Patients with parastomal hernia seldom develop severe situations such as incarceration and intestinal obstruction, because parastomal hernias usually have a big hernia ring through which hernia contents can pass freely. Only a small percentage of patients with parastomal hernia accept surgical repair due to the bulge that has affected daily life and ruined body image. This patient exceptionally developed an internal hernia caused by an adhesive band constricting the proximal colon and some small intestine in the parastomal hernia. It is a rare case of "hernia within hernia" that indicates prophylactic surgical repair; laparoscopic procedure may be a good option for patients with parastomal hernia in early stage to prevent such severe conditions. Several studies concluded that using a prophylactic mesh in a sublay position at primary stoma formation procedure is a promising method that lowers the high incidence rate of parastomal hernia [4
In this complicated case of "hernia within hernia", we preferred a relatively conservative therapy that consisted of lysis of the adhesive band, removal of the distal colon, and relocation of the stoma but did not include a hernia repair in emergency. Placing an IPOM or a sublay position in this kind of patient without bowel preparation may result in a disastrous infection. We had experienced a similar case of incarcerated ventral hernia using a prosthetic mesh in emergency surgery that finally led to a fatal infection. So postponing the hernia repair to a scheduled surgery might be more feasible and safer.
It is a principle that the stoma should be relocated into a quadrant of the contrary side of the abdominal wall in parastomal hernia repair procedures. Relocation of the stoma into a quadrant of the same side of the abdominal wall may increase recurrence rates in the new site [6
]. In this case, we relocated the stoma into the nearby area of the primary stoma, because the recurrence of the parastomal hernia in the new site in this obese patient with diabetes was anticipated and the secondary parastomal hernia repair surgery was scheduled during the first operation. It is more convenient for surgeons to repair two defects in same side using single mesh than in two sides using two meshes. Another reason we put the stoma into the same side is that the mobility of the distal colon was decreased because of massive adhesion in the abdominal cavity.
The incidence of iatrogenic bowel injury during incisional and ventral hernia repair was reported to be 1.78% in a systematic review [7
]. Unrecognized bowel injury is a serious complication of laparoscopic incisional hernia repair and is usually due to thermal, trocar or tack injuries to intestines. Inadvertent enterotomy during separation of adhesions with ultrasonic scalpel usually results in acute peritonitis that needs an emergency exploratory laparotomy to repair the bowel perforation. Mesh tiled on the abdominal peritoneum usually needs to be removed from the anchoring site when it has been contaminated by the bowel contents spilled from a ruptured bowel, because the contaminated mesh being kept in place may lead to a catastrophic abdominal infection or some late complications such as enterocutaneous fistula due to erosion of intestines by the mesh. Fortunately, in this case, the perforated bowel was located in the right lower abdominal cavity so the tainted fluid did not contaminate the mesh overlaying on the opposite side of the abdominal wall. Another reason for our bold decision of keeping the mesh in place is that the prosthetic mesh Proceed (Ethicon Inc., Somerville, NJ, USA) we used in this patient is distinctive for its large-pore and monofilament technology [8
] that together enable fluid to be easily drained through the mesh and keep bacteria from retaining and proliferating. There are still controversies in the management of bowel injury and the methods of hernia repair following the recognition of an enterotomy. Many surgeons are determined to proceed with hernia repair using a prosthetic mesh as planned if the contamination is minimal or absent [9
]. Although we succeeded in this casein which the enterotomy was unrecognized initially, removal of the mesh was strongly recommended when a ruptured bowel and intestinal spillage were confirmed during the secondary laparotomy.
In summary, this is a rare case of "hernia within hernia" because of the large parastomal hernia sac and an adhesive band that extended from the hernia sac wall to distal colon and formed an internal hernia ring. It should be kept in mind that some serious complications may occur during the treatment of huge parastomal hernias. Prophylactic mesh fixed in a sublay position at primary abdomino-perineal resection and stoma formation procedure may lower the high incidence of parastomal hernia and consequent complications.