Sigmoid colostomy incision hernia

　　1. Etiology

　　After sigmoid colostomy, the normal anatomical relationship changes, and the formation of a gap between the sigmoid colon and the lateral abdominal wall becomes the potential basis for the disease. Various causes of increased intraperitoneal pressure are the triggering factors for the occurrence of the disease.

　　2. Pathogenesis

　　During sigmoid colostomy, the colon pulled to the abdominal wall incision forms a gap between the colon and the left abdominal wall, with the inner boundary being the sigmoid colon, the outer boundary being the lateral abdominal wall, and the posterior side being the iliac oblique muscle, resembling a hernial ring. If the gap is not sutured or poorly sutured during surgery, and if significant abdominal distension or intestinal peristalsis dysfunction occurs postoperatively, it is easy to cause the small intestine to herniate into the pelvic cavity through this abnormal channel, forming an internal hernia, causing mechanical obstruction, incarceration, or even strangulation of the small intestine. The sigmoid colostomy loop can also become obstructed due to compression by the small intestinal loop passing through the hernial ring.

　　During acute intestinal obstruction, the intestine swells, accumulates gas and fluid, and the intraluminal pressure increases, which can compress the intestinal wall and cause hemodynamic disorders, leading to intestinal strangulation and necrosis, and metabolic disorders of water and electrolytes; during chronic intestinal obstruction, the intestinal wall above the hernial ring presents chronic hypertrophic inflammatory changes.

　　A large number of intestinal loops herniate and are compressed and incarcerated by the hernial ring, which can cause intestinal wall hemodynamic disorders and strangulation, necrosis, clinical manifestations of diffuse peritonitis and toxic shock, and blood may be aspirated from the abdominal puncture.

　　1. Acute Peritonitis:It is a common severe surgical disease caused by bacterial infection, chemical irritation, or injury. Most cases are secondary peritonitis, originating from organ infection in the abdominal cavity, necrotic perforation, trauma, etc.

　　2. Toxic Shock Syndrome:It is a syndrome caused by staphylococcal exotoxin, characterized by high fever, vomiting, diarrhea, confusion, and rash, which can quickly progress to severe and refractory shock. It mainly occurs in menstruating women who use vaginal tampons. The main symptoms are caused by toxins produced by Staphylococcus aureus.

　　Most cases of this disease (about 70% of the cases) occur during the recovery period of intestinal peristalsis after colostomy surgery or before discharge, and can also occur several years after surgery, with clinical manifestations of acute or chronic intestinal obstruction.

　　16. Acute intestinal obstruction

　　Patients may suddenly develop intermittent and severe abdominal pain around the umbilicus and lower left abdomen, abdominal distension, vomiting, cessation of defecation and flatus, hyperactive bowel sounds, and may hear the sound of water passing through.

　　14. Chronic intestinal obstruction

　　Some patients may experience long-term abdominal pain and discomfort after sigmoid colostomy surgery. This condition is often due to a large paracolic defect of the sigmoid colon, causing the small intestine to herniate into the pelvic cavity and have poor passage of intestinal contents. Once a large amount of intestinal loops herniate and are compressed by the hernial ring, acute obstruction may occur on the basis of chronic intestinal obstruction.

　　The sigmoid colonic paracolic groove is the pathological basis for the formation of an external hernia adjacent to the sigmoid colostomy. Therefore, eliminating and reducing the paracolic groove during sigmoid colostomy surgery is the key to preventing this disease.

　　9. In surgery, it is necessary to routinely suture and fix the mesentery of the sigmoid colon segment to the left parietal peritoneum, seal the left colonic paracolic groove, and prevent the small intestine from herniating into the pelvic cavity through the left colonic paracolic groove to form an internal hernia.

　　8. Try to perform the sigmoid colostomy through an extraperitoneal approach to completely eliminate the left colonic paracolic groove, so that the sigmoid colon segment of the colostomy cannot form a gap with the left abdominal wall.

　　7. Before the sigmoid colon is brought out, the lateral peritoneum of the colon is cut open, and the sigmoid colon and part of the descending colon are fully mobilized. Then, the sigmoid colon is brought out through an extraperitoneal stoma on the abdominal wall. The mesentery of the sigmoid colon is sutured to the cut lateral peritoneum with 4号线 in an interrupted manner, with each suture approximately 1cm apart. The number of sutures should be determined according to the length of the cut lateral peritoneum. After suturing, check with the finger to ensure that the index finger cannot pass through, which can prevent complications such as an external hernia adjacent to the colostomy or the colostomy retracting into the abdominal cavity.

　　6. Avoid using drugs to enhance intestinal peristalsis, such as neostigmine, during the postoperative recovery period of intestinal peristalsis.

　　In addition, some people in China believe that before closing the abdomen, it is possible to reduce the tendency of the small intestine to penetrate into the left colonic paracolic沟 by arranging the small intestine inside the colonic frame and covering it with the omentum. Some foreign scholars, however, advocate using a transabdominal or midline colostomy to replace the left lower abdominal colostomy, and arranging the small intestine in the colonic frame before closing the abdomen. The left colonic paracolic groove does not need to be attended to or sutured.

　　Abdominal X-ray or abdominal plain film shows intestinal gas, and there are signs of intestinal obstruction such as step-like liquid levels.

　　For patients who undergo sigmoid colostomy surgery due to rectal cancer or rectal trauma, acute intestinal obstruction may occur suddenly during the recovery period of intestinal peristalsis after surgery or before discharge, manifested as sudden pain around the umbilicus and lower left abdomen, accompanied by nausea, vomiting, no flatus, and defecation, with rapid development of the condition; or there may be chronic intestinal obstruction after surgery, such as progressive abdominal distension and abdominal pain, with slow development of the condition.
　　Signs
　　Abdominal tenderness, most pronounced in the lower abdomen, hyperactive bowel sounds, and later abdominal muscle tension, decreased bowel sounds, or even disappearance.
　　X-ray examination
　　Abdominal X-ray or plain film shows signs of intestinal obstruction such as intestinal gas accumulation and liquid level.

　　1. Foods that are good for the body with para-colonic hernia of the sigmoid colon stoma:

　　Diet should be light. For the first few days after surgery, adjust the diet according to individual conditions, with fluid and semi-liquid foods as the mainstay, and eat more high-protein foods to promote wound healing. Supplement a variety of vitamins, eat more fresh vegetables and fruits. Various lean meats, milk, eggs, and other foods rich in protein can be eaten more.

　　2. Foods that should not be eaten with para-colonic hernia of the sigmoid colon stoma:

　　Avoid overly greasy foods, foods that should not be chosen: Foods such as preserved bean curd, scallions, chili peppers, chives, etc. are not conducive to wound healing because they are prone to cause infection.

　　(The above information is for reference only, please consult a doctor for details)

　　1. Treatment

　　Non-surgical treatment for para-colonic hernia cannot solve the problem, so surgery should be performed when suspected of the disease to reposition the intestinal loops and suture and close the gap between the sigmoid colon and the lateral abdominal wall peritoneum.

　　For those with chronic intestinal obstruction and suspected of having the disease, due to the possibility of concurrent acute intestinal obstruction, intestinal strangulation, and intestinal necrosis at any time, the patient and family should be informed truthfully, and they should be encouraged to actively accept surgical treatment. For those with acute intestinal obstruction, surgery should be performed as soon as possible. If there is no intestinal necrosis, the small intestine should be repositioned and the cleft repaired and closed; if intestinal necrosis has occurred, the necrotic intestinal segment should be resected, intestinal anastomosis performed, and the cleft adjacent to the sigmoid colon stoma repaired.

　　2. Prognosis

　　The treatment of para-colonic hernia, the key is to repair and close the cleft. If the cleft is small, it is sufficient to perform intermittent suture of the sigmoid colon mesentery and lateral peritoneum; for those with a large cleft gap that cannot be sutured between the sigmoid colon mesentery and the lateral peritoneum, Marlexmesh can be used for repair, with good therapeutic effects.