“…Complications that may occur during post‐TRAM follow‐up are most commonly hernias irrespective of whether a mesh had or had not been used at closure . A low parastomal hernia rate, at least in the short term, has been reported where the stoma trephine has been purposely positioned well above the AL .…”