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

Abstract

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. 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. 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. 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.