Scientific Papers

Early postoperative parastomal evisceration after explorative laparotomy: case report of a rare and potentially life-threatening surgical complication | Patient Safety in Surgery

The term “stoma” refers to a segment of the digestive tract surgically connected to the anterior abdominal wall, allowing for the disposal of waste products, either on a permanent or temporary basis. Its etymology traces back to the Greek word “Stoma”, which translates to “mouth”. stomas have assumed a pivotal role in the surgical management of bowel neoplasms, with colorectal cancer reigning as the primary indication for intestinal ostomies [4]. This fact underscores their significance. Although surgeons perform intestinal stomas as a routine part of their responsibilities, this seemingly straightforward procedure harbors the potential for a diverse range of complications if not meticulously planned and executed. In a systematic review encompassing eighteen randomized controlled trials, which scrutinized stoma-related complications in adults, the cumulative incidence of such complications hovered around 26.5% [5]. Predominating among these were peristomal skin complications. Intriguingly, even though this study spanned over 1,000 patients across a span of 35 years, not a single instance of early parastomal evisceration was reported. Early parastomal evisceration constitutes a perilous postoperative occurrence that, if not addressed promptly, can trigger severe complications. The condition is so uncommon that its coverage in medical literature is confined to a handful of case reports. Considering its scarcity, several authors have pointed to the likelihood of underreporting of this particular postoperative complication [2]. A comprehensive survey of existing literature only yielded ten cases of early parastomal evisceration, as succinctly summarized in Table 1. Notably, the earliest occurrences were within the first 72 h of the postoperative period. To the best of our knowledge, the case we present stands as the inaugural instance of bowel evisceration through a stoma site within the initial 48 h after surgery.

Table 1 Reported cases of early parastomal evisceration

The potential emergence of early parastomal evisceration in a patient’s postoperative course is contingent upon two distinct categories of risk factors: those intrinsic to the individual patient, arising from their medical and surgical history, and those associated with the execution of the surgical procedure itself. Patient-specific risk attributes, intricately tied to each patient’s medical background, can significantly influence the likelihood of parastomal evisceration. Elements within this category encompass advanced age, malnutrition, escalated intra-abdominal pressure elicited by factors such as chronic cough, prostatism, chronic obstructive pulmonary disease (COPD), or asthma. Moreover, the utilization of corticosteroids has also been identified as a pertinent risk factor [6]. The medical literature further implicates additional factors responsible for heightening intra-abdominal pressure, including disseminated malignancies, ascites, and instances of bowel obstruction within a previously explored peritoneal cavity [3]. Even the regression of intestinal edema could create enough space in the stoma site for the evisceration of intestinal loops [3]. Furthermore, it is widely acknowledged that surgical failures can often be attributed to technical challenges and the involvement of less experienced surgeons. These issues manifest as a disproportion between stoma diameter and the aponeurotic opening, ineffective aponeurotic stoma closure, inadequate fascia and cutaneous fixation, and delayed stoma maturation [2]. This underscores the critical role of meticulous surgical technique in mitigating the risk of complications. One of the pivotal steps in the creation of an ostomy is the fascial opening. It is advised to create a 3 to 4-centimeter cruciate incision in the anterior fascia. Following this, a vertical incision of equal length is made in the posterior rectus sheath after splitting the rectus abdominis muscle along its fibers [1]. In a recent experimental simulation study, Ambe explored the impact of a circular excision of the fascia in decreasing pressures at the ostomy site. This technique, proposed by the author, aims to diminish the risk of parastomal hernia [7]. In our comprehensive examination of published literature, the majority of cases (eight out of ten) displayed patient-related risk factors [2, 3, 6, 8,9,10,11,12], with two instances occurring without predisposing factors [9, 13]. Notably, pulmonary disorders like COPD and respiratory failure necessitating mechanical ventilation emerged as prominent patient-related risk factors. Meanwhile, our analysis of technical and surgical strategy failures yielded eight cases, with only one case showing no technical issues [9] and another lacking sufficient data [8]. Among these eight cases, the incongruity in diameter between the bowel and stoma site emerged as a recurrent concern [3, 10, 12]. In the context of our presented case, the patient’s advanced colon cancer, paralytic ileus, and prior peritoneal cavity exploration amplified the likelihood of this unfortunate post-operative event. However, akin to a substantial portion of cases in the literature, technical mishandling, specifically aponeurotic sheath closure failure, stood out as the focal point of this complication. The approach to addressing evisceration hinges on the viability of the affected bowel. Prompt intervention is imperative to forestall intestinal ischemia and infarction. The surgical course involves expanding the hernia opening, carefully reducing the eviscerated bowel, and possibly necessitating resection of necrotic tissue. Stoma revision and proper closure of the aponeurotic sheath (Fig. 2) are fundamental steps in this. A tension-free closure is key to reduce the risk of surgical wound dehiscence. When needed, relaxation incisions on the anterior aponeurotic sheath, on both sides of the suture line, could help reduce tension. In cases of concomitant peritoneal carcinomatosis, the use of a mesh could potentially add complexity to a planned cytoreductive surgery [14].

Fig. 2
figure 2

Closure of the aponeurotic sheath. The insertion of a closed Metzenbaum scissors through the aponeurotic opening in contact with the bowels ensures an adequate closure of the aponeurotic sheath (Neither tight nor loose)

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