Construction of a Permanent

End-Colostomy Using a 25 mm Circular

Stapler to Prevent Parastomal Hernia Formation
David B. Stewart, MD, Rafael Figueroa, MD, and Walter A. Koltun, MD

arastomal hernias are a frequent complication of stoma

formation, regardless of the type of stoma being constructed. The incidence of parastomal hernia in the literature
has a wide range because of the large number of small, heterogeneous, retrospective studies with differing definitions of
what constitutes a hernia, different lengths of follow-up, and
an admixture of different kinds of stomas for comparison that
may not have been formed in the same manner. However,
more than one study1-3 has suggested that the incidence of
parastomal hernia associated with a permanent end colostomy is as high as 50%. Although not all parastomal hernias
require repair, it has been estimated4 that up to one-third will
require herniorraphy, making prevention of this common
problem even more important. Though several options for
repairing a parastomal hernia have been proposed, including
direct local tissue repair, resiting the stoma with closure of
the original aperture, and the application of mesh around the
stoma, all have had inconsistent results. There are currently
no randomized trials that have clearly demonstrated which of
these techniques, if any, are best and in which particular
circumstances one technique might be chosen over another.
Obviously a technique of stoma creation that would minimize such hernia occurrence, and thereby avoid the need for
a subsequent hernia repair, would be preferable.
The causes of paracolostomy hernia include obesity, increased intra-abdominal pressure from problems such as
chronic cough and ascites, poor nutrition, immunosuprression, and factors related to the location and technique used in
formation of the stoma aperture. With regard to this last
factor, it is conventional to place the colostomy through the
center of the rectus muscle. Yet, a recent review of the incidence of parastomal hernias suggested that the location of the
stoma with respect to the rectus muscle had no influence on
hernia formation.1 This finding, as well as the inability to
demonstrate the superiority of any one of several prophylactic measures, may indicate that the location of the aperture

Department of Surgery, Division of Colon and Rectal Surgery, Penn State

College of Medicine, Milton S. Hershey Medical Center, Hershey, PA.
Address reprint requests to Walter A. Koltun, MD, Professor of Surgery,
Division of Colon and Rectal Surgery, Penn State College of Medicine,
Milton S. Hershey Medical Center, 500 University Drive, MCH137, Hershey, PA 17033-0850. E-mail: wkoltun@hmc.psu.edu

1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved.

doi:10.1053/j.optechgensurg.2008.10.004

and the placement of mesh or biologic materials around the

aperture are not as important to hernia prevention as are
other factors. A common finding associated with paracolostomy hernia is a greatly enlarged fascial defect, suggesting the
continued tearing or disruption of the fascia after the initial
creation of the stoma. This is consistent with obesity and
increased intra-abdominal pressure as being risk factors for
hernia development. Thus, a method to avoid the further
enlargement of the fascial defect might decrease subsequent
hernia formation.
We describe a novel technique of end colostomy formation
that uses a circular stapling device to create the stoma aperture. The rationale for this form of construction is that subsequent hernia formation is frequently because of further
enlargement and tear of the initial fascial defect. The use of
the circular stapler provides for a reinforcing ring of staples in
the fascia that inhibits further enlargement of the defect, so
minimizing subsequent hernia formation.

Operative Technique
The initial approach to end colostomy formation should be
according to well-established principles of stoma surgery. An
appropriate location for the stoma site should be at least 5 cm
away from surgical scars and bony prominences, and should
be visible to the patient. For the purpose of this description,
stoma formation will assume the conventional placement of
the stoma through the rectus muscle. Kocher clamps are
placed on the rectus fascia and subdermal tissue to ensure
that the aperture has a straight course through the abdominal
wall rather than obliquely drifting through its layers. A cylinder of subcutaneous fat may be removed to better expose
the underlying rectus fascia after the circular skin incision is
excised. Traditionally, a longitudinal or cruciate anterior rectus fasciotomy would be created at this point, sparing the
rectus muscle. However, the present approach is to place a
circular stapler base flush against the rectus fascia, deploying
the pin through the abdominal wall and into the peritoneal
cavity (see Figs 1 and 2). The anvil for the stapling device is
then attached to the pin, and the device is closed completely
as it would be with an intestinal anastomosis, but here, instead, compressing the posterior and anterior layers of the
abdominal fascia. The stapler is fired, cutting a circular aper171

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D.B. Stewart, R. Figueroa, and W.A. Koltun

Figure 1 Abdominal wall seen from the intra-abdominal side. The circular stapler base is flush against the anterior
abdominal wall fascia applied from the outside through the cutaneous stoma defect. Note the spike of the circular
stapler through the abdominal wall ready to engage the anvil applied from the intra-abdominal side.

Preventing parastomal hernia formation

Figure 2 Cross sectional view of the circular stapler as it is on apposition to the abdominal wall. The base of the stapler
is through the skin circumferential incision and subcutaneous adipose tissue and in direct contact with the anterior
sheath of the rectus abdominis fascia.

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D.B. Stewart, R. Figueroa, and W.A. Koltun

Figure 3 Circumferential abdominal wall defect created after firing the stapler. The staple lines are seen reinforcing the
fascial defect, approximately 15 mm in size. A Babcock clamp is introduced into the abdominal cavity through this
fascial defect. The transected colon is grasped with the clamp and delivered through the defect for creation of the stoma.

Preventing parastomal hernia formation

ture in the abdominal wall through the action of the circular
blade of the stapler. Additionally, the tissue layers of the
abdominal wall are stapled together along the circumference
of this circular opening (Fig 3). The defect allows for greater
ease in delivering the bowel through the opening. The remainder of the procedure, including colostomy maturation,
is done according to the surgeons usual practice. This technique does not require any additional opening of or reinforcement of the rectus fascia. Pexing seromuscular stitches
can be applied to the colon along the posterior fascia, to avoid
subcutaneous prolapse of the colon itself or a sliding hernia
that is still possible with this technique. The authors have
found that the 15 to 16.5 mm aperture created by 25 mm
circular stapler is large enough for colostomy creation in the
elective setting where there is no large bowel obstruction or
colonic distention or edema, though a larger diameter stapler
could potentially be used in cases where the colon is of larger
caliber. However in one case of the senior authors, where a
31 mm stapler was used in the elective setting, a sliding,
subcutaneous hernia developed within several months. The
15 to 16.5 mm diameter opening created by the 25 mm
stapler has never caused obstruction at the level of the fascia
in the authors experience, whereas at the same time minimized the subsequent development of a sliding hernia.

175

Summary
The use of a 25 mm circular stapler for colostomy creation
allows for standardization in the size of the abdominal wall
opening. The aperture so created is large enough to accommodate the delivery of the colon, but avoids making a defect
that is initially too large or becomes larger with time with
the subsequent development of a parastomal hernia. The
use of the stapler creates a reinforced circular defect rather
than a linear one, which is a more durable fascial opening
that better resists further enlargement from mechanical
stress, thereby minimizing subsequent parastomal hernia
formation.

References
1. Carne PWG, Robertson GM, Frizelle FA: Parastomal hernia. Br J Surg
90:784-793, 2003
2. Ortiz H, Sara MJ, Armendariz P, et al: Does the frequency of paracolostomy hernias depend on the position of the colostomy in the abdominal
wall? Int J Colorectal Dis 9:65-67, 1994
3. Burgess P, Matthew VV, Devlin HB: A review of terminal colostomy
complications following abdominoperineal resection for carcinoma. Br J
Surg 71:1004, 1984
4. Janes A, Cenzig Y, Israelsson L: Preventing parastomal hernia with a
prosthetic mesh. Arch Surg 139:1356-1358, 2004