European Hernia Society Guidelines Research Articles

1082 Maximising Surgical Outcomes in Midline Incisional Hernia Repairs: Are We Employing Every Possible Optimisation?

Abstract Introduction Large midline Incisional hernia repair can involve complex surgery which poses many challenges, with a high recurrence and complication rate. The recently published European Hernia Society Guidelines has identified several risk factors contributing to the increased complications after surgical repair. We aim to assess the effect of these modifiable risk factors for adverse outcomes within our patient population. Method All adult patients who underwent a repair of midline incisional hernias larger than 3cm in a DGH hospital between July 2021 and July 2022 were included. Data on patient demographics, modifiable risks factors and complications were collected. Analysis was performed using Microsoft Excel. Results 26 patients (age: 64 [33-84] years; M:F, 9:17) underwent a midline incisional hernia repair were included. The average hernia size was 8cm. The average body mass index (BMI) was 33.1, seven were smokers and three had diabetes mellitus. Of the three patients who developed a recurrence, average BMI was 36 and two were smokers. None of the patients were counselled for weight loss or smoking cessation. Conclusions In our cross-sectional study, patients with a large hernia, high BMI, diabetes, a smoking history are associated with adverse outcomes. We aim to highlight and raise the awareness to surgeons who perform these repairs to counsel their patients on their modifiable risk factors and its associated risk of hernia recurrence. Preoperative optimisation improves surgical outcome and subsequently reduces healthcare costs.

522 A Snapshot Audit of Incisional Hernia Rates Following Colorectal Cancer Resection

Abstract Aim Incisional hernia is a common complication of colorectal surgery. Recent European Hernia Society guidelines recommend strategies such as small bites closure and off-midline incisions to reduce incisional hernia rates. We aimed to evaluate our centres incisional hernia rate and performance against these categories Method All patients undergoing surgery for colorectal cancer in 2020 were included. Operative details including incision location and closure method were collected. Post-operative CT scans were assessed and correlated with clinic letters to determine presence of incisional hernia. Patients were excluded if they underwent re-operation through the midline within 12 months, or if had no imaging after 12 months. Results 118 patients were included. The incisional hernia rate was 31.4% at a mean follow-up of 24.9 months. Large bites closure (Hughes or loop PDS, n=80) had a higher incisional hernia rate compared to small bite closure ( n=38) (35.0% vs 23.6%). Incisional hernia rates were 44.1% in laparotomy incisions, 37.2% in midline extraction sites, 8% in Pfannensteil extraction sites and 0% in transverse extraction sites. Overall, IH rates in midline incisions were 40.7%, compared to 6.3% in off-midline incisions. Conclusions Incisional Hernia rates remain high following colorectal cancer surgery in our institution. Small bites closure and off-midline incisions appear to reduce this risk, but use of these techniques remains low. Work is ongoing to identify and implement strategies to improve uptake of small bites and off-midline incisions.

Open transversus abdominis release in incisional hernia repair: technical limits and solutions.

Incisional hernias with a defect width of more than10cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique. A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions. The standard PCSTAR can generally be used for a defect width of up to 15-17cm. For defects greater than 17cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0-97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. For a defect width greater than 17cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.

Inguinal hernia: Lichtenstein VS Shouldice technique repair: A randomized controlled trial

BackgroundInguinal hernia repair is the most frequent operation in general surgery. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27 % in men and 3 % in women. European Hernia Society guidelines state that the Lichtenstein technique (mesh-based repair) is the standard treatment of elective inguinal hernia in adults. Some authors consider the Shouldice technique (tissue-based repair) the best conventional method for open hernia repair. In this study, we compared these two methods. MethodsIn This randomized study, 452 patients were randomly allocated into 2 groups. 51 patients were lost during follow-up period and were excluded from further analysis in the study. Finally, the analyzed patients were 183 patients in Shouldice technique group and 218 patients in Lichtenstein technique group. All patients were examined after 1 week, 1, 3 months, 1, 2, and 3 years after the operation date. ResultsAfter 3 years follow up Recurrence of hernia in Shouldice technique group was 7.1 % and in Lichtenstein technique group was 3 % with significant differences (p-value 0.006). No statistically significant differences were found between the groups in wound infection, Seroma, hematoma, Hydrocele, Bladder damage, chronic pain in the inguinal region, and Patient Satisfaction level after surgery. ConclusionIt seems that inguinal hernia treatment by the Lichtenstein technique is better than the Shouldice technique in elective patients.

A postoperative body weight increase is a novel risk factor for incisional hernia of midline abdominal incision after elective gastroenterological surgery.

Midline abdominal incisions (MAIs) are widely used in both open and minimally invasive surgery. Incisional hernia (IH) accounts for most long-term postoperative wound complications. This study explored the risk factors for IH due to MAI in patients with clean-contaminated wounds after elective gastroenterological surgery. The present study targeted patients enrolled in 2 randomized controlled trials to evaluate the efficacy of intraoperative interventions for incisional SSI prevention after gastroenterological surgery for clean-contaminated wounds. The patients were reassessed, and pre- and intraoperative variables and postoperative outcomes were collected. IH was defined as any abdominal wall gap, regardless of bulge, in the area of a postoperative scar that was perceptible or palpable on clinical examination or computed tomography according to the European Hernia Society guidelines. The risk factors for IH were identified using univariate and multivariate analyses. The study population included 1,281 patients, of whom 273 (21.3%) developed IH. Seventy-four (5.8%) patients developed incisional SSI. Multivariate logistic regression analysis revealed that female sex (odds ratio [OR], 1.39; 95% confidence interval [CI] 1.03-1.86, p = 0.031), high preoperative body mass index (OR, 1.81; 95% CI 1.19-2.77, p = 0.006), incisional SSI (OR, 2.29; 95% CI 1.34-3.93, p = 0.003), and postoperative body weight increase (OR, 1.49; 95% CI 1.09-2.04, p = 0.012) were independent risk factors for IH due to MAI in patients who underwent elective gastroenterological surgery. We identified postoperative body weight increase at one year as a novel risk factor for IH in patients with MAI after elective gastroenterological surgery.

How often is prophylactic parastomal mesh placement performed after rectal resection without sphincter preservation? An analysis of German nationwide hospital discharge data among 41,697 patients

PurposeThe European Hernia Society guidelines of parastomal hernias, published in 2017, strongly recommend prophylactic synthetic non-absorbable mesh upon the construction of a permanent end colostomy to reduce the incidence of parastomal hernias. This study aims to evaluate the implementation of the guidelines in Germany.MethodsThis is a retrospective multicentric analysis conducted in December 2022 at the University Hospital Brandenburg an der Havel. Anonymous data on rectal resection without sphincter preservation in the period 2010–2020 were extracted from the German nationwide hospital discharge data set. Individuals with a hernia and < 18 years old were excluded. Another exclusion criterion was a performed colectomy or proctocolectomy with an ileoanal pouch and placement of an absorbable mesh. The primary endpoint was the annual rate of prophylactic parastomal mesh placement following rectal resection without sphincter preservation in Germany. Cases reporting both non-absorbable mesh placement and rectal resection without sphincter preservation were considered prophylactic mesh insertions.ResultsA total of 41,697 patients received a rectal resection without sphincter preservation and without non-absorbable mesh placement. Among these individuals, 27,089 were male and 14,608 were female. The rate of reoperations (3.1%) and the length of hospital stay (25.3 days ± 19.32) remained almost constant during these 10 years. The rate of prophylactic mesh placement was increasing from 0.2% (n = 8) in 2010 to 6.4% (n = 198) in 2020.ConclusionsCurrently, only the minority of patients who have undergone rectal resection without sphincter preservation receive prophylactic mesh insertion.

Clinical value of mesh prophylaxis for parastomal hernia based on evidence-based medicine

The incidence of parastomal hernia is substantially high, significantly affecting the quality of life of patients with stoma. How to effectively solve the problem of parastomal hernia is a long-term focus of hernia and abdominal wall surgery and colorectal surgery. The European Hernia Society guidelines on prevention and treatment of parastomal hernia published in 2018 has recommended the use of a prophylactic mesh to prevent parastomal hernia for the first time. In the following 5 years, more randomized controlled trials of multi-center, large-sample, double-blind, long-term follow-up have been published, and no significant effect of mesh prophylaxis has been observed on the incidence of parastomal hernia. However, whether mesh could decrease surgical intervention by limiting the symptoms of parastomal hernias would become a potential value of prophylaxis, which requires further research to elucidate.

EHS guidelines for inguinal hernia repair. The reality of the current situation in Spain. A proposal to standardize its implementation during surgical training

Laparoscopic inguinal hernia repairs are underused in our country and do not fulfil to the recommendations of the European Hernia Society (EHS) guidelines. Thus, it is essential to establish measures that increase its use. We propose that the Spanish Association of Surgeons (AEC) promote these actions and that they should be incorporated into the specialty program.The proposed measures include Standardization of learning; reinforce anatomical knowledge; regulated practices with simulators; promote the use of the open posterior approach; rotations through centers of excellence; accreditation of specialized units and use a registry of activity as quality control.

Guías de la EHS para el tratamiento de la hernia inguinal. La realidad de su uso en España. Una propuesta para estandarizar su implementación durante la residencia de cirugía general

Laparoscopic inguinal hernia repairs are underused in our country and do not fulfil to the recommendations of the European Hernia Society (EHS) guidelines. Thus, it is essential to establish measures that increase its use. We propose that the Spanish Association of Surgeons (AEC) promote these actions and that they should be incorporated into the specialty program.The proposed measures include standardization of learning; reinforce anatomical knowledge; regulated practices with simulators; promote the use of the open posterior approach; rotations through centers of excellence; accreditation of specialized units, and use a registry of activity as quality control.

Perspectives of prevention and treatment of parastomal hernia-what do we really know and where should we go?

Parastomal hernia is a frequent complication after ostomy formation, causing a significant reduction of the quality of life of patients. In contrast to surgical dogmas dealing with the surgical technique of ostomy formation, mesh-based prophylaxis of parastomal hernia seemed to be effective, leading to the strong recommendation in the European Hernia Society(EHS) guidelines. More recent studies do not favor prophylaxis of parastomal hernia anymore, mainly due to the lack of clearly differentiating the techniques. The mostly used keyhole technique (flat mesh) cannot be equated with the “chimney technique” (3-dimensional mesh) that can be easily performed laparoscopically. Very recent results of the Finnish Randomized Study showed a dramatic reduction of parastomal hernia using the chimney technique. Concerning therapy of parastomal hernia, the chimney technique was also revealed to be effective. The laparoscopic “sandwich technique” should also be used therapeutically with very promising mid- and long-term results and seems to be superior to any other approaches. In a conclusion, investigating the prevention of parastomal hernia should clearly differentiate between the keyhole and chimney techniques and adopt strict technical standardization. Therapy of parastomal hernia should be based on the most effective sandwich or the chimney technique in specialized centers, according to recent registry results. Both techniques are based on the intraperitoneal placement of meshes requiring 3-dimensionality or the possibility of overlapping two meshes. Up to now, these requirements are only fulfilled by meshes made by polyvinylidene fluoride.

OC-004 LIGNOCAINE INFILTRATION FOR LICHTENSTEIN REPAIR UNDER LOCAL ANESTHESIA: TECHNIQUE AND RESULTS

Abstract Background Lichtenstein inguinal hernia repair (LIHR) is the most commonly performed operation for inguinal hernia, even in developed nations. The European Hernia Society (EHS) guidelines recommend that local anesthesia (LA) should be considered an option in all patients undergoing LIHR. However, most patients still undergo this repair under general anesthesia (GA) or spinal anesthesia (SA). Even in a low resource area like North Ghana, only 37% patients had LIHR under LA. Specialty hernia clinics perform a majority of inguinal hernia repairs under LA. They have standardized their technique of administration of LA and the technique described by Amid et al. is simple, easily learnt, and works well in the hands of an average surgeon as well as a surgical trainee. However, not all surgeons are comfortable in performing this operation under LA. One possible reason for this is that the surgeon prefers a relaxed operating feld and he has heard stories of bad experiences with LA because of non-optimal technique of LA with unacceptable intensity of pain during LA. Aim To present a short video demonstrating the technique of infiltration of lignocaine for Lichtenstein repair under LA. Materials and methods Video. Results In our series of 30 patients, median intra-operative pain VAS was 2.5(0,5). 30% patients reported a VAS&amp;gt;3 during operation. All patients successfully underwent operation using LA. Conclusion LA should be strongly considered for all patients with unilateral inguinal hernia undergoing open repair.

WE5.3 Emergency laparoscopic “hybrid” IPOM+ repair of incarcerated umbilical hernia in patient with BMI 62 and small bowel obstruction; a case study

Abstract Background Large abdominal incisions in obese patients are associated with considerable rates of systemic and wound complications. Recently published European Hernia Society guidelines recommend laparoscopic intraperitoneal on-lay mesh (IPOM) repair for large hernia defects and patients at higher risk of wound morbidity, ideally with closure of the defect and a 5 cm overlap. Case Presentation: We report on a 69-year-old, morbidly obese (BMI 62), comorbid woman who presented as an emergency with a 5-day history of vomiting and abdominal pain. A pre-operative computed tomography (CT) scan confirmed small bowel obstruction secondary to a ventral abdominal wall hernia. Operative findings confirmed an obstructed paraumbilical hernia containing small bowel and omentum. A laparoscopic “hybrid” IPOM+ repair was performed, with a generous overlap. She recovered uneventfully with no surgical complications. Discussion: Minimally-invasive surgical techniques are preferred for obese patients with evidence suggesting lower perioperative complications and recurrence rates compared with open repair. However, additional challenges must be taken into consideration including; surgeon expertise, timing of operation, surgeon ergonomics, distortion of surface anatomical landmarks, need for higher pneumoperitoneum pressures and the physiological effects of this on the patient. Conclusion With preoperative planning, our case study demonstrates that IPOM ventral hernia repair remains a viable option for severely obese patients even in emergency presentations. The closure of the defect is recommended whenever feasible. Addition of the hybrid approach (excision of the sac with a limited incision after the laparoscopic closure) reduces the risk of postoperative seromas.

Author response to: European Hernia Society guidelines on management of rectus diastasis.

Author response to: European Hernia Society guidelines on management of rectus diastasis.

Laparoscopic treatment (reTAPP) for recurrence after laparoscopic inguinal hernia repair

For inguinal hernia recurrences, the European Hernia Society guidelines recommend laparo-endoscopic repair (LR) following a previous open surgery (OS) and, conversely, OS following previous laparo-endoscopic repair. Laparoscopic treatment of recurrences after previous LR is controversial. The purpose of this study was to determine the safety, feasibility, and reliability of a repeated transabdominal preperitoneal laparoscopic repair (reTAPP) for a recurrent hernia. We analyzed and compared a series of patients with recurrent inguinal hernia after LR who underwent repair by a conventional approach with similar patients who underwent reTAPP between January 2010 and December 2018. Between January 2010 and December 2018, 2488 transabdominal preperitoneal laparoscopic inguinal hernia (TAPP) repairs were performed. Recurrence was observed in 46 (1.8%). Of these patients, 18 (39%; Group 1; G1) underwent conventional open repair (Lichtenstein technique) and 28 (61%; Group 2; G2) reTAPP. In G2, repair was successful in 24 patients (86%); however, four cases (14%) needed conversion to OS because of technical difficulties. Two patients re-recurred (4.3%), one in G1 which was resolved in a third approach with a reTAPP and the other in G2 which was resolved with OS. ReTAPP surgery for recurrences after previous TAPP repair proved to be safe and was associated with a shorter length of hospital stay and morbidity and recurrence rates comparable to OS at a highly specialized center. Randomized studies with a larger number of cases are necessary to confirm these findings and draw more robust and objective conclusions.

Management of abdominal wound dehiscence: update of the literature and meta-analysis.

Abdominal wound dehiscence (AWD) is associated with significant morbidity and mortality. We aimed to provide a contemporary overview of management strategies for AWD. PubMed, EMBASE, the Cochrane library and a clinical trials registry were searched from 2009 onwards using the key words "abdominal wound dehiscence", "fascial dehiscence" and "burst abdomen". Study outcomes included surgical site infection (SSI), recurrence, incisional hernia and 30-day mortality. Studies reported by the EHS clinical guidelines on AWD were included and compared with. OpenMetaAnalyst was used for meta-analysis to calculate statistical significance and odds ratios (OR). Nineteenstudies were includedreporting on a total of 632 patients: 16 retrospective studies, one early terminated randomized controlled trial, one review and the European Hernia Society guidelines. Nine studies reported use of synthetic mesh (n = 241), two of which used vacuum-assisted mesh-mediated fascial traction (VAWCM) (n = 19), six without VAWCM (n = 198) and one used synthetic mesh with both VAWCM (n = 6) and without VAWCM (n = 18); two used biological mesh (n = 19). Seven studies reported primary suture closure (n = 299). Three studies reported on an alternative method (n = 91). Follow-up ranged between 1 and 96months. Meta-analysis was performed to compare the primary suture group with the synthetic mesh group. Heterogeneity was low to moderate depending on outcome. The overall SSI rate in the primary suture group was 27.6% versus 27.9% in the synthetic mesh group, resulting in mesh explantation in five patients; OR 0.65 (95% CI 0.23-1.81). Incisional hernia rates were 11.1% in the synthetic mesh group (19/171) and 30.7% in the primary suture group (67/218); OR 4.01 (95% CI 1.70-9.46). Recurrence rate did not show a statistically significant difference at 2.7% in the synthetic mesh group (3/112), compared to 10.2% in the primary suture group (21/206); OR 1.81 (95% CI 0.18-17.80). Mortality rates varied between 11.2% and 16.7% for primary suture group versus synthetic mesh; OR 1.85 (95% CI 0.91-3.76). Included studies were of low to very low quality. The use of synthetic mesh results in a significantly lower rate of incisional hernia, whereas SSI rate was comparable to primary suture repair.

Laparoscopic Repair of Primary and Secondary Epigastric Hernias. Technical Considerations of the IntraPeritoneal On Lay Mesh + Defect Closure (IPOM-Plus Technique)

We present our experiences with the laparoscopic repair of primary and secondary (incisional) epigastric hernias that occur in the vicinity of bony structures. In our institute, we retrospectively reviewed 51 patients with primary and secondary epigastric hernias from 2002 to 2016. The European Hernia Society guidelines were used for classifying these hernias. Laparoscopic dissection of the falciform ligament, intracorporeal suturing of the defect and intraperitoneal composite mesh onlay placement was performed in all patients. There were 32 males and 19 females with a mean age of 40 years and a mean BMI of 29.5kg/m2. There were multiple defects in eight patients (15.68%). The mean hernial defect size was 5.75 cm2 (range 3–8.5 cm2). The surface of the used mesh was ranging from 225–400 cm2 (mean 312.5 cm2). Mean follow-up was nine months. Morbidity rate was 11.7% and the recurrence rate was 1.9%. Upper abdominal hernias are difficult to manage laparoscopically because of the complexity of dissection and their anatomic proximity to the falciform ligament, xiphoid and costal margins. Multiple defects and associated hernias can also be easily identified and laparoscopically repaired simultaneously with the placement of a large mesh. The mesh borders can be adequately fixed beyond the bony confines via the laparoscopic approach, which would otherwise be impossible in the open technique. Laparoscopic repair of these hernias is safe and effective and provides all the benefits of minimally invasive surgery.

Desarda versus Lichenstein technique for primary inguinal hernia treatment: one year results of a randomised clinical trial

Background: The ideal operation to treat inguinal hernia is still far to define. The Shouldice method and other tissue-based techniques are still acknowledged to be acceptable for primary inguinal hernia repair according to European Hernia Society guidelines. Desarda’s technique, presented in 2001, is an original hernia repair method using an undetached strip of external oblique aponeurosis. This randomized trial compared outcomes after hernia repair with Desarda and mesh-based Lichtenstein techniques.Methods: A total of 42 participants (40 males and 2 females) were randomly assigned to the Desarda (group 1) and Lichtenstein (group 2), 19 vs 23 respectively. The primary outcomes measured were recurrence (for maximum follow up of 1 year and minimum of 5 months) and chronic pain. Additionally, operative time, early and late complications, foreign body sensation, and return to everyday activity were examined in hospital and at 7, 30 days, and 6, 12 months after surgery.Results: During the follow-up, one recurrence was observed in Desarda group after 10 months of surgery. Chronic pain was experienced by 10.5% and 8.7% of patients from groups Desarda and Lichtenstein respectively. Foreign body sensation and return to activity were comparable between the two groups. Operative time was less in Desarda group. There was significantly less seroma production in the Desarda group.Conclusions: The results of primary inguinal hernia repair with the Desarda and Lichtenstein techniques are comparable at the 1 year follow up. The technique may potentially increase the number of tissue-based methods available for treating groin hernias.

Study of non-mesh technique of Desarda for inguinal hernia

Background: The tissue based techniques are still acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda’s no mesh technique, introduced in 2001, is a hernia repair method using an undetached strip of external oblique aponeurosis. This study compares the results with the studies done worldwide on Desarda’s technique.Methods: A total 120 cases were studied for 2 years (2015-2017), the primary outcomes measured were postoperative pain scores on day 1,7,30 using visual analogue scale, time taken to return to basic activities, time measured from skin incision to skin closer. Complications like cord oedema, seroma, fever, surgical site infection, chronic groin pain and recurrence were evaluated.Results: After a 15-month mean follow up period, 01 (0.83%) case had a recurrence among 120 patients. Mean operative time is 60 min; mean pain score on day-1, 7, 30 are 3.35, 0.9 and 0.008 respectively. Mean time taken to return back to work is 24 hours; complications like chronic groin pain, foreign bodysensation are not seen in single cases. These results are comparable with the studies done worldwide.Conclusions: In Desarda’s technique of inguinal hernia repair does not use mesh, so no complication related with the foreign body are seen and postoperative pain is less, early return to basic activities and Postoperative complications are less.

Prophylactic antibiotic for open mesh repair of inguinal hernia; from principe to nécessité

PURPOSE: The use of prophylactic antibiotics (PAs) in open mesh repair (MR) of inguinal hernia (IH) is controversial. Clean surgeries do not require PA. However, prosthetic implants may require PA. As a part of quality improvement project, “guideline-based treatment for IH” where the European Hernia Society guidelines were adapted and PA was administered only if necessary, not as a routine for open MR of IH since May 1, 2015. The aim of this study was to assess the practice in the use of PA in open MR of IH and the outcome at a single surgical unit. METHODS: This is a retrospective analysis of health records of all the male patients who underwent open MR of IH at a single surgical center, during the period from May 1, 2015 to May 1, 2016, where it was considered not to administer PA routinely, but to only when required (de necessite). Data of patients who underwent open MR of IH during the period May 1, 2014–April 30, 2015, where PA was administered routinely (de principe) for open MR of IH, were collected for comparison. Demographic, immune-compromised status, operation techniques, PA, and surgical site infections data were analyzed. RESULTS: There were 62 and 78 male patients who underwent open MR of IH during PA de principe and PA de necessite periods, respectively. The mean ages were 38.32 (range 21–74) and 35.51 (range 21–70) years, respectively, during PA de principe and PA de necessite. There were no patients with immunocompromised status. PA usage has reduced from 96.8% (n = 60) during the PA de principe to 11.5% (n = 9) during PA de necessite period. Surgical site infection rate was 1.6% and 1.3%, respectively, during PA de principe and PA de necessite periods. CONCLUSION: In a low-risk environment, open MR of IH can be carried out without PA in a majority of patients.

Interpretation of 2017 European Hernia Society Guidelines for The Prevention and Treatment of Parastomal Hernias

European Hernia Society issued a guideline for the prevention and treatment of parastomal hernias in 2017, which is the first international guideline for the parastomal hernia. This guideline proposed 12 problems about incidence, diagnosis and treatment, and discussed these problems in depth. The main contents of this guideline are summarized as follows: (1) End colostomy is associated with a higher incidence of parastomal hernia compared to other types of stomas. (2) Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. (3) The use of the European Hernia Society classification for uniform research reporting is recommended. (4) There is insufficient evidence on the policy in watchful waiting. (5) There is insufficient evidence on the route and location of stoma construction, and the size of the aperture. (6) The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present.(7) It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. (8) So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, most data in this guideline were retrospective without high level evidence. A lot of questions remain controversial and more high-level evidence are expected to solve these problems.