Parastomal Hernias

July 11, 2022

Treatment Talk | Parastomal Hernias With Dr. Benjamin Poulose and Patient Advocate Darrell N.

Year: 2022

You can read the full transcript of Treatment Talks | Parastomal Hernias at the bottom of this page.

Part 1: Causes and Treatments for Parastomal Hernias

Video (20 min) | Transcript (PDF)

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Part 2: The Patient Experience with a Parastomal Hernias

Video (6 min) | Transcript (PDF)

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Part 3: Question and Answer about Parastomal Hernias

Video (24 min) | Transcript (PDF)

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Full Transcript of Treatment Talk | Parastomal Hernias

Morgan Stout:

Parastomal hernias are common problem for about 50% of patients that have a stoma after a radical cystectomy. A parastomal hernia is when intestines protrude through the abdominal wall at the side of the stoma. My name is Morgan Stout, and I’m the Outreach and Education Manager here at the Bladder Cancer Advocacy Network. Today, I am joined by Dr. Benjamin Poulose, from the Ohio State University and patient advocate, Darrell, from Chicago. Welcome. First, Dr. Poulose will talk about parastomal hernia, what it is and how it’s treated. And then I will hand it over to Darrell, to talk about the lived experience of having a parastomal hernia. So with that, Dr. Poulose, I will hand it over to you.

Dr. Poulose:

Hi, thanks everybody. I really appreciate the opportunity to chat with you this evening, and I’m looking forward to a very robust discussion and it should be a really fun one. So I’m going to share my screen here. Thanks again. And as Morgan mentioned, I’m one of the faculty here at Ohio State, and my practice is largely in hernias and also specifically parastomal hernias. And these are some of my disclosures. I do receive salary support from our quality collaborative, which collects data around hernias in general. And I also receive research support from the following institutions. And I also have a startup company listed there, that’s unrelated to the content I’m talking about here. A little bit about myself. So I actually was born in Southern India in a very tropical climate, and it was a beautiful area. My parents left for the opportunities here in the United States and we moved to Brooklyn, New York. And from there, my parents followed the jobs and we ended up from Brooklyn, New York, in love with North Kansas, which is where I grew up. So I definitely grew up in the Midwest, went to school as an undergraduate at UNC Chapel Hill. And then I did my medical school at John’s Hopkins Hospital in Baltimore. Left there and did my surgical training at Vanderbilt University, went to Ohio for my specialization in minimally invasive surgery and abdominal wall reconstruction. Back to Vanderbilt as faculty for 10 years there, and I founded the Vanderbilt Hernia Center. And then apparently, all roads lead back to Ohio, so back to Ohio for a job and have been here at Ohio State now for the past four years and it’s been a ton of fun. So you would think that we would have the ability to take a hole in the anterior abdominal wall or core musculature, and close it maybe with some type of mesh and people do okay.

Dr. Poulose:

Well, it gets complicated, because even that simple process can be very, very challenging to keep that hole closed over time. It gets even more complicated when you have to have a control hole, if you will, when you have an ostomy of any sort, be it a urostomy, a colostomy, or an ileostomy, where you have to keep that hole just wide enough to allow it to pass through, not too big and not too small. So these are the topics I’m going to cover today. What is a parastomal hernia? Why do they happen? How do we treat parastomal hernias? And I also have some discussion time at the end to chat, I’m sure you’ll have a lot of questions. So what is a parastomal hernia? So as mentioned, a stoma itself is kind of a controlled hernia, where you have to have a hole in the abdominal core musculature, to allow the ostomy to pass through. But a parastomal hernia is, alongside that hole, you have something else passing through, and typically it’s a piece of small intestine or even colon, that can pass through and get stuck in between the abdominal wall and also where the ostomy is. And this can lead to several symptoms. Sometimes it can be completely asymptomatic and not have any symptoms associated with it. Other times you can have pain, even blockages from it, that can result in some serious consequences potentially. So looking at ostomies overall, about just under half a million ostomies are created in the US alone, with the mean age there. And if you look at the different type of stomas that you can have, colostomies really are the majority, but also ileostomies and urostomies are fairly common as well. So some facts about ostomies, oftentimes their intention, intended to be temporary type of things. But however, over 40 to 60% of ostomies actually are never reversed, and they’re there for life.

Dr. Poulose:

Ostomies in general are created to improve quality of life, oftentimes due to a life saving cancer operation that can result in an ostomy, basically diverting either food or urine away from where the cancer was. Stoma complications, including parastomal hernia, certainly can reduce quality of life. And that’s something we’ll spend a fair amount of time talking about here. So how often do these occur, parastomal hernias? In one study… this is done at a colorectal hospital in England, 203 end colostomies and 150 end ileostomies were evaluated over a long time. And if you look at over this timeframe, ostomy is formed anywhere from 16 to 37% of the time, and it’s probably higher than this. A very famous colorectal surgeon, Dr. Gathright, once mentioned, “If you have an ostomy long enough, you have a 100% risk of parastomal hernia.” Well, why is this? And we think we’re just beginning to understand why this is the case. If you think about the torso, not necessarily as how we traditionally think about the abdomen organs inside it, but more as a functional unit of the core muscles, where there’s a pelvic floor, the back and the diaphragm and of course the anterior abdominal wall. If you have a hole in the anterior abdominal wall, either a hernia or an ostomy, which again is a controlled hernia, it’s a natural weakness that can lead to hernias forming around the valve where the stoma is.

Dr. Poulose:

So it gets complicated as mentioned, also because as a field, we think that physicians and surgeons have really underestimated the complexity of the anterior abdominal wall. And it becomes hard, because especially when you think about why ostomies are created to treat cancers, I mean, that’s complex enough. And for other reasons, let alone trying to think about how to prevent a hernia from forming. But we do know it’s very similarly complex just to treat these hernias and sometimes even more complex to prevent these hernias from happening in the first place. And hate to bring this up, this may bring up some PTSD from high school or even college in terms of physics, we can’t escape physics. There are two laws that are at play here, Laplace’s law, which describes wall tension on across a cylinder. And also Pascal’s principle, which tells us that force of flow applied in a fluid system, is then applied to every area in that fluid system. Those two concepts are really critical, because our trunk or our core muscles is basically a big cylinder that has to obey those laws. And so, there’s a baseline pressure inside our abdominal cavities that is constantly pushing things out. And you can imagine if there’s a hole anywhere in that cylinder or the core, it’s a natural, weak spot that allows things to protrude through. Now, repairing that core muscles or those core muscles, be it with a hernia repair or other means, we are learning that you can actually stabilize the abdominal core and treat those hernias. Ostomies though, we can’t completely stabilize the abdominal core musculature for that main reason as we mentioned, that it’s kind of a controlled hernia with a natural, weak spot there. And this is why we think that hernias form at some point over the course of having the ostomy for years. So what causes parastomal hernias? Certainly there are some risk factors, including increasing age, obesity, steroid use, sometimes technical errors when you create the ostomy can lead to hernias forming. And we also think that tobacco use, may play a role in it from a wound healing standpoint, although that’s not very well thought to be contributing to the hernias forming in the first place. The biggest factor really, is it just happens, for the reasons I mentioned in terms of that interplay between pressures and core muscles and you have a controlled hernia, it just happens over time because we live our life and we have a baseline pressure in our abdominal cavity, it tends to push things out through holes there. So how and why do we treat parastomal hernias? I’m going to go a little bit over non-operative management, which is really key for managing symptoms associated with the parastomal hernias, and we’ll talk a little bit about surgery.

Dr. Poulose:

Non-operative management is really, really important. And this is really important because if you think about what I just said and what the information I presented, that if you wait long enough, you’re going to have a hernia associated with an ostomy. Well, if that’s true, then you have to think, you have to have an ability to manage yourself as a patient over time with unfortunately, some component of a hernia. Now, a lot of times they don’t cause any symptoms and so then you would think that the threshold of recommending repair, would not be met. Because if it doesn’t cause many symptoms although you have a hernia, although it’s not an ideal situation, it’s somewhat of a controlled situation that most people learn how to live with. And these are the mainstays of learning how to live with a parastomal hernia. Certainly local skincare is really important, especially if you’re having difficulty placing a pouch over the ostomy, because of the hernia itself. You of course want to minimize spillage, leakage and you can sometimes use different types of adhesives and different barriers to help manage that. Belts, braces and trusses can help to some degree. The only problem with this is, sometimes it’s very difficult to fit something that adequately holds enough pressure to kind of keep the hernia at bay, if you will. And I added mindfulness here, not so much to kind of be cute about it. It’s really an important point, because if you’re coming to me or another abdominal core specialist with a parastomal hernia, oftentimes our recommendation especially at the early onset of it, if it’s not causing a lot of symptoms, is just to wait, and to deal with some of the issues that you may face with having a parastomal hernia.

And the reason why this is important, is because we’re trying to stretch out as much time as possible between doing surgery, knowing that even after you repair it, there’s a very, very high chance of it coming back. And this sometimes becomes a mind game, especially if you’ve had a history of cancer. Because one thing that I’ve found is that, most of us who have problems like that, and most of you who’ve had cancers treated, you’re very much in the mindset of, well, we want to take care of things right now, and attack these cancers, and attack these parastomal hernias and fix them. And sometimes, that’s a little bit difficult to apply to these parastomal hernias, so it’s really a change in mindset that’s different than what a lot of folks are used to dealing with. And that’s important, because I think some acceptance of having the parastomal hernia, knowing it’s not going to be fixed for a while, is an important way to manage these hernias themselves.

Dr. Poulose:

I think one thing that’s really key, is finding a knowledgeable and dedicated ostomy nurse, because they have a number of tricks available to them, to making your life easier to live with the parastomal hernia, that can oftentimes end up having the parastomal hernia for years and not necessarily having surgery. This is a patient of mine who had a cystectomy about three years ago, presented to me with a parastomal hernia, you can see there. And he tried to use an abdominal binder to a reasonable degree, and used the binder for about three years. And then the hernia just kept protruding more and more to the point where the binder was not very helpful. He was having a lot of pain from the parastomal hernia and more importantly, he and myself and the urologist thought that the hernia itself, was causing some obstruction of his urinary tract causing to have some decreased renal function. And so I’ll tell you his outcome later on in the talk, and we went ahead and repaired it for those reasons. And I think that’s an important example of the threshold we would use for deciding to recommend surgery or not. So parastomal hernia repair, again, it’s a very common surgical disease and wide variation care is obtained. I’m going to change my talk here for one second, here we go. And so, our goal with parastomal hernia repair is to take this hernia here itself, that’s adjacent to the bowel coming through the ostomy, and fix it. And either put a piece of mesh below it or a piece of mesh on top of it, and then have things heal up and you should be okay. So when should you consider this kind of surgery? As mentioned before, when you have severe pain, when you have blockage of fluid coming from the ostomy, and as mentioned for urostomy, this can cause a decrease in renal function.

Dr. Poulose:

And also, when you have extensive leakage that cannot be controlled by any recommendations that our ostomy nurses have, and especially if you’re having leakage on a daily basis that’s just making your life miserable, those would be pretty clear indications to go ahead and do the repair. In extreme situations also, we recommend repair. This is a patient who had an ileostomy and actually had parastomal hernia, but also had a prolapse of the ileostomy. The bowel was just kind of pushing through the middle there, leading to a very unstable and difficult situation for which we performed a repair. So if you look at the common types of parastomal hernia repair, they really break down in three different categories. One is what’s called a local open repair, where we make an incision somewhere around the stoma itself. We do know that if you don’t use mesh, there’s a very high chance of early recurrence of these ostomy hernias. If you use mesh, it does decrease the chance of recurrence. And it does vary the time to recurrence, which is often very, very variable. The laparoscopic repair, and also it’s now done robotically, can reduce wound complications, it does afford you a wider choice of mesh materials. The problem with the laparoscopic or even a robotic repair, is that we can only tend to place the mesh inside the abdominal cavity, and that has some consequences for later on, trying to repair a recurrence of the hernia or other surgery you might have. Abdominal wall reconstruction is a more complex, technically difficult operation, where we would do very complex maneuvers to the muscle and the what are called the fascial coverings of the muscle around where the hernia is. And sometimes we may actually recommend moving the ostomy to a different spot, to then start with the fresh site.

Dr. Poulose:

And that is an advantage of this more formal and extensive abdominal wall reconstruction, sometimes we can even place prophylactic mesh at the new site, to help extend the time without having a hernia at that site. However, it is a complex operation to perform, and this should only be used after initial local efforts that repairs have failed. And certainly, unfortunately you can still get a new parastomal hernia at the new site there as well. So why don’t we know more about hernias after cancer surgery? And this is an important point to make, especially for groups like yours. Unfortunately, there’s very little dollars, federal funding dollars that go towards hernia research and prevention. And if you think about this, it kind of makes sense at face value, you have to choose between curing cancer and fixing hernias. I think most people would agree that curing cancer is probably more important. Where it becomes a little more complicated, is after we cure the cancer, and now you have a hernia impacting your quality of life and your cancer survivorship. We do need some additional information to help us figure out what to do. Obviously, we need both. We need investments both in curing cancer, but also, in making sure your life as a cancer-free patient, is of high quality and you’re not dealing with a lot of consequences from oftentimes a curative recession of cancer, but now that’s impacting your quality of life. We did a study a few years back looking at cancer survivorship, and we just wanted to see what’s the chance of developing any kind of hernia in your core muscles after having life saving cancer surgery for an intra-abdominal cancer. Well, if you look at the information we found, it was actually fascinating. In this graph, we show different operations on the left, and on the bottom, you see the percentage of the study population that developed a hernia. The yellow bars show the percentage of patients with the hernia for each one of those operations.

Dr. Poulose:

And what we found is that overall, amazingly enough, 41%, just less than half, developed a hernia within two years of their life saving cancer operation. Specifically to this group after cystectomy, it was even higher than that. About 45% of patients in two years developed some type of hernia, most of these were in fact parastomal hernias. So the other kind of compelling discussion that’s increased in its focus is, what about the time of the creation of the ostomy, can you help reduce the chance of the hernia forming, for instance, by placing mesh prophylactically in the area to reinforce that? We are finding that there is some information to show us that this actually may have some benefit in at least delaying the formation of parastomal hernias, but it’s very, very in its early stages. And one of the trade offs is, now you have to place… you’re using mesh at the time of an initial operation, which has its own consequences, but our initial results are that, it does have some advantage however, the jury’s not quite out yet on the effectiveness of this. So in summary, we’ve gone over what a parastomal hernia is. We talked a little bit about why they happen specifically in terms of this pressure in the core muscles there. And we talked a little bit also about treating parastomals, learning that the non-operative management with local skincare, meshes, binders, hernia belts, and finding a really experienced and invested awesome nurse, really can extend the time of having a parastomal hernia, but not so much where it impacts your quality of life negatively. And then of course, we’ll transition now to talking about our patient experiences. I want to hear from you in terms of your thoughts and some further discussion about this particular topic. So to wrap up, this patient actually did really well, the one I was mentioning to you. And we were able to fix his parastomal hernia and he did really well, and he’s been doing well for about a year and a half now. So we can get good outcomes, we just got to be careful when you finally decide to fix these and repair these hernias. Thank you.

Morgan Stout:

Thank you so much, Dr. Poulose, that was incredibly informative. Now I would like to turn it over to Darrell, to talk a little bit about his experience with a parastomal hernia.

Darrelll:

Thanks, Morgan. Thanks, Dr. Poulose. So I noticed the hernia starting probably within the first year. And since that time, I’ve lost a bunch of weight, so when you mentioned overweight being a factor, that kind of lit a light bulb in my experience. And as I continue to lose weight, the parastomal hernia seems to have increased, and now there’s a definite dome. There’s very little pain, or there’s an occasional pain that I do experience usually when I’m lifting something, or right after I’ve lifted something. But it doesn’t really bother me, and I don’t seem to notice any challenge with the flow of urine through my urostomy or any problems otherwise. I did wait for my doctor to approve even going back to the gym, but I had stopped… I had minimized working out prior to my cystectomy and as again, I was overweight and I had neoadjuvant chemotherapy, so energy was down, so I did kind of limit working out then as well. At the beginning, I started looking at the hernia belt, what I found was that… I currently use a Stealth Belt regularly, and I think some of their experiences, it definitely does assist in relieving or supporting a hernia. And my urologist says that many of his patients use Stealth Belts as well. So in a nutshell, that’s kind of my experience with a parastomal hernia. I think there are others that may have a bit more pain.

Dr. Poulose:

Thanks Darrell, thanks for sharing that. I think that story is a really compelling one. And again, congratulations for all you’ve been through. And it’s one of those things that I can only imagine having undergone what you’ve gone through, and then thinking about all the things about taking care of the cancer, and now you got to deal with this. And I think it came up in the chat too, that maybe we should be more informative of our patients, when you have these discussions about doing these operations about some of the potential ramifications of having the ostomy and having hernias. Because I think, well, kind of what you’re getting at this point in your care, this is the thing you’re dealing with. And so knowing about that beforehand, I think we do a poor job as surgeons informing our patients of these kind of ramifications. And we’re working on addressing that, and building more of an awareness around this. I do thank you also, for sharing your point about the weight changes and how it impacts things. I’m curious, as you lost weight, were you able to notice the hernia more?

Darrelll:

Yes.

Dr. Poulose:

And how long did you say have you had the hernia for?

Darrelll:

Probably four years and I just celebrated five years since my cystectomy.

Dr. Poulose:

Wow. Congratulations.

Darrelll:

Thank you.

Dr. Poulose:

That’s great. And it’s a situation like I was describing, not ideal of course to have the hernia, but if it’s not causing a lot of symptoms and you’re not having much leakage and certainly it’s not impeding the urine flow, that’s an okay situation. And unfortunately, there are a lot of surgeons out there, especially hernia abdominal core surgeons, who may recommend to someone like you, “Hey, why don’t we go ahead and fix it?” I would strongly advise against that, mainly because it’s not an ideal scenario, but we know that if you go in and fix it, you can often change it to more of a bigger deal when the hernia comes back, which we know it will come back at some point, when your situation wasn’t that bad to begin with. You just got to be careful about when to do the surgery itself.

Darrelll:

And that’s been kind of the discussion that my urologist and I have had. That if it’s not bothering you, let’s wait because it is, again, major surgery to repair it.

Dr. Poulose:

Yes, exactly. And I would definitely agree with your urologist. It’s one of those things where you just got to be careful before you make that recommendation to do the operation.

Morgan Stout:

Well, thank you both so much. And I think that leads into a great start to our question and answer, and discussion session. And we’ve already had a lot of really great questions come in. And for our listeners, if you have a question, please put them in the Q&A box, we’ll get to as many as we can. And I think as you saw in the chat, Dr. Poulose and even Darrell, the biggest question is, what can people do to prevent getting those parastomal hernias? Is there particular exercises they can do or something in that vein, planks, crunches, something to prevent that parastomal hernia from happening?

Dr. Poulose:

That’s a great question. We’re literally just scratching the surface at beginning, to answer this. And I’ll go back and basically state again, that we are about 20 to 30 years behind in our research, compared to the necessary research that occurred in not only the management of cancers, like bladder cancer, colon cancer, pancreatic cancer, all the types of cancers that we naturally want to have a lot of information for. But what we’re learning is that, yes, maintaining core health, even before the big operation that creates the stoma, is critical. I mean, I’m convinced… Darrell, you saw the website and you can see where my bias lies with this, but the kind of the analogy I give is, if you’re going to run even a 5K, let alone a 10K or a marathon, you’re going to train a little for that. You’re going to run, jog a little bit, maybe get on the treadmill. I don’t think anyone would get up and say, “You know what? I’m just going to go run a 10K tomorrow.” Not having done anything. And the reason why, is we know in our heads that physiologically, we’re just not there yet. And so what we’re learning for surgery, is that it takes a toll physically and mentally, I mean, many of you know that because you’ve gone through major surgery. And so preparing for that both mentally and physically, specifically for the abdominal core, we’re learning does have some benefit. Now, how it changes the formation of hernias after you have an ostomy, we don’t know just yet. What we do know is that the things that are under your control in terms of being a healthy person in terms of trying reduce some weight, even before these ostomies are created, reducing your nicotine intake, getting diabetes under control, all those things can also help. And I do think core exercises even prior to these operations, probably has some benefit, but we’re just learning its impact on hernia information.

Morgan Stout:

Sure, absolutely. Along those same lines, is there a certain type of exercise that folks with a stoma should avoid? Is there something that you’ve noticed that patients who have a parastomal hernia, if they’re exercising, there’s some sort of commonality in that?

Dr. Poulose:

Yeah. So what we do know, is that exercises or even activities that increase the abdominal pressure to a very high degree over a short amount of time, tend to be the things you want to try and avoid. The best example I can give you for that, is forceful coughing, forceful sneezing, those are two activities that really increase your intra-abdominal pressure very quickly. I mean, we’re human beings, so we’re going to cough and sneeze, but there are ways to train yourself to not use your core muscles so much as your upper airway muscles. As far as activities and exercises are concerned, the ones that tend to also increase your intra-abdominal pressure over a very small amount of time, heavy weights done with squats, bench pressing heavy weights, some of the HIIT, the high impact interval therapy type of things. It’s the ones that are really kind of having a really big load on your core muscles over a short amount of time, that I would suggest probably avoiding.

Morgan Stout:

Sure. And if somebody was looking for some guidance, maybe they weren’t experienced with exercising prior to their surgery, is there a place that you could recommend that they go see maybe a physical therapist or a professional that might be able to help guide them?

Dr. Poulose:

Yes, absolutely. In fact, the one thing that I really admire about physical therapists, is they think very, very holistically about the body. Surgeons, and I am certainly guilty of this, especially being at a center like Ohio State, we think very, very narrowing, small little compartments that are our own little areas of practice, but yeah, I think physical therapists are really… it’s advantageous to have a physical therapist work with you. The other thing is, just like physicians and surgeons, physical therapists also have different specialties. I’m going to send you a link in the chat, where we actually worked with about 16 physical therapists over the past several years across the country, and actually came up with an abdominal core surgery rehabilitation protocol. It’s right there. You can have any one of your physical therapists close by to you, follow that protocol. It’s really kind of centered around surgical recovery, but a lot of the exercises can be used even now as well.

Morgan Stout:

Absolutely. Thank you so much. We had a question about, if you saw any variation between parastomal hernias for patients with an ileal conduit versus an Indiana pouch.

Dr. Poulose:

Yeah. That’s really interesting. In my own practice, and I’ve taken care of patients with both, they seem to be far less with Indiana pouches. And the main reason why is, the actual hole you make for the Indiana pouch, is far smaller than actually bringing up a loop of valve through the anterior abdominal wall. So Indiana pouches actually in my own experience, have had less parastomal hernias associated with it, not zero. But I think with the traditional urostomy, they’re a little higher.

Morgan Stout:

Sure. We did have a really great question about if there was a parastomal hernia that had mesh applied to it, and if the repair was done, would it be a problem if the mesh was there when they went in and did a second repair?

Dr. Poulose:

Yeah. If you go back to my earlier slide when I said it gets complicated, this is why it gets really complicated. It does. If you’re going through the same approach, like say you’re going from the outside again, where mesh has already been placed, there will be a lot of scar tissue that the mesh is going to kind of fuse to whatever’s coming through the hernia itself, and your surgeon just has to be prepared to deal with that to some degree. And this is also one reason why you have to be careful, not only about when to use mesh and certainly just when to do the repair in general, but where you place the mesh, do you place it inside the abdominal cavity where all the bowels are, or do you place it outside of the abdominal cavity or within the core muscles itself? The short answer is yes, it does make it more complicated, which is also one of the reasons why you want to try to [inaudible 00:34:57] down the road as far as you can, to minimize those complicated surgeries.

Morgan Stout:

Sure. Thank you so much. We had a shout out from Dorothy, for Darrell. Dorothy and Darrell share a clean and clear anniversary, but this question is about product. So you’ve got the parastomal hernia, or maybe you just have a stoma in general, where do you go to find reputable supplies, reputable hernia belts, those sort of things? I would love it if both of you weighed in. We know Darrell has an affinity for a Stealth Belt.

Dr. Poulose:

Great. Sure. I can start answering that. So as far as supplies, I actually think there is nothing to replace an experienced ostomy nurse. I’m going to say that… I’m going to sound like a broken record, it’s so helpful and they’re so useful. And they have an entire organization under themselves, because of how complex this topic is. And so even if you don’t have one locally available to you, there is it’s a WOCN association. I forgot the exact name of it, but they actually have a website where patients can go in and ask questions, I believe. And so you can have access to some of this information, and I would strongly urge you to get in touch with an ostomy nurse, just for the supplies.

Morgan Stout:

On that note, there is also a find a WOCN portion of their website, I very frequently recommend it to patients, where you can put in your zip code, and it will tell you who has a registered WOCN in your area. So if you’re looking for that, that’s a great place. Darrell, how did you go about finding the Stealth Belt?

Darrelll:

A lot of that was watching YouTube videos on the care and keeping of my ileal conduit. There was one gentleman that had a series that actually recommended using a Stealth Belt, and found positives. I had also tried a product from another manufacturer that didn’t provide the level of support, it was just one of the belts that wrapped around that had elastic to it. And all of the major manufacturers, have hernia belt attachments to their product. All of the three major Hollister, Convatec, Coloplast, all have products that attach. And I think most of them have convex barriers, because I use a two piece, but those products help get a better fit for those of us with hernias, those of us that… they’re also have convex besides the flat ones. I’m still able to use just the plain flat barrier, because it’s very flexible. And I use Hollister products.

Darrelll:

But again, always reach out to your manufacturer of the product you’re using, many of them have WOCNs on staff or have ability to contact some of their product or one of the nurses, to help when a patient reaches out. So there are many avenues to find that support. Also, we’re coming up on early October, where the UOAA also celebrates National Ostomy Day, so there will be some publication of resources around that time as well out. We’re also going to be featuring a coffee and conversation with one of the manufacturers in September.

Morgan Stout:

Absolutely. And I know that this is a really great topic that is being covered at the WOCN Conference next week, so it’s on everybody’s minds. We did have a very interesting question that came in about supporting the abdominal wall. You mentioned coughing, or forceful coughing and sneezing. One of our participants said, does holding the abdomen specifically over the stoma, much like heart patients would hold that pillow over their chest after a surgery. Does that help stabilize the abdominal wall?

Dr. Poulose:

Yeah, I think it does. So certainly, it can help prevent things from pushing through, especially if you can feel a forceful cough come on. What I usually recommend to my patients is… again, how many times do we cough during a year? Probably hundreds, if not thousands of times. It’s hard to remember to do that, so short answer is yes, I do think it does help. And what I recommend to them is, if they have the flu or just consistent coughing for whatever reason, just put your hand just around your stomach, just to provide some temporary, additional counterpressure to the pressure developed by the cough. Whether that helps, I think it does help a fair amount. I’ve had a lot of patients who noticed their first instance of a parastomal hernia during coughing and sneezing, where it’s something just kind of they felt it pushed through.

Morgan Stout:

That’s great. That’s super helpful. We did have a question that came in about inguinal hernias, and if they are as common after a radical cystectomy like a parastomal hernia, and if this isn’t your area of expertise, that’s totally understandable. But is that something that is similar or can be dealt with in a similar fashion?

Dr. Poulose:

Yeah, I do take care of a lot of patients with inguinal hernias and incisional hernias, in addition to parastomal hernias. And so what we’ve noticed is that with urologic surgery in general, more so in the prostatectomy patient population, but definitely in the cystectomy population as well, we do see probably a little bit of an uptick in inguinal hernias, whether that’s due to just everyone’s a little bit more hyper focused on it than others, it’s still up to debate, but we do see it. Our general recommendations are pretty much the same across the board with inguinal hernias, where if you are not having a whole lot of symptoms from it and it’s not bothering you, it may be good to well enough to leave it alone. And when it progressed to causing you pain or even some functional problems, then that would be the threshold to say, “Let’s go ahead and repair it.”

Morgan Stout:

Sure, thank you. Here’s another really great question is, what can patients do to reduce the chance of a second hernia after the repair of a first hernia?

Dr. Poulose:

Great question. I think the first thing is going back at some of those risk factors I put there in terms of getting control of diabetes, stopping nicotine use, getting to a healthy weight can also help just like the initial prevention of the hernia to form in the first place. I do think after you’ve had a repair, you do really want to be careful of those high pressure activities, if you want to call them that. The coughing fits, the sneezing fits, the exercises I mentioned that increase abdominal pressure over a short amount of time. Again, I don’t want the message to be here that you shouldn’t exercise, I’m just talking about very specific exercises that increase pressure over a really short amount of time. The best example is you go to the gym and you see those folks on the really heavyweight areas, doing 250 pound squats over like three seconds, that’s the worst thing you can do for this, but other exercises are fine.

Morgan Stout:

Sure, absolutely. I’m sure all of our audience will keep that in mind next time they’re in one of those types of situations.

Dr. Poulose:

Right.

Morgan Stout:

We did have another question that was dropped in. Is it harder to repair a hernia as you get older?

Dr. Poulose:

No, I don’t think so. And so if you are a healthy person… and I think this is more and more true, especially over the last 20 years, honestly, age is less of a factor. And so we see a lot of patients who are above 70, 80 years old, who develop hernias and the repair is pretty much just the same as doing it in a 40 year old patient. Now what can happen is, as some other things, other medical conditions you may have progress, that can sometimes impact the safety of doing the repair. But no, I think age is less and less of a factor now.

Morgan Stout:

That’s great to hear. So how does one go about finding a surgeon who’s experienced enough to handle a parastomal repair? Not everybody can come to the Ohio State University to see you. So how do they go about finding a good surgeon?

Dr. Poulose:

So I think the first is talking to your primary care doctor, because your primary care doctor will often have resources to access hernia surgeons who then, you could find out if they specifically take care of patients with parastomal hernias, because not all hernia surgeons take care of patients with parastomal hernia specifically. The other person who would be a great reference is your urologist, because your urologist, who creates a lot of urostomies, will definitely have a go-to person to help manage parastomal hernias. The other resource is actually going to the American Hernia Society website. As you mentioned with the WOCN group, the American Hernia website also, you can have the ability to find a hernia specialist near you.

Morgan Stout:

Great. That is very helpful. We did have another question that was back to physical therapy. If a physical therapist is recommending an emphasis on your pelvic floor exercises versus the rest of your core exercises, does that seem to track with what you know about preventing and keeping those parastomal hernias in check?

Dr. Poulose:

Yeah. In fact, our pelvic floor colleagues within physical therapy, are probably the most in tune to this whole idea of the core concept. And so, I think most of them when they’re making their recommendations, they’re not just thinking of the pelvic floor, they’re actually thinking of the entire core musculature. So yeah, I think they’re a very experienced group, I’ve learned a ton from them. And what you see in that protocol I just put up on the chat, is largely developed specifically from pelvic floor physical therapists. So I also think that if you want them to focus on different areas, just ask them, because I do think that we’re learning more that actually, modulating the pelvic floor, strengthening the pelvic floor, can have a positive impact on other areas as well.

Morgan Stout:

Great. How long do patients typically stay in the hospital after a hernia repair surgery?

Dr. Poulose:

For something like this for parastomal hernia, those first two options I had on the slides, either making a cut alongside your ostomy or doing it laparoscopically or robotically, usually it’s an overnight stay. The bigger operations, the more complex abdominal wall reconstructions, is anywhere from three to five days.

Morgan Stout:

And how long does it take for that parastomal hernia repair to finish healing, once you’ve been sent home?

Dr. Poulose:

About two months. It takes about two months for all the healing to occur. And then during that recovery time, you start gradually increasing your activity level as the healing occurs.

Darrelll:

Would doing activity too soon, increase the odds of a second hernia?

Dr. Poulose:

I think it depends what kind of activity it is. If you’re going to go to the gym and do all those really intense exercises a week after the surgery, definitely don’t do that. If you’re going to get up and walk, go up and downstairs, do your day to day stuff and then start some low impact work, even abdominal core plank work, that kind of stuff, that’s okay. So that’s a really important point, Darrell, I’m glad you brought it up. And the first thing I will say, it is never your fault as a patient. I just want to emphasize that because I have a lot of patients who they think they did something wrong or, no. We don’t have the technology, we’re not smart enough yet how to figure out how to prevent this from happening in the first place. And I don’t ever want to dissuade anyone from increasing your activity level after a surgery, you just got to be careful about the type of activity you’re doing basically.

Morgan Stout:

That’s very helpful to know. And with that, that answers our last two questions. We’ll give folks just one more minute, I think we have time for one more question. But otherwise, this has been a phenomenal program and Dorothy would like to say, thank you so much for reassuring her that her parastomal hernia is not the largest one out there.

Dr. Poulose:

Yeah, absolutely.

Morgan Stout:

All right. With that, I’m going say thank you one more time to our sponsor, Bristol Myers Squibb, the EMD Serono, Pfizer partnership, UroGen and Merck, for their support of this program. Again, please take a minute to fill out that survey and thank you so much, Dr. Poulose and Darrell, for your participation in this. It’s been so insightful and it will be incredibly helpful for patients to come. Thank you.

Dr. Poulose:

Thanks again. Thanks for having us.

Darrelll:

Thank you.