Principles and parallels of prevention and repair of parastomal hernia with meshes

Abstract

After formation of a permanent terminal stoma by enterostomy, parastomal hernia (PSH) occurs in up to 80% of cases and leads to a wide variety of symptoms and complications with a high rate of emergency operations due to incarceration (ca. 15%). Consequently, greater consideration should be given to PSH prevention even as early as the time of enterostomy and generously applied indications for elective repair of manifest PSH. The aim of this article is to summarize and evaluate the current evidence for PSH repair and prevention. Poor postoperative results after attempted repair of manifest PSH with slit meshes in different layers of the abdominal wall shift the focus onto stoma lateralization (sandwich and Sugarbaker techniques) or 3‑dimensional tunnel-shaped implants with meshes to cover the stomal edges. To date, the best strategy for PSH prevention has still not been defined and techniques with slit meshes show different results. Nevertheless, 10 prospective randomized trials, meta-analyses, aCochrane review and guidelines from the European Hernia Society (EHS) about various slit-mesh devices in sublay, onlay and intraperitoneal positions confirmed significantly reduced rates of PSH after mesh augmentation compared to conventionally sutured enterostomy without morbidity associated with the implanted material. Despite the positive data situation PSH prevention is seldom performed in daily practice, which is due to uncertainty surrounding the most suitable surgical strategy, the necessity to spend additional time at the end of ademanding operation, the aversion to implanting meshes into acontaminated operative field and the lack of remuneration of preventive surgical procedures. Future trials should, therefore, no longer compare standard enterostomy techniques with one prevention method in general but should have anew focus on techniques providing adequate results in PSH repair (Sugarbaker, sandwich and 3‑Dtunnel meshes), probe the advantages and evaluate the differences in outcome between these strategies.