Is parastomal hernia repair with polypropylene mesh safe?

Repair of Parastomal Hernias

Parastomal hernias are an inevitable consequence of ostomy formation and their repairs remain a challenge to many surgeons. With multiple systems of classification and a multitude of techniques for hernia repair ranging from suture to mesh repair, the literature remains sparse with regards to the optimal method of repair. The authors describe the most commonly adopted techniques, discuss preventative measures, and review the current literature in the context of perioperative outcomes and hernia recurrence.

Occurrence and prevention of incisional hernia following laparoscopic colorectal surgery

Among minimally invasive surgical procedures, colorectal surgery is associated with a notably higher incidence of incisional hernia (IH), ranging from 1.7% to 24.3%. This complication poses a significant burden on the healthcare system annually, necessitating urgent attention from surgeons. In a study published in the World Journal of Gastrointestinal Surgery, Fan et al compared the incidence of IH among 1614 patients who underwent laparoscopic colorectal surgery with different extraction site locations and evaluated the risk factors associated with its occurrence. This editorial analyzes the current risk factors for IH after laparoscopic colorectal surgery, emphasizing the impact of obesity, surgical site infection, and the choice of incision location on its development. Furthermore, we summarize the currently available preventive measures for IH. Given the low surgical repair rate and high recurrence rate associated with IH, prevention deserves greater research and attention compared to treatment.

Parastomal hernias after cystectomy and ileal conduit urinary diversion: surgical treatment and the use of prophylactic mesh: a systematic review

BACKGROUND

Parastomal hernia after ileal conduit urinary diversion is an underestimated and undertreated clinical entity, which heavily impairs patients' quality of life due to symptoms of pain, leakage, application or skin problems. As for all gastrointestinal stomata the best surgical repair technique has yet to be determined. Thereby, surgery for ileal conduit parastomal hernias poses some specific perioperative challenges. This review aims to give an overview of current evidence on the surgical treatment of parastomal hernia after cystectomy and ileal conduit urinary diversion, and on the use of prophylactic mesh at index surgery in its prevention.

METHODS

A systematic review was performed according to PRISMA-guidelines. The electronic databases Embase, PubMed, Cochrane Library, and Web of Science were searched. Studies were included if they presented postoperative outcomes of patients undergoing surgical treatment of parastomal hernia at the ileal conduit site, irrespective of the technique used. A search was performed to identify additional studies on prophylactic mesh in the prevention of ileal conduit parastomal hernia, that were not identified by the initial search.

RESULTS

Eight retrospective case-series were included for analysis, reporting different surgical techniques. If reported, highest complication rate was 45%. Recurrence rates varied highly, ranging from 0 to 80%. Notably, lower recurrence rates were reported in studies with shorter follow-up. Overall, available data suggest significant morbidity after the surgical treatment of ileal conduit parastomal hernias. Data from five conference abstracts on the matter were retrieved, and systematically reported. Regarding prophylactic mesh in the prevention of ileal conduit parastomal hernia, 5 communications were identified. All of them used keyhole mesh in a retromuscular position, and reported on favorable results in the mesh group without an increase in mesh-related complications.

CONCLUSION

Data on the surgical treatment of ileal conduit parastomal hernias and the use of prophylactic mesh in its prevention is scarce. Given the specific perioperative challenges and the paucity of reported results, more high-quality evidence is needed to determine the optimal treatment of this specific surgical problem. Initial results on the use of prophylactic mesh in the prevention of ileal conduit parastomal hernias seem promising.

Parastomal Hernia Repair Using a Silo Biologic Mesh

BACKGROUND

A parastomal hernia (PSH) is an enlargement of the stoma's original opening through the abdominal wall's musculature around a colostomy, ileostomy, or urostomy. Its incidence can be up to 48%. The described methods for its repair have high recurrence rate.This article presents a 3-dimensional silo technique for PSH repair (PSH-R). The aims of this technique are to enhance the structural strength of the tunnel wall, to reinforce both the sidewalls and the fascia above and below the muscular opening, and to maintain a stable stoma opening.

METHODS

All consecutive patients undergoing PSH-R with the silo technique between January 2009 and May 2018 by 2 plastic surgeons were included. The outcome parameters of interest were hernia recurrence and wound-related complications.

RESULTS

This study reports 22 patients (9 male, 13 female) with a mean age of 66.7 years and an average body mass index of 29.2. The variety of ostomy types included 10 colostomies, 7 ileostomies, and 5 urostomies. Postoperatively, there were 3 surgical site infections, 1 seroma, and 2 wound healing delays. Six patients were readmitted, 3 of those because of small bowel obstruction. These 3 cases all required reoperation, in addition to 1 operative revision for stoma retraction. During our average follow-up of 19.9 months, 3 cases of PSH recurrence were diagnosed for a recurrence rate of 13.6%.

CONCLUSIONS

This silo technique is associated with favorable complication and low recurrence rates compared with the available techniques in surgical literature. In our practice, it has established itself as a new and safe technique for complex or recurrent PSHs and should be considered in a surgeon's armamentarium. This technique has become our standard for treatment of recurrent PSHs.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis

BACKGROUND

Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention.

METHODS

PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20).

CONCLUSION

PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Other Surgeries in Patients with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) will often require abdominal surgical intervention for indications not directly related to their IBD. Because these patients often have a history of multiple previous abdominal operations and/or ostomies, they are at increased risk for incisional and parastomal hernias. They may also have develop symptomatic cholelithiasis, chronic pain, or desmoid disease. All of these potentially surgical issues may require special consideration in the IBD population.

Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure

Introduction

Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel.

Patients and Methods

Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects.

Results

Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma.

Conclusion

Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.

Prosthetic mesh placement for the prevention of parastomal herniation

BACKGROUND

Parastomal herniation is a common problem following formation of a stoma after both elective and emergency abdominal surgery. Symptomatic hernias give rise to a significant amount of patient morbidity, and in some cases mortality, and therefore may necessitate surgical treatment to repair the hernial defect and/or re-site the stoma. In an effort to reduce this complication, recent research has focused on the application of a synthetic or biological mesh, inserted during stoma formation to help strengthen the abdominal wall.

OBJECTIVES

The primary objective was to evaluate whether mesh reinforcement during stoma formation reduces the incidence of parastomal herniation. Secondary objectives included the safety or potential harms or both of mesh placement in terms of stoma-related infections, mesh-related infections, patient-reported symptoms/postoperative quality of life, and re-hospitalisation/ambulatory visits.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2018, Issue 1), Ovid MEDLINE (1970 to 11 January 2018), Ovid Embase (1974 to 11 January 2018), and Science Citation Index Expanded (1970 to 11 January 2018). To identify ongoing studies, we also searched the metaRegister of Controlled Trials (mRCT) on 11 January 2018.

SELECTION CRITERIA

We considered for inclusion all randomised controlled trials (RCTs) of prosthetic mesh (including biological/composite mesh) placement versus a control group (no mesh) for the prevention of parastomal hernia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies identified by the literature search for potential eligibility. We obtained the full articles for all studies that potentially met the inclusion criteria and included all those that met the criteria. Any differences in opinion between review authors were resolved by consensus. We pooled study data into a meta-analysis. We assessed heterogeneity by calculation of I2 and expressed results for each variable as a risk ratio (RR) with corresponding 95% confidence intervals (CI). We expressed continous outcomes as mean difference (MD) with corresponding 95% CIs.

MAIN RESULTS

We included 10 RCTs involving a total of 844 participants. The primary outcome was overall incidence of parastomal herniation. Secondary outcomes were rate of reoperation at 12 months, operative time, postoperative length of hospital stay, stoma-related infections, mesh-related infections, quality of life, and rehospitalisation rate. We judged the risk of bias across all domains to be low in six trials. We judged four trials to have an overall high risk of bias.The overall incidence of parastomal hernia was less in participants receiving a prophylactic mesh compared to those who had a standard ostomy formation (RR 0.53, 95% CI 0.43 to 0.66; 10 studies, 771 participants; I2 = 69%; low-quality evidence). In absolute numbers, the incidence of parastomal hernia was 22 per 100 participants (18 to 27) receiving prophylactic mesh compared to 41 per 100 participants having a standard ostomy formation.There were no differences in the need for reoperation (RR 0.90, 95% CI 0.50 to 1.64; 9 studies, 757 participants; I2 = 0%; low-quality evidence); operative time (MD -6.50 (min), 95% CI -18.24 to 5.24; 6 studies, 671 participants; low-quality evidence); postoperative length of hospital stay (MD -0.95 (days), 95% CI -2.03 to 0.70; 4 studies, 500 participants; moderate-quality evidence); or stoma-related infections (RR 0.89, 95% CI 0.32 to 2.50; 6 studies, 472 participants; I2 = 0%; low-quality evidence) between the two groups.We were unable to analyse mesh-related infections, quality of life, and rehospitalisation rate due to sparse data or because the outcome was not reported in the included studies.

AUTHORS' CONCLUSIONS

This Cochrane Review included 10 RCTs with a total of 844 participants. The review demonstrated a reduction in the incidence of parastomal hernia in people who had a prophylactic synthetic mesh placed at the time of the index operation compared to a standard ostomy formation. However, our confidence in this estimate is low due to the presence of a large degree of clinical heterogeneity, as well as high variability in follow-up duration and technique of parastomal herniation detection. We found the rate of stoma-related infection to be similar in both the intervention and control groups.

Parastomal hernia repair using the "top hat" technique - An initial experience in 30 patients at Memorial Sloan Kettering Cancer Center

Parastomal hernia repair remains a significant surgical challenge. Recurrence after standard "keyhole" or primary suture repair is common. We adopted and modified a new technique using a construct shaped like an inverted top hat. We review our experience over the last six years in the first 30 patients (31 consecutive procedures). Of these 31 procedures, six (19%) resulted in a parastomal hernia recurrence with a median follow-up of 31 months (range 0.5-80). Four of the recurrences occurred in our initial experience, when we constructed the top hat of xenograft alone. When the technique was modified, using a synthetic composite mesh for the underlay portion of the hat, there were only two subsequent recurrences in 16 patients (13%) with a median follow-up of 22 months. One of these "recurrences" was secondary to infection of the top hat construct, which had to be removed. This initial success in preventing recurrence of parastomal hernia is probably due to the design of the construct, for it occludes the vulnerable stoma/fascial angle, through which most parastomal hernia recurrences occur.

A case of incisional hernia repair using Composix mesh prosthesis after antethoracic pedicled jejunal flap reconstruction following an esophagectomy

BACKGROUND

An incisional hernia in a case of antethoracic pedicled jejunal flap esophageal reconstruction after esophagectomy is a very rare occurrence, and this hernia was distinctive in that the reconstructed jejunum had passed through the hernial orifice; a standard surgical treatment for such a presentation has not been established. Herein, we describe a case of repair using mesh prosthesis for an atypical and distinctive incisional hernia after antethoracic pedicled jejunal flap esophageal reconstruction.

CASE PRESENTATION

A 77-year-old woman with a history of subtotal esophagectomy who had undergone antethoracic pedicled jejunal flap reconstruction complained of epigastric prominence and discomfort without pain. On examination, she had an abdominal protrusion between the xiphoid process and the umbilicus that contained the small bowel. Computed tomography showed that the fenestration of the abdominal wall that was intentionally created for jejunum pull-up was dehisced in a region measuring 9 × 15 cm and the small intestine protruded through it into the subcutaneous space without strangulation. Because the hernial orifice was too large and the reconstructed jejunum was passing through the hernial orifice in this case, we applied a parastomal hernia repair method that was modified from the inguinal hernia repair using the Lichtenstein technique. After 3 years and 5 months following surgery, the patient has recovered without hernia recurrence or other complications.

CONCLUSION

We consider this to be the first case of repair using Composix mesh prosthesis for repair of an atypical and distinctive incisional hernia after an antethoracic pedicled jejunal flap reconstruction. This method seems to be useful and could potentially be widely adopted as the surgical treatment for this condition.

Open Retromuscular Repair of Parastomal Hernias with Synthetic Mesh

Parastomal hernias (PHs) cause significant morbidity in patients with permanent ostomies, and several laparoscopic and open repair techniques have been described. We report our experience with open retromuscular repair of PHs using permanent synthetic mesh. A prospectively maintained database was retrospectively reviewed to identify patients undergoing PH repair. Primary outcomes are surgical site occurrence, surgical site infection (SSI), and hernia recurrence. Variables were analyzed using Pearson's χ2 test or Fisher's exact test. Values of P < 0.05 were considered significant. Forty-six patients underwent retromuscular PH repair with permanent synthetic mesh. There were 26 patients with colostomies and 20 with ileostomies. All the patients were repaired using a keyhole retromuscular technique and direct passage of stoma through mesh. Transversus abdominis release was performed in 65.2 per cent of cases. Permanent synthetic polypropylene mesh was used in all cases. Surgical site occurrence occurred in 47.8 per cent of patients, SSI in 17.4 per cent, and hernia recurrence in 21.7 per cent. Resiting the stoma yielded the highest rate of SSI (40%) compared with leaving the stoma in situ (11.8%) or rematuring the stoma (0%; P = 0.011). Open keyhole retromuscular PH repair of PH with permanent synthetic mesh is safe, effective, and durable.

The use of a composite synthetic mesh in the vicinity of bowel - For repair and prophylaxis of parastomal hernias. Does it increase the risk of short term infective complications?

AIMS

The use of synthetic meshes in potentially infected operative fields such as in the vicinity of large bowel, is controversial. This study describes our experience with the use of a synthetic composite mesh for prophylaxis and repair of parastomal hernias.

METHODS

Data were collected retrospectively over a 7-year period from 2008 to 2015. An IPOM (DynaMesh™) was used either during the formation of the stoma to reinforce the abdominal wall around the stoma or during the surgical repair of existing parastomal hernias, using keyhole or sandwich technique. Majority of meshes were placed laparoscopically. Clinical data and outcomes any stoma wound complications were collected.

RESULTS

Forty seven patients were included with a male to female ratio of 34:13. Median age was 66 years (38-91 years) with median follow-up of 17 months (3-73 months). Twenty seven patients had a prophylactic mesh placement (PMP) around colostomy after resection of colorectal cancer. None of these patients had any wound complications. Twenty patients had repair of parastomal hernias (RPH). One patient (1/20) in this group had a superficial wound infection around the stoma site and underwent an incision and drainage. One patient developed seroma and one had parastomal wound haematoma.

CONCLUSIONS

The use of a composite synthetic mesh using a laparoscopic IPOM technique for the prophylaxis and treatment of parastomal hernias, even in a clean contaminated surgical field, is safe and feasible.

Stoma Complications

When created properly, an ileostomy or colostomy can dramatically improve a patient's quality of life. Conversely, when a patient develops complications related to their stoma, the impact on physical and mental health can be profound. Unfortunately, significant morbidity is associated with stoma creation conveying high rates of both early and late-term complications. Early complications include stomal ischemia/necrosis, retraction, mucocutaneous separation, and parastomal abscess. Late complications include parastomal hernia, prolapse, retraction, and varices. This review will discuss commonly occurring nondermatological stoma complications and detail management strategies for the ostomate and the surgeon.

Prophylactic mesh placement for the PREvention of paraSTOmal hernias: The PRESTO systematic review and meta-analysis

Background

Parastomal hernia (PH) is the most common complication after ostomy formation. Prophylactic mesh placement may be effective in reducing the rate of PH at the stoma site. The aims of this systematic review were to summarize the evidence with regard to the safety and effectiveness in comparison with the standard procedure without mesh placement and to identify important risk constellations.

Method

A systematic literature search was performed in PubMed, EMBASE and the Cochrane library with no language or date restrictions. Randomized (RCTs) and non-randomized controlled trials (nRCTs) were included. The main outcomes of interest were PH (primary outcome) rate and stoma-related complications (secondary outcomes) such as stenosis or fistula. Statistical analysis included meta-analyses of pooled data and subgroup analyses.

Results

Eleven trials (eight RCTs; three nRCTs) with a total of 755 patients were included. PH rate varied from 0% to 59% in the intervention and from 20% to 94% in the control group. RCTs showed a significant reduction of PH rate in the mesh group (OR 0.24; 95% CI 0.10 to 0.58, p = 0.034), whereas included nRCTs did not. No significant differences were observed in postoperative complication rates. Subgroup analyses showed superiority of non-absorbable meshes and sublay mesh positioning in open surgery.

Conclusion

Prophylactic mesh placement is safe and reduces PH rate. A recommendation for prophylactic non-absorbable meshes in a sublay position can be made for patients undergoing open colorectal operations with end-ostomies. Further research endeavors should focus on patient-oriented outcomes, not only PH rate, with respect to tailored treatment in specific patient populations.

Prophylactic mesh use during primary stoma formation to prevent parastomal hernia

Introduction Parastomal hernia (PSH) is a common problem following stoma formation. The optimal technique for stoma formation is unknown although recent studies have focused on whether placement of prophylactic mesh at stoma formation can reduce PSH rates. The aim of this study was to systematically review use of prophylactic mesh versus no mesh with regard to occurrence of PSH and peristomal complications. Methods A systematic search was performed using PubMed, Embase™ and the Cochrane Library to identify randomised controlled trials that analysed placement of prophylactic mesh versus no mesh at time of initial surgery. Meta-analysis was performed using random effects methods. Results A total of 506 studies were identified by our search strategy. Of these, 8 studies were included, involving 430 patients (217 mesh vs 213 no mesh). Prophylactic mesh placement resulted in a significantly lower rate of PSH formation (42/217 [19.4%] vs 92/213 [43.2%]) with a combined risk ratio of 0.40 (95% confidence interval [CI]: 0.21-0.75, p=0.004). Placement of prophylactic mesh did not result in increased peristomal complications (15/218 [6.9%] vs 16/227 [7.0%]) with a combined risk ratio of 1.0 (95% CI: 0.49-2.01, p=0.990). Conclusions Prophylactic placement of mesh at primary stoma formation may reduce the incidence of PSH, without an increase in peristomal complications. However, the overall quality of the randomised controlled trials included in the meta-analysis was poor, and should prompt caution regarding the applicability of the findings of the individual studies and the meta-analysis to everyday practice.

A novel antibacterial cellulose based biomaterial for hernia mesh applications

A novel bacterial cellulose/collagen–hydroxypropyltrimethyl ammonium chloride chitosan composite (BCC–H), as an ideal artificial hernia mesh, was synthesized by combining solution impregnation with the EDC/NHS chemical crosslinking method .

Outcomes of Retromuscular Approach for Abdominal Wall Reconstruction in Patients with Inflammatory Bowel Disease

Ventral hernia repair (VHR) in patients with inflammatory bowel disease (IBD) presents unique surgical challenges including impaired wound healing, concomitant intestinal operations, along with likely future abdominal surgeries. Appropriate techniques and mesh choices in these patients remain under active debate. Herein we report our experience with using a retromuscular approach for major VHR in a consecutive cohort of IBD patients. We identified all patients with IBD undergoing open VHR with retrorectus mesh placement between 2007 and 2013 in our prospectively maintained database. Main outcomes included patient and hernia characteristics, perioperative details, wound complications, and hernia recurrence. A total of 38 patients with IBD met inclusion criteria. Mean hernia defect size was 338 cm2. Synthetic mesh was used in 16 patients and biologic mesh was used in 22 of patients. A surgical site occurrence (SSO) occurred in 13 (34.2%) patients, 7 (18.4%) of which were surgical site infections (SSIs). There were no instances of postoperative intestinal complications or enterocutaneous fistulae. At the mean follow-up 37 months, there were 3 (9.4%) recurrences. Our retromuscular repairs were associated with a low rate of wound morbidity and no intestinal complications. Furthermore, we report a relatively low rate of recurrences, especially in this series of complex multiply recurrent hernias. Overall, our retromuscular approach seems to be safe and effective in hernia patients with IBD.

Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience

BACKGROUND

The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years.

METHODS

A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality.

RESULTS

Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1).

CONCLUSIONS

Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.

Parastomal hernia: a growing problem with new solutions

Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias.

Single-center experience with parastomal hernia repair using retromuscular mesh placement

BACKGROUND

Parastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement.

METHODS

From 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences.

RESULTS

There were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m(2). Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n = 29), lightweight polypropylene (n = 15), or absorbable synthetic mesh (n = 2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11%) developed a recurrence; three patients required re-repair.

CONCLUSION

In this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.

Short- and long-term outcomes of incarcerated inguinal hernias repaired by Lichtenstein technique

Introduction

The use of tension-free inguinal hernia repair techniques using commercially available implants is now rather common. However, it is widely accepted that the use of biomaterials should be limited to non-infected surgical fields. As such, most current studies pertain to the application of various implants during the surgical repair of uncomplicated hernias.

Aim

To compare the short- and long-term outcomes of incarcerated inguinal hernia repair using the Lichtenstein or Bassini technique.

Material and methods

Between 1997 and 2012, 107 patients were operated on an emergency basis due to the incarceration of inguinal hernias – 105 subjects were included for further analysis in our study.

Results

Postoperative complications were observed in 13 out of the 84 (15.5%) patients subjected to Lichtenstein repair. In 9 of these patients (10.7%), morbidity was associated with the surgical wound. In 2 cases (2.4%), a small inflammatory infiltration was observed and resolved within a few days. Serous fluid accumulation within the wound was observed in 3 patients (3.6%), but the fluid was successfully drained by puncture. Finally, hematoma formed in 4 cases (4.8%). In total, 4 complications (19%) were recorded in the group of 21 patients who were operated on with the Bassini technique. In 3 of these cases (14.3%), the complications were related to suppuration of the surgical wound.

Conclusions

Polypropylene mesh may be safely implanted during the repair of incarcerated hernia and this approach is reflected by satisfactory long-term outcomes.

Avoidance and management of stomal complications

The construction of an intestinal stoma is fraught with complications and should not be considered a trivial undertaking. Serious complications requiring immediate reoperations can occur, as can minor problems that will subject the patient to daily and nightly distress. Intestinal stomas undoubtedly will dramatically change lifestyles; patients will experience physiologic and psychologic detriment with stoma-related problems, however minor they may seem. Common complications include poor stoma siting, high output, skin irritation, ischemia, retraction, parastomal hernia (PH), and prolapse. Surgeons should be cognizant of these complications before, during, and after stoma creation, and adequate measures should be taken to avoid them. In this review, the authors highlight these often seen problems and discuss management and prevention strategies.

Systematic review of open techniques for parastomal hernia repair

Parastomal hernia formation is common following formation of an abdominal stoma, with the risk of subsequent incarceration, obstruction and strangulation. Current treatment options include non-operative management, stoma relocation and fascial repair with or without mesh. The purpose of this systematic review was to evaluate the effectiveness and safety of open mesh repair of a parastomal hernia and to compare open non-mesh fascial repair with mesh techniques of parastomal hernia repair. Electronic databases were searched for studies comparing the two surgical techniques in accordance with preferred reporting items for systematic reviews and meta-analyses. The primary outcome of the study was the comparison of recurrence rates of parastomal hernia for each technique. Secondary outcomes included comparison of mortality, wound infection, mesh infection and any other complication. Twenty-seven studies of parastomal hernia repair were included and divided into two subgroups for open mesh repair and non-mesh fascial repair. Non-mesh fascial repair resulted in a high recurrence rate (around 50%). Reported recurrence rates for mesh repair were substantially lower, at 7.9-14.8%, depending on the position of the mesh in relation to the abdominal fascia and the length of follow-up. Morbidity and mortality did not differ significantly between the techniques used to repair a parastomal hernia. This study shows that mesh repair of a parastomal hernia is safe and significantly reduces the rate of recurrence compared with sutured repair, which should only be used in exceptional circumstances. There is insufficient evidence to determine which mesh technique (onlay, sublay or underlay) is most successful in terms of recurrence rates and morbidity.

Parastomal hernia repair

Occurrence of parastomal hernia is considered a near inevitable consequence of stoma formation, making their management a common clinical dilemma. This article reviews the outcomes of different surgical approaches for hernia repair and describes in detail the laparoscopic Sugarbaker technique, which has been shown to have lower recurrence rates than other methods. Also reviewed is the current literature on the impact of prophylactic mesh placement during ostomy formation.

Laparoscopic versus open repair of parastomal hernias: an ACS-NSQIP analysis of short-term outcomes

BACKGROUND

Parastomal hernia (PSH) is a frequent complication following the creation of a stoma. While a significant number of cases require operative management, data comparing short-term outcomes of laparoscopic versus open repair of parastomal hernias are limited.

METHODS

The ACS-NSQIP was retrospectively reviewed from 2005 to 2011 for all PSH cases that underwent open or laparoscopic repair. Patients characteristics, operative details, and outcomes were listed for both procedure types. Selected end points were compared on multivariate regression analysis.

RESULTS

Among the 2,167 identified parastomal hernia cases, only 222 (10.24 %) were treated laparoscopically. The open and laparoscopic groups were similar with respect to mean patient age (63 vs. 63 years; p = 1) and gender distribution as the majority of patients were females (56.8 %). However, open repair was more likely to be performed in patients with a higher ASA class (III and IV) (p < 0.001). Also, the open approach was more likely to be used emergently (8.64 vs. 3.60 %; p = 0.01) and for recurrent hernias (6.99 vs. 3.15 %; p < 0.05). After adjusting for all potential confounders including age, gender, ASA, emergency designation of the operation, hernia type, and wound class, laparoscopy was associated with shorter operative time (137.5 vs. 153.4 min; p < 0.05), shorter length of hospital stay by 3.32 days (p < 0.001), lower risk of overall morbidity (OR = 0.42; p < 0.001), and a lower risk of surgical site infections (OR = 0.35; p < 0.01) compared to open repair. Mortality rates were similar in the laparoscopic and open groups (0.45 vs. 1.59 %, respectively; p = 0.29).

CONCLUSIONS

Laparoscopic parastomal hernia repair is safe and appears to be associated with better short-term outcomes compared to open repair in selected cases. Large prospective randomized trials are needed to confirm those results and to assess long-term recurrence rates.

The persistent challenge of parastomal herniation: a review of the literature and future developments

AIM

The aim of this review article was to outline current evidence relating to the treatment and prevention of parastomal herniation with a view to guide surgeons dealing with patients potentially affected by this complication.

METHOD

Medline and PubMed databases were searched using the keywords 'parastomal hernia/herniation', 'stoma hernia/herniation' and 'stoma complications'. Evidence was obtained from randomized and non-randomized studies. Case reports and articles not written in English were excluded. Qualitative assessment of all included studies was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence.

RESULTS

The search revealed a total of 228 publications of which 115 fulfilled the selection criteria. Stoma formation through the rectus muscle is complicated by parastomal herniation in up to 50% of cases. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. The 'Sugarbaker' technique appears to be superior to the 'keyhole' technique when a laparoscopic approach is used. Prophylactic mesh reinforcement of the stoma trephine appears to reduce the herniation rate to approximately 15% and is accompanied by a decrease in symptomatic hernias requiring repair without any difference in stoma-related morbidity.

CONCLUSION

Large prospective controlled trials are required to compare surgical techniques of stoma formation in reducing the incidence of parastomal herniation. Despite limited evidence, routine prophylactic mesh reinforcement of the stoma trephine should be offered to all patients undergoing permanent stoma formation.

Management and complications of stomas

Stomas are created for a wide range of indications such as temporary protection of a high-risk anastomosis, diversion of sepsis, or permanent relief of obstructed defecation or incontinence. Yet this seemingly benign procedure is associated with an overall complication rate of up to 70%. Therefore, surgeons caring for patients with gastrointestinal diseases must be proficient not only with stoma creation but also with managing postoperative stoma-related complications. This article reviews the common complications associated with ostomy creation and strategies for their management.

A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation

AIM

Despite advances in surgical technique, parastomal herniation is common. This systematic review aims to assess the efficacy of prophylactic mesh at primary operation in reducing the incidence of parastomal hernia.

METHOD

Medline, EMBASE and CENTRAL were searched for relevant publications between January 1980 and January 2010. The search strategy included text terms and MESH headings for parastomal hernia, mesh and prevention and/or prophylaxis of hernia. No language restrictions were applied. Bibliographies from the papers requested in full were manually checked. All randomized controlled trials were included regardless of the language of publication. Results were extracted from the papers by two observers independently on a predefined data sheet. Disagreements were resolved by discussion. REVMAN 5 was used for statistical analysis.

RESULTS

Of 27 possible studies three randomized controlled trials fulfilled the criteria for systematic review, with a total of 128 patients (mesh 64, no mesh 64). The two study groups were well matched demographically. The incidence of parastomal hernia in the mesh group was 12.5% (8/64) compared with 53% (34/64) in the control group (P < 0.0001). There was no difference in mesh related morbidity in the two groups.

CONCLUSION

Although only three trials with 128 patients fulfilled the criteria for this systematic review, the data suggest that the use of prophylactic prosthetic mesh at the time of primary stoma formation reduces the incidence of parastomal hernia.

[Correction of parastomal hernia using meshes]

The incidence of parastomal hernia in ileal conduit urinary diversion ranges from 4% to 16%. Surgical correction is necessary in about one third of cases and different techniques of surgical reconstruction have been described. Primary fascial repair has a high recurrence rate of 46-100% whereas stoma translocation is associated with complication rates of up to 88%. The use of alloplastic material (usually polypropylene meshes) has reduced the recurrence rate by up to 100% for primary fascial repair and 71% for stoma translocation down to 33%.Composite meshes consist of two layers, a polypropylene layer and an expanded polytetrafluoroethylene (ePTFE) layer. The former is placed against the abdominal wall for permanent reinforcement by ingrowing connective tissue and the ePTFE layer is placed against the abdominal organs preventing adhesions with the bowel. The intraperitoneal placement of such composite meshes is a standardized, simplified, gentle and controllable surgical procedure. This article reports experiences with the surgical correction of parastomal hernias in ileal conduits using composite meshes.

Outcomes using a bioprosthetic mesh at the time of permanent stoma creation in preventing a parastomal hernia: a value analysis

PURPOSE/METHODS

A retrospective review of the medical records of all patients who had a prosthetic placed at the time of stoma creation for the prevention of a parastomal hernia was performed. The purpose of this study was to evaluate the safety, efficacy, and cost-effectiveness of bioprosthetics.

RESULTS

A bioprosthetic was used in 16 patients to prevent the occurrence of a parastomal hernia. The median follow-up was 38 months. There were no mesh-related complications, and no parastomal hernias occurred. On value analysis, to be cost-effective, the percentage of patients who would have subsequently needed surgical repair of a parastomal hernia would have to be in excess of 39% or the bioprosthetic would have to cost less than $2,267 to $4,312.

CONCLUSIONS

These data show the safety and efficacy of using a bioprosthetic at the time of permanent stoma creation in preventing a parastomal hernia and defines the parameters for this approach to be cost-effective.

3D intrastomal ultrasonography, an instrument for detecting stoma-related fistula

BACKGROUND

The aim of the present study was to evaluate the recently developed 3D intrastomal ultrasonography in diagnosing stoma-associated complaints and suspected complications after parastomal hernia repair such as peristomal fistula and abscesses.

METHODS

3D intrastomal ultrasonography was used to image peristomal tissue in two patients with complaints after parastomal hernia repair performed with IPOM (intraperitoneal onlay mesh). One patient had ulcerative colitis and one Crohn's disease. Both patients were investigated because of pain and in one case also signs of a subcutaneous abscess.

RESULTS

Intrastomal ultrasonography revealed fistulas connected to the intestinal segment leading to the stoma in both cases. Both cases also showed signs of a fistula descending to the abdominal cavity. In one case, a subcutaneous abscess was identified and in the other a small abscess adjacent to the fistula and the edge of the fascia.

CONCLUSIONS

Stoma complaints after surgery for parastomal hernia with implantation of IPOM mesh can be diagnosed using 3D intrastomal ultrasonography. This new 3D technique for imaging intrastomal hernia can be used to complement traditional methods in the detection of stoma-associated abscesses and fistulas with or without foreign material such as mesh.

Surgical treatment of a parastomal hernia

Purpose

Parastomal hernia is a major complication of an intestinal stoma. This study was performed to compare the results of various operative methods to treat parastomal hernias.

Methods

Results of surgical treatment for parastomal hernias (postoperative recurrence, complications and postoperative hospital stays) were surveyed in 39 patients over an 11-year period. The patients enrolled in this study underwent surgery by a single surgeon to exclude surgeon bias.

Results

Seventeen patients were male, and twenty-two patients were female. The mean age was 65.9 years (range, 36 to 86 years). The stomas were 35 sigmoid-end-colostomies (90%), 2 loop-colostomies (5%), and 2 double-barrel-colostomies. Over half of the hernias developed within two years after initial formation. Stoma relocation was performed in 8 patients, suture repair in 14 patients and mesh repair in 17 patients. Seven patients had recurrence of the hernia, and ten patients suffered from complications. Postoperative complications and recurrence were more frequent in stoma relocation than in suture repair and mesh repair. Emergency operations were performed in four patients (10.3%) with higher incidence of complications but not with increased risk of recurrence. Excluding emergency operations, complications of relocations were not higher than those of mesh repairs. Postoperative hospital stays were shortest in mesh repair patients.

Conclusion

In this study, mesh repair showed low recurrence and a low complication rate with shorter hospital stay than relocation methods, though these differences were not statistically significant. Further studies, including randomized trials, are necessary if more reliable data on the surgical treatment of parastomal hernias are to be obtained.

[Parastomal hernias]

The overall incidence of parastomal hernias is 35-50%. Different methods of hernia repairs (local fascial repair, stoma relocation and various types of mesh repairs) did not provide satisfactory results. Laparoscopic approach makes peristomal incision unnecessary and decreases the potential risk of mesh infection as well. In spite of all attempts the incidence of recurrent parastomal hernias is as high as 12-35%. These unsatisfactory results supported the idea of mesh implantation at the time of the initial stoma formation. In this study the authors inserted a self-designed two-layered special meshin 17 cases as a prevention and after 5 years follow-up period no parastomal hernias were recorded. The only complication noted was a minor stricture on the surface of the skin, that could have easily been corrected. Therefore, the authors support the idea of preventive mesh insertion at time of definitive stoma formation.

Parastomal hernia repair outcomes in relation to stoma site with diisocyanate cross-linked acellular porcine dermal collagen mesh

PURPOSE

Biologic meshes are increasingly used in parastomal hernia repair. This study evaluates the efficacy and safety of diisocyanate cross-linked acellular porcine dermal collagen mesh for parastomal hernia repair, with particular reference to the relationship of the stoma site to the rectus sheath.

METHODS

Hernias were repaired via a lateral approach, with onlay placement of the biologic mesh. A retrospective case note review and analysis of clinical outcomes was performed. The relationship of the stoma to the rectus sheath was determined by abdominal computed tomography (CT) and intraoperative findings.

RESULTS

Over a 16-month period, 27 consecutive patients, median age 72 years, underwent parastomal hernia repair utilising onlay biologic mesh to reinforce the external oblique aponeurosis. There were 20 paracolostomy and seven paraileostomy hernias. Eleven stomas passed through the rectus sheath and 16 were lateral to it. Recurrences occurred in 3 of 11 stomas within and 12 of 16 stomas lateral to the rectus sheath (P = 0.022). The median time to recurrence was 10.1 months. The median follow up of patients without recurrence was 16.6 months (range 0.2-39.3). There was one perioperative death. One patient developed a superficial post-operative abscess that was managed conservatively, but there were no complications related to the biologic mesh and no mesh required removal.

CONCLUSIONS

For parastomal hernias within the rectus sheath, diisocyanate cross-linked porcine dermal collagen mesh onlay repair gives good results and is safe to use. Repair of a parastomal hernia where the stoma is lateral to the rectus sheath has a significantly higher risk of recurrence and is not recommended.

Repair of parastomal hernias with biologic grafts: a systematic review

BACKGROUND

Biologic grafts are increasingly used instead of synthetic mesh for parastomal hernia repair due to concerns of synthetic mesh-related complications. This systematic review was designed to evaluate the use of these collagen-based scaffolds for the repair of parastomal hernias.

METHODS

Studies were retrieved after searching the electronic databases MEDLINE, EMBASE and Cochrane CENTRAL. The search terms 'paracolostomy', 'paraileostomy', 'parastomal', 'colostomy', 'ileostomy', 'hernia', 'defect', 'closure', 'repair' and 'reconstruction' were used. Selection of studies and assessment of methodological quality were performed with a modified MINORS index. All reports on repair of parastomal hernias using a collagen-based biologic scaffold to reinforce or bridge the defect were included. Outcomes were recurrence rate, mortality and morbidity.

RESULTS

Four retrospective studies with a combined enrolment of 57 patients were included. Recurrence occurred in 15.7% (95% confidence interval [CI] 7.8-25.9) of patients and wound-related complications in 26.2% (95% CI 14.7-39.5). No mortality or graft infections were reported.

CONCLUSIONS

The use of reinforcing or bridging biologic grafts during parastomal hernia repair results in acceptable rates of recurrence and complications. However, given the similar rates of recurrence and complications achieved using synthetic mesh in this scenario, the evidence does not support use of biologic grafts.

Long-term follow-up of laparoscopic repair of parastomal hernia using a bilayer mesh with a slit

BACKGROUND

Open surgery for parastomal hernia has been associated with high morbidity and recurrence rates exceeding 50%. Laparoscopic mesh repair is a promising alternative. Published series on laparoscopic mesh repair of parastomal hernia, however, are few with relative short follow-up.

METHODS

Seventy-two consecutive patients with 48 paracolostomy and 24 paraileostomy hernias were studied prospectively. Using a two-layer mesh with polypropylene on the parietal side and nonadhesive PTFE toward the viscera, a slit with a central keyhole was cut in the mesh modified after Hofstetter. Covering the fascial defect, the slit was closed laterally. Of the 70 patients discharged alive, 66 were followed for 6 months to 11 years (median=3 years). Four patients were lost for follow-up.

RESULTS

Lysis of adhesions to the anterior abdominal wall, necessary in 68 patients (94%), was frequently a cumbersome and time-consuming task. In nine patients it was the apparent cause of inadvertent full-thickness enterotomy and seromuscular lesion in three and six patients, respectively. Three procedures (4%) were converted to open surgery. Postoperative complications were observed in 16 patients (22%), nine of whom required repeat surgery (13%). Two patients (3%) died. The median hospital stay was 3 days. Late mesh-related complications were observed in five patients (7%) after 5-34 months. Three patients developed abscess that required mesh removal in two patients, including one patient with a small bowel fistula. In two patients the mesh was removed because of small-bowel obstruction and stenosis of the colon at the level of the mesh, respectively. Parastomal hernia recurred in two patients 1 month and 52 months after surgery (recurrence rate=3%, 95% confidence interval=1-10).

CONCLUSIONS

Laparoscopic repair of parastomal hernia using bilayer mesh with a slit is associated with a risk of substantial postoperative morbidity, including late mesh-related complications, but a recurrence rate of less than 10%.

Reoperation for stoma-related complications

Stoma complications are common. Most do not require reoperation, but when surgery is indicated, numerous options are available. Complications can arise early or late, and they can vary from benign to life-threatening. Meticulous preoperative planning is crucial in preventing stoma complications. Good communication with the patient is important in the decision-making process.

Short-term outcomes with the use of bioprosthetics for the management of parastomal hernias

PURPOSE

This study was undertaken to determine the safety and short-term outcomes using bioprosthetics for the management of parastomal hernias.

METHODS

A retrospective review of prospectively collected data for all of the patients who underwent repair of a parastomal hernia was conducted.

RESULTS

Between April 2004 and September 2007, 20 consecutive patients had 22 parastomal hernias repaired through a midline incision using a bioprosthetic with the stoma entering the abdomen lateral to the graft. A colostomy was present in 17 patients; an ileostomy was present in 3 patients. All of the patients had parastomal hernia-related complications. Postoperatively there were no infections of the midline wound or the prosthetic, and none of the grafts were removed. There were 4 seromas (40%) that required aspiration in the 10 procedures performed before the routine placement of a drain. No incisional hernias have developed in the midline wound. There have been 2 (9%) recurrent parastomal hernias on physical examination at a median follow-up of 18 months (range, 12-54).

CONCLUSIONS

These data suggest that bioprosthetics are safe and are effective in the short term for the repair of parastomal hernias.

Parastomal hernia repair: laparoscopic ventral hernia meshplasty with stoma relocation. The current state and a clinical case presentation

BACKGROUND

Parastomal hernia is a frequent complication after performing an ostomy, and although different technical options have been described, it lacks an ideal intervention to resolve it. The use of meshes and the laparoscopic approach, has led to a significant advance in resolving this condition. However, the ideal technique should guarantee must ensure integral repair of the abdominal wall, taking into account the functionality of the stoma. In large parastomal eventrations the repairing of the ventral hernia with a mesh and relocating the stoma in another quadrant may be an intervention that fulfills both principles, and open approach being described.

METHODS

We review the current state of surgical management of this condition and analyze the different technical options. Present the first description for using a laparoscopic technique with meshplasty and stoma relocation in an obese patient with a complex parastomal hernia, with results in the 18 month follow up.

CONCLUSIONS

Surgical technique repair of the parastomal hernia is sometimes a complex issue, which possibly requires different solutions according to the characteristics of the hernia and patient. The technique described of meshplasty with stoma relocation by laparoscopic approach has been revealed as an affordable technique, with minor inconvenience to the patient, absence of complications and good functional results in the long term, benefiting from the advantages of minimally invasive surgery itself.

[Parastomal hernias: background, current status and future prospects]

Parastomal hernia (PH) is the most common delayed complication in stoma surgery. Only a third of these are operated on, something which is partly explained by the high recurrence rate observed after repair. The use of prosthetic materials has improved the results, although they continue to be below the ideal. For this reason, it has been proposed that the best solution may be in preventing the PH. Several studies show promising results, with very marked reductions in the percentage of IH, on placing a prophylactic peristomal prosthesis. In this article we present a review of the risk factors associated with PH, a classification of the existing diversity of repair techniques, and an algorithm is proposed for the management of PH, including its prevention.

Parastomal hernia: complications of extra-peritoneal onlay mesh placement

OBJECTIVE

To determine the complication and infection risks following extra-peritoneal onlay mesh placement in parastomal hernia repair.

DESIGN

A retrospective analysis of medical records was performed.

BACKGROUND

Parastomal hernia is a frequent complication of enterostomata. Fascial repair using a prosthetic mesh has been generally accepted as the best method of parastomal hernia repair. New studies suggest the use of a prophylactic mesh placement at the initial operation, but fear of wound infection and mesh removal is still high.

PATIENTS AND METHODS

A retrospective review of patient records was performed of all patients with extra-peritoneal parastomal hernia repair using a prosthetic mesh between 1997 and 2006. The patient demographic data, enterostomy indication, therapy, and outcome were recorded.

RESULTS

In the 10-year study period, 16 parastomal hernia repairs using an extra-peritoneal prosthetic mesh in the onlay position were performed. In one patient, a mesh infection occurred, resulting in mesh removal (6.2%). The recurrence rate was 19% after a mean follow-up of 33 months.

CONCLUSION

Parastomal hernia repair using a prosthetic mesh is a safe and effective method, with the lowest recurrence rates and acceptably low infection rates. Prosthetic materials should not be used in cases of fecal contamination.

Waist circumference is an independent risk factor for the development of parastomal hernia after permanent colostomy

PURPOSE

This study was performed to evaluate the risk factors of parastomal hernia after abdominoperineal rectal amputation.

METHODS

This was a retrospective study of consecutive patients who underwent abdominoperineal rectal amputation for rectal cancer between January 1999 and August 2006. The effects of age, sex, surgical approach, chemotherapy, waist circumference, and body mass index on the development of a parastomal hernia were analyzed.

RESULTS

Forty-one patients underwent 19 open and 22 laparoscopic abdominoperineal rectal amputations. A parastomal hernia developed in 19 patients (46 percent) after a median follow-up period of 31 (range, 5-80) months. We observed ten hernias in the open group and nine in the laparoscopic group (P = 0.453). There were no significant differences in the type of surgical approach, age, sex, or adjuvant therapy in patients who developed a parastomal hernia compared with those who did not. Waist circumference proved to be an independent risk factor (P = 0.011). When the waist circumference exceeds the calculated threshold of 100 cm, there is a 75 percent probability to develop a parastomal hernia.

CONCLUSIONS

Abdominal obesity increases the risk of developing a parastomal hernia, therefore, it might be advisable to place a prophylactic mesh during colostomy formation when the patient's waist exceeds 100 cm.