Parastomal hernia
Introduction
Introduction to the ostomy The sputum (mouth) technique is a sputum formed by protruding the artificial contents of the intestine or the ureter in order to transfer the contents of the intestine or urine, and is called an artificial fistula-induced hernia. Parastomal hernias often occur in patients who have not completely healed between the ostomy channel and the viscera that passes through the abdominal wall. It is a late complication after ostomy. The occurrence of parastomal hernia is closely related to the general and local conditions of the patient. The abdominal wall is weak, postoperative abdominal pressure is increased, malnutrition, obesity and local infection are the basis of the occurrence of parastomal hernia. At the same time, the choice of stoma site The technique of ostomy is also closely related to the occurrence of parastomal hernia. basic knowledge The proportion of sickness: 0.004% - 0.005% Susceptible people: no specific population Mode of infection: non-infectious Complications: bloating, nausea and vomiting
Cause
Cause of parastomal paralysis
The occurrence of parastomal hernia is closely related to the general and local conditions of the patient. The abdominal wall is weak, postoperative abdominal pressure is increased, malnutrition, obesity and local infection are the basis of the occurrence of parastomal hernia. At the same time, the choice of stoma site The technique of ostomy is also closely related to the occurrence of parastomal hernia.
Malnutrition (24%):
Malignant tumors, anemia, hypoproteinemia, obesity, diabetes, liver and kidney dysfunction, and lack of vitamins can all affect the repair of postoperative tissues. If the intestinal tract (or ureter) and artificial channels fail to heal completely, it will increase Opportunities happening beside the mouth.
Improper choice of stoma position (20%):
It is generally believed that the incidence of parastomal hernia is closely related to the choice of stoma position. Studies have shown that the rectus abdominis has a restraining function, and the incidence of parastomal hernia is lower in patients with transabdominal rectus. The incidence of parastomal hernia is relatively high in the rectus abdominis or incisional stoma, and the extraperitoneal stoma can reduce the incidence of parastomal hernia and early postoperative sputum.
Tissue defects in the stoma area (10%):
For example, the tissue defect in the stoma area, the contraction of the lateral muscles, etc., causes the tissue adjacent to the stoma to contract to the periphery, and the caliber of the stoma is enlarged.
Degenerative changes in the abdominal wall muscles (15%):
In elderly patients, the abdominal wall muscles have degenerative changes, the repair ability is reduced, and the intensity is weak.
Radiotherapy and chemotherapy (14%):
Most patients with ostomy (mouth) are colorectal tumors, bladder tumors, intestinal obstruction, Crohn's disease, etc. Postoperative radiotherapy and chemotherapy are often needed to affect the metabolism and wound repair of normal tissues.
Improper operation (13%):
Common situations are:
1 Surgical operation is rude, excessive blood vessel or nerve damage leads to muscle atrophy, abdominal wall strength is reduced,
2 Aseptic operation is not strict, hemostasis is not complete, and wound infection occurs after operation.
3 Anesthesia is not satisfactory, forced traction and suture, local tension is too large and the tissue of each layer is poorly aligned.
Pathogenesis
There are two classification methods for parastomal hernia.
1. There are four types of classification according to the position of the cockroach.
1 true ostomy: a peritoneal sac is highlighted by the enlarged fascia defect, the most common clinical, accounting for about 90% of the parastomal hernia.
2 between the stoma: fascia defect enlargement, abdominal fistula with the stoma to the subcutaneous protrusion of the mouth, most of this type of prolapse.
3 subcutaneous prolapse: the fascia ring is intact, the intestinal tract is long and subcutaneous, and it is pseudo-sputum.
4 pseudo-sputum: due to weak abdominal wall or lateral rectus abdominis nerve injury, stoma fistula prolapse.
2. There are 4 types according to the size of the carcass:
1 small stoma: next to the diameter <3cm.
2 medium-sized stoma: diameter is greater than 3 ~ 6cm.
3 large ostomy beside: diameter is greater than 6 ~ 10cm.
4 huge type of stoma: diameter > 10cm.
Prevention
Ostomy prevention
According to the reasons for the occurrence of parastomal sputum, different targeted measures are taken.
1. Obese patients should properly control their weight and strengthen their abdominal muscles.
2. The choice of ostomy position should be suitable for selection points:
1 The position of the stoma should be chosen in the left lower abdomen or the upper right abdomen.
2 should be stoma near the abdominal incision, try to avoid stoma incision through the abdomen.
3 Choose as far as possible through the rectus abdominis or the extraperitoneal stoma.
3. The size of the stoma should be suitable. Generally, the diameter is between 1.5 and 2.0 cm. Obese people can expand appropriately. The intestine should be pulled out of the skin by about 1 cm.
4. Strict aseptic operation during operation to avoid rough operation, complete hemostasis, prevention of wound infection, and appropriate application of antibiotics.
5. Choose appropriate anesthesia, the effect should be satisfactory, to ensure tissue suture without tension.
6. Strengthen nutritional support treatment after surgery.
7. Actively treat diseases that cause increased intra-abdominal pressure.
Complication
Parastomal complications Complications, bloating, nausea and vomiting
1. Chemical dermatitis: due to the prominent sputum contents pulling the abdominal wall skin, destroying the tightness of the stoma, leading to leakage of secretions such as intestinal fluid, stimulating inflammation of the skin, redness, pain and erosion.
2. Invasion in the side of the stoma: the patient has severe pain, bloating, nausea, vomiting, stop exhaustion and other serious symptoms, the mass can not be returned and accompanied by tenderness, immediate emergency surgery.
Symptom
Ostomy paralysis symptoms common symptoms bloating dull pain abdominal pain
It is related to the size of the sputum and the presence or absence of complications. There is no obvious clinical symptoms in the early stage or a subcutaneous mass that protrudes outward only at the side of the stoma. It appears when standing for a long time, walking, coughing, forced bowel movements, and urination. Reduce or disappear when resting or lying down, the mass will gradually increase, because the expansion of the hernia sac involves the abdominal wall and stoma, some patients may have local dull pain, feeling of fullness, fullness, indigestion, constipation and other discomfort, huge can affect dressing and life.
Examine
Inspection of the stoma
1, first go to the general surgery to do abdominal examination to determine whether there is suspicious hernia, if necessary, do B-ultrasound, abdominal plain film examination clear.
2. For patients with umbilical hernia without comorbidities, examination, liver function, renal function, electrolytes and C-reactive protein were the main tests.
3. For patients with other diseases of the lungs and whose diagnosis is unclear, the examination program may include liver function tests and ultrasound examination of blood urea nitrogen (BUN), serum creatinine, and gastrointestinal diseases.
Diagnosis
Diagnosis and identification of parastomal hernia
diagnosis
1. The patient has a history of abdominal fistula (mouth) within 2 years.
2. Clinical features swell expansion, or accompanied by prolapse of the stoma fistula, accompanied by abdominal pain when swollen.
Differential diagnosis
1. Uterine round ligament cyst: The mass is located in the inguinal canal. It is round or elliptical. It has a sexy capsule with clear boundary and high tension. Its upper end does not extend into the abdominal cavity. It is generally not easy to be confused with the parastomal sputum.
2. The spermatic cyst or the testicular insufficiency: the mass is located in the inguinal canal or the spermatic testicular, with clear boundaries. The former has a sac sexy, high tension, the same scrotum can be found in the same side of the testis, the latter is tough, for the sense of substance, the same side of the scrotum testicular absent.
In fact, the differential diagnosis is not difficult. The basic characteristics shared by the above diseases are: non-reversible masses, the upper boundary of the mass does not enter the outer ring or the inner ring, and there is no "bow handle", and there is no cough impact.
