Tech Coloproctol (2014) 18:427–432 DOI 10.1007/s10151-013-1110-z
REVIEW
Systematic review of open techniques for parastomal hernia repair J. Al Shakarchi • J. G. Williams
Received: 17 October 2013 / Accepted: 16 December 2013 / Published online: 22 January 2014 Ó Springer-Verlag Italia 2014
Abstract 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 J. Al Shakarchi Department of Surgery, Sandwell Hospital, West Bromwich, UK J. Al Shakarchi (&) Apartment 273 Hemisphere, 18 Edgbaston Crescent, Birmingham B5 7RJ, UK e-mail: [email protected] J. G. Williams Department of Colorectal Surgery, New Cross Hospital, Wolverhampton, UK
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. Keywords
Parastomal Hernia Repair Mesh
Introduction A parastomal hernia is an incisional hernia related to an abdominal stoma. The reported incidence of hernias varies depending on the type of stoma and size of the aperture in the abdominal wall. The incidence of parastomal hernia is higher for colostomies than ileostomies, with rates as high as 48.1 % reported [1]. Most patients who develop a parastomal hernia will be asymptomatic. However, patients can complain of difficulty fitting a stoma appliance, abdominal discomfort, swelling and unsightly bulge at the site of the stoma. Another consequence of a parastomal hernia is an increased risk of stoma prolapse, making stoma management difficult and often requiring surgical correction. The risks of an untreated parastomal hernia include incarceration, obstruction and strangulation, which can all lead to significant morbidity and mortality when emergency surgery is required [2]. Current treatment options include non-operative management, stoma relocation and repair of the enlarged fascial defect, with or without mesh. There are currently three types of mesh fascial repair determined by the level in the abdominal wall where the mesh is placed. Onlay repair places the mesh subcutaneously, fixed on top of the fascia of
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the anterior rectus sheath. Sublay mesh technique places the mesh between the rectus abdominis muscle and posterior rectus sheath. The underlay technique places the mesh intraabdominally, fixed to the peritoneum, with the stoma emerging through the mesh or laterally to the mesh (Sugarbaker technique). In asymptomatic patients, a conservative approach tends to be the preferred. This is because surgical repair can be challenging, with no guarantee of success. Where surgery is required, there is no clear guidance as to which surgical technique is the most effective. The purpose of this systematic review was to evaluate open mesh repair and to compare it with open non-mesh sutured fascial repair of parastomal hernias in terms of recurrence rates as well as morbidity and mortality. Laparoscopic approaches and the use of biological meshes were not considered as they are relatively new, and the literature contains fewer studies with small numbers of patients. Furthermore, not all parastomal hernias are suitable for a laparoscopic approach.
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extracted included primary and secondary outcomes as well as year of publication, number of patients included, surgical technique and duration of follow-up. The primary outcome of this study was recurrence rate of the parastomal hernia. Secondary outcomes included mortality, wound infection, mesh infection and any other complication. Patients who underwent each different technique were grouped together accordingly. Statistical analysis Rates of hernia recurrence, wound infection, mesh infection and mortality were calculated for each subgroup, with 95 % confidence intervals (CI) using the method of Clopper and Pearson [4]. Weighted pooled proportions were calculated for the primary and secondary outcomes for each different surgical technique.
Results Materials and methods Search methodology for identification of relevant studies Searches of Pubmed, Medline and the Cochrane Library (January 1950–January 2013) were performed using the following specific search terms as well as a combination of Parastomal, Ileostomy, Colostomy, Hernia, Repair, Defect, Mesh and Fascia, as well as a combination of them, to identify articles in English, dealing primarily with the treatment of parastomal hernia. In addition, the references cited in selected articles were reviewed for any further relevant available studies. All studies of open fascial repair of parastomal hernias were eligible for inclusion. Data were extracted to form two subgroups: open mesh repairs and open non-mesh repairs. Case reports and studies without an abstract were excluded. Articles that assessed laparoscopic techniques or stoma relocation were also excluded as well as any studies looking into the prophylactic placement of a mesh at stoma formation. Due to its novelty, studies assessing the use of biological meshes were also excluded. The systematic review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) [3]. Therefore, all included studies were assessed for inclusion on the basis of their topic, type of study, method, number of patients included and statistical analysis. Primary and secondary outcomes All studies that met the set criteria were thoroughly reviewed and assessed for methodological quality. Data
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Two hundred and eighteen relevant articles and abstracts were identified. After screening the contents of the abstract, 62 full-text articles underwent assessment for eligibility and quality inspection of methodology. Following this, there were 27 articles eligible for the review (Fig. 1). These articles were grouped according to the type of repair performed: fascial suture technique, onlay mesh repair, sublay mesh repair and underlay mesh repair. Non-mesh fascial suture repair One hundred and forty-one repairs, from seven eligible studies, were included in the calculation, and the results are summarised in Table 1. Four patients (2.8 %) died during the post-operative period. Available morbidity data showed a wound infection rate of 9.4 % whilst other complications were reported in 14.1 % of patients. The pooled rate of parastomal hernia recurrence was 57.6 % (range 48.4–66.4 %) after a mean follow-up of 30 months (range 7–65 months). Mesh fascial repair Three types of mesh fascial repair were identified, determined by the level in the abdominal wall that the mesh was placed. Onlay repair places the mesh subcutaneously, fixed on top of the fascia of the anterior rectus sheath. Sublay mesh technique places the mesh between the rectus abdominis muscle and posterior rectus sheath. The underlay technique (both Sugarbaker technique and ‘keyhole’) places the mesh intra-abdominally, fixed to the peritoneum with the stoma either passing under the lateral edge of the mesh or through a pre-cut defect in the mesh.
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Fig. 1 Flow chart showing studies of parastomal hernia repair
Table 1 Study characteristics and outcomes of non-mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Other complications n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection
Rubin [5]
36
5 (13.8)
2 (5.6)
0 (0)
29 (80.6)
31
NS
Cheung [6] Rieger [7]
16 14
0 (0) 4 (28.6)
5 (31.3) 3 (21.4)
3 (18.8) 1 (7.1)
6 (37.5) 7 (50)
38 7
NS NS
Riansuwan [8]
27
2 (7.4)
0 (0)
0 (0)
20 (74.1)
23
C
Pastor [9]
13
NS
NS
0 (0)
7 (53.8)
14
NS
Heo [10]
19
1 (5.3)
3 (15.8)
0 (0)
3 (15.8)
30
NS C
Mclemore [11] Weighted pooled % (95 % CI)
16 141
0 (0)
5 (31.2)
0 (0)
NS
65
9.4 (4.9–15.8)
14.1 (8.6–21.3)
2.8 (0.8–7.1)
57.6 (48.4–66.4)
30a
NS not specified, C clinical, CT CT scan, CI confidence interval, N number a
Mean F/U
Onlay mesh repair Thirteen studies, with a total of 216 parastomal hernia repairs, were eligible for inclusion. The results are summarised in Table 2. All patients undergoing an onlay mesh parastomal hernia repair were pooled. The rate of parastomal hernia recurrence was 14.8 % (range 10.2–20.4 %) after a mean follow-up of 40 months (range 7–65 months). Available morbidity data revealed a wound infection rate of 1.9 % and a mesh infection rate of 1.9 %, whilst other
complications were reported in 11.1 % of patients. There were no deaths reported in this cohort of patients. Sublay mesh repair Four studies with a total of 76 parastomal hernia repairs were eligible for inclusion. The results are summarised in Table 3. The rate of parastomal hernia recurrence was 7.9 % (range 3–16.4 %) after a mean follow-up of 24 months (range 12–32 months). Available morbidity
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Tech Coloproctol (2014) 18:427–432
Table 2 Study characteristics and outcomes of onlay mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Mesh infection n (%)
Other complication n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection NS
Ho [12]
15
0 (0)
0 (0)
2 (13.3)
0 (0)
1 (6.7)
15
De Ruiter [13]
46
0 (0)
3 (6.5)
1 (2.2)
0 (0)
7 (15.2)
51
C
Steele [14] Venditti [15]
58 8
2 (3.4) 1 (12.5)
0 (0) 0 (0)
9 (15.5) 0 (0)
0 (0) 0 (0)
15 (25.9) 0 (0)
51 38
C NS
Luning [16]
16
0 (0)
1 (6.3)
1 (6.3)
0 (0)
3 (18.8)
33
NS
9
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
7
NS
Amin [17] Kald [18]
5
0 (0)
0 (0)
0 (0)
0 (0)
1 (20)
12
NS
Heo [10]
19
0 (0)
0 (0)
3 (15.8)
0 (0)
2 (10.5)
30
NS
Sacclarides [19]
10
0 (0)
0 (0)
4 (40)
0 (0)
1 (10)
NS
NS
Gurita [20]
6
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
24
C
Franks [21]
6
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
26
CT
1 (7.7)
0 (0)
3 (23.1)
0 (0)
NS
65
C
0 (0)
0 (0)
1 (20)
0 (0)
0 (0)
21
NS
1.9 (0.5–4.7)
1.9 (0.5–4.7)
11.1 (7.3–16.1)
0 (0–1.7)
14.8 (10.2–20.4)
40a
Mclemore [11] Tekkis [22] Weighted pooled % (95 % CI)
13 5 216
NS not specified, C clinical, CT CT scan, CI confidence interval, N number a
Mean F/U
Table 3 Study characteristics and outcomes of sublay mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Mesh infection n (%)
Other complications n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection
Kasperk [23]
7
0 (0)
0 (0)
0 (0)
0 (0)
2 (28.6)
NS
NS
Longman [24]
10
0 (0)
0 (0)
1 (10)
0 (0)
0 (0)
30
C
Guzman [25]
25
2 (8)
0 (0)
2 (8)
0 (0)
2 (8)
12
C
Liu [26]
34
1 (2.9)
0 (0)
8 (23.5)
0 (0)
2 (5.9)
32
NS
Weighted pooled % (95 % CI)
76
3.9 (0.8–11.1)
0 (0–4.7)
14.5 (7.5–24.4)
0 (0–4.7)
7.9 (3–16.4)
24a
NS not specified, C clinical, CT CT scan, CI confidence interval, N number a Mean F/U
data revealed a wound infection rate of 3.9 % whilst other minor complications were reported in 14.5 % of patients. There was no reported mesh-related infection in any of the included studies. There were no deaths reported in this group of patients.
complications were reported in 15.4 % of patients. There were no deaths reported in any study.
Underlay mesh repair
Many papers have been published on parastomal hernia repair. Despite this, no firm conclusions can be drawn as to which technique is the best for repairing the fascial defect to eradicate a parastomal hernia. The oldest technique is a simple, sutured repair of the fascial defect around the emerging bowel. However, the present study confirms that this technique is associated with a very high recurrence rate (over 50 %). This is likely to be a consequence of the repair being carried out under tension, using already
Five studies with a total of 65 parastomal hernia repairs were eligible for inclusion. The results are summarised in Table 4. The rate of parastomal hernia recurrence was 9.2 % (range 3.5–19.0 %) after a mean follow-up of 38 months (range 13–78 months). Available morbidity data showed a wound infection rate of 3.1 % and a meshrelated infection rate of 1.5 %, whilst other minor
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Discussion
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Table 4 Study characteristics and outcomes of underlay mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Mesh infection n (%)
Other complication n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection
Byers [27]
9
1 (11.1)
0 (0)
0 (0)
0 (0)
0 (0)
13
NS
Morris-Stiff [28]
7
0 (0)
1 (14.3)
3 (42.9)
0 (0)
2 (28.6)
78
NS
Hofstetter [29] Van Sprundel [30]
13 16
0 (0) 0 (0)
0 (0) 0 (0)
0 (0) 5 (31.3)
0 (0) 0 (0)
0 (0) 1 (6.3)
NS 28
NS C
Stelzner [31]
20
1 (5)
0 (0)
2 (10)
0 (0)
3 (15)
42
C
Weighted pooled % (95 % CI)
65
3.1 (0.4–10.7)
1.5 (0–8.3)
15.4 (7.6–26.5)
0 (0–5.5)
9.2 (3.5–19)
38a
NS not specified, C Clinical, CT CT scan, CI confidence interval, N number a
Mean F/U
weakened tissues. Therefore, the sutured fascial repair of parastomal hernias should be performed only in exceptional circumstances, because of the significantly high recurrence rate compared with mesh repairs. The introduction of synthetic mesh has enabled tensionfree repair of parastomal hernias to be performed by a number of different techniques. Synthetic mesh provides initial reinforcement of the abdominal wall with subsequent ingrowth of fibrous tissue into the interstices of the mesh. Mesh can be placed in several different planes in the abdominal wall. The advantage of the on-lay technique is that it avoids laparotomy. The sublay mesh technique and underlay technique position the mesh on the high-pressure side of the abdominal wall and in theory should be more effective in preventing recurrent parastomal hernia formation, although laparotomy is required for both techniques and the underlay technique has been shown to have the added complication of adhesions between the mesh and the bowel [27]. The use of mesh around bowel has the added risk of mesh infection and fistula formation. Despite the theoretical advantages and disadvantages of each method of mesh repair, our study does not indicate that there is an appreciable difference in recurrence or complication rates between these techniques. The heterogeneity of the literature available on parastomal hernia repair makes it difficult to draw firm conclusions regarding optimal surgical management. The majority of reports are retrospective reviews of small series of patients, with variable follow-up. There are no randomised trials comparing one technique to another, and selection of the operation performed is usually based on surgeon preference and fashion. Our analysis of the results of the different mesh techniques does not show a significant difference in terms of recurrence rates of parastomal hernia or complication rates. To date, there have been no randomised clinical trials published to compare different techniques of repairing a parastomal hernia. In the absence
of properly controlled randomised trials, a number of factors should be considered when assessing the published series. The patients included in the published series differ in type of stoma included and indication for initial surgery. A number of factors are known to influence the risk of recurrent hernia formation, such as age, American Society of Anesthesiologists (ASA) score, body mass index, chest disease, malnutrition and smoking [1] and these vary from series to series. Furthermore, most series provide little detail on these risk factors for recurrence, making comparison of outcomes even more difficult. In addition, not all the studies have stated clearly how recurrent hernia formation was defined or detected. Clinical examination is simple, but detecting a small hernia can be difficult, especially in an obese patient. Computed tomography (CT) scanning of the abdominal wall is regarded as the ‘gold standard’, and it has been established that there is a poor correlation between clinical examination and radiological findings [32] when assessing for parastomal hernia formation. Length of follow-up, which affects the recurrence rate, varies from study to study. Finally, definitions of surgical site infection and mesh infection are not usually clearly stated.
Conclusions The quality of the available literature for parastomal hernia repair is poor, and therefore it is difficult to draw robust conclusions as to the best technique of repair. Open nonmesh fascial repair is associated with a higher recurrence rate than open mesh repairs and should be used in specific situations where mesh is contraindicated. There is not enough evidence available to determine which mesh technique (onlay, sublay or underlay) has the best outcome. The reported rate of mesh infection is low and should not preclude the use of mesh in parastomal hernia repairs.
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432 Conflict of interest
Tech Coloproctol (2014) 18:427–432 None.
References 1. Carne PW, Robertson GM, Frizelle FA (2003) Parastomal hernia. Br J Surg 90:784–793 2. Thompson MJ, Trainor B (2005) Incidence of parastomal hernia before and after a prevention programme. Gastrointest Nurs 3:23–27 3. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. PLoS Med 6:e1000097 4. Clopper CJ, Pearson ES (1934) The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 26:404–413 5. Rubin MS, Schoetz DJ, Matthews JB (1994) Parastomal hernia. Is stoma relocation superior to fascial repair? Arch Surg 129:413–419 6. Cheung MT, Chia NH, Chiu WY (2001) Surgical treatment of parastomal hernia complicating sigmoid colostomies. Dis Colon Rectum 44:266–270 7. Rieger N, Moore J, Hewett P, Lee S, Stephens J (2004) Parastomal hernia repair. Colorectal Dis 6:203–205 8. Riansuwan W, Hull TL, Millan MM et al (2010) Surgery of recurrent parastomal hernia: direct repair or relocation? Colorectal Dis 12:681–686 9. Pastor DM, Pauli EM, Koltun WA et al (2009) Parastomal hernia repair: a single center experience. JSLS 13:170–175 10. Heo SC, Oh KH, Song YS et al (2011) Surgical treatment of a parastomal hernia. J Korean Soc Coloproctol 27:174–179 11. McLemore EC, Harold KL, Efron JE et al (2007) Parastomal Hernia: short term outcome after laparoscopic and conventional repairs. Surg Innov 14:199 12. Ho KMT, Fawcett DP (2004) Parastomal hernia repair using the lateral approach. BJU Int 94:598–602 13. De Ruiter P, Bijnen AB (2005) Ring-reinforced prosthesis for paracolostomy hernia. Dig Surg 22:152–156 14. Steele SR, Lee P, Martin MJ, Mullenix PJ, Sullivan ES (2003) Is parastomal hernia repair with polypropylene mesh safe? Am J Surg 185:436–440 15. Venditti D, Gargiani M, Milito G (2001) Parastomal hernia surgery: personal experience with use of polypropylene mesh. Tech Coloproctol 5:85–88 16. Luning TH, Spillenaar-Bilgen EJ (2009) Parastomal hernia: complications of extra-peritoneal onlay mesh placement. Hernia 13:487–490
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17. Amin SN, Armitage NC, Abercrombie JF et al (2001) Lateral repair of parastomal hernia. Ann R Coll Surg Engl 83:206–208 18. Kald A, Landin S, Masreliez C, Sjo¨dahl R (2001) Mesh repair of parastomal hernias: new aspects of the onlay technique. Tech Coloproctol 5:169–171 19. Saclarides TJ, Hsu A, Quiros R (2004) In situ mesh repair of parastomal hernias. Am Surg 70:701–705 20. Gurita P, Popa R, Ba˘la˘la˘u B, Sca˘unas¸ u R (2012) Parastomal hernia mesh repair, variant of surgical technique without stoma relocation. J Med Life 5:157–161 21. Franks ME, Hrebinko RL (2001) Technique of parastomal hernia repair using synthetic mesh. Urology 57:551–553 22. Tekkis PP, Kocher HM, Payne JG (1999) Parastomal hernia repair: modified Thorlakson technique, reinforced by polypropylene mesh. Dis Colon Rectum 42:1505–1508 23. Kasperk R, Klinge U, Schumpelick V (2000) The repair of large parastomal hernias using a midline approach and a prosthetic mesh in the sublay position. Am J Surg 179:186–188 24. Longman RJ, Thompson WH (2005) Mesh repair of parastomal hernias—a safety modification. Colorectal Dis 7:292–294 25. Guzman-Valdivia G, Guerrero TS, Laurrabaquio HV (2008) Parastomal hernia repair using mesh and an open technique. World J Surg 32:465–470 26. Liu F, Jiye L, Yao S, Zhu Y, Yao J (2010) In situ repair of parastomal hernia with sublay methods in 34 cases. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 24:933–936 27. Byers JM, Steinberg JB, Postier RG (1992) Repair of parastomal hernias using polypropylene mesh. Arch Surg 127:1246–1247 28. Morris-Stiff G, Hughes LE (1998) The continuing challenge of parastomal hernia: failure of a novel polypropylene mesh repair. Ann R Coll Surg Engl 80:184–187 29. Hofstetter WL, Vukasin P, Ortega AE et al (1998) New technique for mesh repair of paracolostomy hernias. Dis Colon Rectum 41:1054–1055 30. Van Sprundel TC, Gerritsen van der Hoop A (2005) Modified technique for parastomal hernia repair in patients with intractable stoma care problems. Colorectal Dis 7:445–449 31. Stelzner S, Hellmich G, Ludwig K (2004) Repair of paracolostomy hernias with a prosthetic mesh in the intraperitoneal onlay position: modified Sugarbaker technique. Dis Colon Rectum 47:185–191 32. Janes A, Weisby L, Israelsson LA (2011) Parastomal hernia: clinical and radiological definitions. Hernia 15:189–192
REVIEW
Systematic review of open techniques for parastomal hernia repair J. Al Shakarchi • J. G. Williams
Received: 17 October 2013 / Accepted: 16 December 2013 / Published online: 22 January 2014 Ó Springer-Verlag Italia 2014
Abstract 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 J. Al Shakarchi Department of Surgery, Sandwell Hospital, West Bromwich, UK J. Al Shakarchi (&) Apartment 273 Hemisphere, 18 Edgbaston Crescent, Birmingham B5 7RJ, UK e-mail: [email protected] J. G. Williams Department of Colorectal Surgery, New Cross Hospital, Wolverhampton, UK
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. Keywords
Parastomal Hernia Repair Mesh
Introduction A parastomal hernia is an incisional hernia related to an abdominal stoma. The reported incidence of hernias varies depending on the type of stoma and size of the aperture in the abdominal wall. The incidence of parastomal hernia is higher for colostomies than ileostomies, with rates as high as 48.1 % reported [1]. Most patients who develop a parastomal hernia will be asymptomatic. However, patients can complain of difficulty fitting a stoma appliance, abdominal discomfort, swelling and unsightly bulge at the site of the stoma. Another consequence of a parastomal hernia is an increased risk of stoma prolapse, making stoma management difficult and often requiring surgical correction. The risks of an untreated parastomal hernia include incarceration, obstruction and strangulation, which can all lead to significant morbidity and mortality when emergency surgery is required [2]. Current treatment options include non-operative management, stoma relocation and repair of the enlarged fascial defect, with or without mesh. There are currently three types of mesh fascial repair determined by the level in the abdominal wall where the mesh is placed. Onlay repair places the mesh subcutaneously, fixed on top of the fascia of
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the anterior rectus sheath. Sublay mesh technique places the mesh between the rectus abdominis muscle and posterior rectus sheath. The underlay technique places the mesh intraabdominally, fixed to the peritoneum, with the stoma emerging through the mesh or laterally to the mesh (Sugarbaker technique). In asymptomatic patients, a conservative approach tends to be the preferred. This is because surgical repair can be challenging, with no guarantee of success. Where surgery is required, there is no clear guidance as to which surgical technique is the most effective. The purpose of this systematic review was to evaluate open mesh repair and to compare it with open non-mesh sutured fascial repair of parastomal hernias in terms of recurrence rates as well as morbidity and mortality. Laparoscopic approaches and the use of biological meshes were not considered as they are relatively new, and the literature contains fewer studies with small numbers of patients. Furthermore, not all parastomal hernias are suitable for a laparoscopic approach.
Tech Coloproctol (2014) 18:427–432
extracted included primary and secondary outcomes as well as year of publication, number of patients included, surgical technique and duration of follow-up. The primary outcome of this study was recurrence rate of the parastomal hernia. Secondary outcomes included mortality, wound infection, mesh infection and any other complication. Patients who underwent each different technique were grouped together accordingly. Statistical analysis Rates of hernia recurrence, wound infection, mesh infection and mortality were calculated for each subgroup, with 95 % confidence intervals (CI) using the method of Clopper and Pearson [4]. Weighted pooled proportions were calculated for the primary and secondary outcomes for each different surgical technique.
Results Materials and methods Search methodology for identification of relevant studies Searches of Pubmed, Medline and the Cochrane Library (January 1950–January 2013) were performed using the following specific search terms as well as a combination of Parastomal, Ileostomy, Colostomy, Hernia, Repair, Defect, Mesh and Fascia, as well as a combination of them, to identify articles in English, dealing primarily with the treatment of parastomal hernia. In addition, the references cited in selected articles were reviewed for any further relevant available studies. All studies of open fascial repair of parastomal hernias were eligible for inclusion. Data were extracted to form two subgroups: open mesh repairs and open non-mesh repairs. Case reports and studies without an abstract were excluded. Articles that assessed laparoscopic techniques or stoma relocation were also excluded as well as any studies looking into the prophylactic placement of a mesh at stoma formation. Due to its novelty, studies assessing the use of biological meshes were also excluded. The systematic review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) [3]. Therefore, all included studies were assessed for inclusion on the basis of their topic, type of study, method, number of patients included and statistical analysis. Primary and secondary outcomes All studies that met the set criteria were thoroughly reviewed and assessed for methodological quality. Data
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Two hundred and eighteen relevant articles and abstracts were identified. After screening the contents of the abstract, 62 full-text articles underwent assessment for eligibility and quality inspection of methodology. Following this, there were 27 articles eligible for the review (Fig. 1). These articles were grouped according to the type of repair performed: fascial suture technique, onlay mesh repair, sublay mesh repair and underlay mesh repair. Non-mesh fascial suture repair One hundred and forty-one repairs, from seven eligible studies, were included in the calculation, and the results are summarised in Table 1. Four patients (2.8 %) died during the post-operative period. Available morbidity data showed a wound infection rate of 9.4 % whilst other complications were reported in 14.1 % of patients. The pooled rate of parastomal hernia recurrence was 57.6 % (range 48.4–66.4 %) after a mean follow-up of 30 months (range 7–65 months). Mesh fascial repair Three types of mesh fascial repair were identified, determined by the level in the abdominal wall that the mesh was placed. Onlay repair places the mesh subcutaneously, fixed on top of the fascia of the anterior rectus sheath. Sublay mesh technique places the mesh between the rectus abdominis muscle and posterior rectus sheath. The underlay technique (both Sugarbaker technique and ‘keyhole’) places the mesh intra-abdominally, fixed to the peritoneum with the stoma either passing under the lateral edge of the mesh or through a pre-cut defect in the mesh.
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429
Fig. 1 Flow chart showing studies of parastomal hernia repair
Table 1 Study characteristics and outcomes of non-mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Other complications n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection
Rubin [5]
36
5 (13.8)
2 (5.6)
0 (0)
29 (80.6)
31
NS
Cheung [6] Rieger [7]
16 14
0 (0) 4 (28.6)
5 (31.3) 3 (21.4)
3 (18.8) 1 (7.1)
6 (37.5) 7 (50)
38 7
NS NS
Riansuwan [8]
27
2 (7.4)
0 (0)
0 (0)
20 (74.1)
23
C
Pastor [9]
13
NS
NS
0 (0)
7 (53.8)
14
NS
Heo [10]
19
1 (5.3)
3 (15.8)
0 (0)
3 (15.8)
30
NS C
Mclemore [11] Weighted pooled % (95 % CI)
16 141
0 (0)
5 (31.2)
0 (0)
NS
65
9.4 (4.9–15.8)
14.1 (8.6–21.3)
2.8 (0.8–7.1)
57.6 (48.4–66.4)
30a
NS not specified, C clinical, CT CT scan, CI confidence interval, N number a
Mean F/U
Onlay mesh repair Thirteen studies, with a total of 216 parastomal hernia repairs, were eligible for inclusion. The results are summarised in Table 2. All patients undergoing an onlay mesh parastomal hernia repair were pooled. The rate of parastomal hernia recurrence was 14.8 % (range 10.2–20.4 %) after a mean follow-up of 40 months (range 7–65 months). Available morbidity data revealed a wound infection rate of 1.9 % and a mesh infection rate of 1.9 %, whilst other
complications were reported in 11.1 % of patients. There were no deaths reported in this cohort of patients. Sublay mesh repair Four studies with a total of 76 parastomal hernia repairs were eligible for inclusion. The results are summarised in Table 3. The rate of parastomal hernia recurrence was 7.9 % (range 3–16.4 %) after a mean follow-up of 24 months (range 12–32 months). Available morbidity
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Table 2 Study characteristics and outcomes of onlay mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Mesh infection n (%)
Other complication n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection NS
Ho [12]
15
0 (0)
0 (0)
2 (13.3)
0 (0)
1 (6.7)
15
De Ruiter [13]
46
0 (0)
3 (6.5)
1 (2.2)
0 (0)
7 (15.2)
51
C
Steele [14] Venditti [15]
58 8
2 (3.4) 1 (12.5)
0 (0) 0 (0)
9 (15.5) 0 (0)
0 (0) 0 (0)
15 (25.9) 0 (0)
51 38
C NS
Luning [16]
16
0 (0)
1 (6.3)
1 (6.3)
0 (0)
3 (18.8)
33
NS
9
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
7
NS
Amin [17] Kald [18]
5
0 (0)
0 (0)
0 (0)
0 (0)
1 (20)
12
NS
Heo [10]
19
0 (0)
0 (0)
3 (15.8)
0 (0)
2 (10.5)
30
NS
Sacclarides [19]
10
0 (0)
0 (0)
4 (40)
0 (0)
1 (10)
NS
NS
Gurita [20]
6
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
24
C
Franks [21]
6
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
26
CT
1 (7.7)
0 (0)
3 (23.1)
0 (0)
NS
65
C
0 (0)
0 (0)
1 (20)
0 (0)
0 (0)
21
NS
1.9 (0.5–4.7)
1.9 (0.5–4.7)
11.1 (7.3–16.1)
0 (0–1.7)
14.8 (10.2–20.4)
40a
Mclemore [11] Tekkis [22] Weighted pooled % (95 % CI)
13 5 216
NS not specified, C clinical, CT CT scan, CI confidence interval, N number a
Mean F/U
Table 3 Study characteristics and outcomes of sublay mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Mesh infection n (%)
Other complications n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection
Kasperk [23]
7
0 (0)
0 (0)
0 (0)
0 (0)
2 (28.6)
NS
NS
Longman [24]
10
0 (0)
0 (0)
1 (10)
0 (0)
0 (0)
30
C
Guzman [25]
25
2 (8)
0 (0)
2 (8)
0 (0)
2 (8)
12
C
Liu [26]
34
1 (2.9)
0 (0)
8 (23.5)
0 (0)
2 (5.9)
32
NS
Weighted pooled % (95 % CI)
76
3.9 (0.8–11.1)
0 (0–4.7)
14.5 (7.5–24.4)
0 (0–4.7)
7.9 (3–16.4)
24a
NS not specified, C clinical, CT CT scan, CI confidence interval, N number a Mean F/U
data revealed a wound infection rate of 3.9 % whilst other minor complications were reported in 14.5 % of patients. There was no reported mesh-related infection in any of the included studies. There were no deaths reported in this group of patients.
complications were reported in 15.4 % of patients. There were no deaths reported in any study.
Underlay mesh repair
Many papers have been published on parastomal hernia repair. Despite this, no firm conclusions can be drawn as to which technique is the best for repairing the fascial defect to eradicate a parastomal hernia. The oldest technique is a simple, sutured repair of the fascial defect around the emerging bowel. However, the present study confirms that this technique is associated with a very high recurrence rate (over 50 %). This is likely to be a consequence of the repair being carried out under tension, using already
Five studies with a total of 65 parastomal hernia repairs were eligible for inclusion. The results are summarised in Table 4. The rate of parastomal hernia recurrence was 9.2 % (range 3.5–19.0 %) after a mean follow-up of 38 months (range 13–78 months). Available morbidity data showed a wound infection rate of 3.1 % and a meshrelated infection rate of 1.5 %, whilst other minor
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Discussion
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Table 4 Study characteristics and outcomes of underlay mesh fascial repair of parastomal hernia References
No of repairs
Infection n (%)
Mesh infection n (%)
Other complication n (%)
Mortality n (%)
Recurrence n (%)
Follow-up (months)
Method of recurrence detection
Byers [27]
9
1 (11.1)
0 (0)
0 (0)
0 (0)
0 (0)
13
NS
Morris-Stiff [28]
7
0 (0)
1 (14.3)
3 (42.9)
0 (0)
2 (28.6)
78
NS
Hofstetter [29] Van Sprundel [30]
13 16
0 (0) 0 (0)
0 (0) 0 (0)
0 (0) 5 (31.3)
0 (0) 0 (0)
0 (0) 1 (6.3)
NS 28
NS C
Stelzner [31]
20
1 (5)
0 (0)
2 (10)
0 (0)
3 (15)
42
C
Weighted pooled % (95 % CI)
65
3.1 (0.4–10.7)
1.5 (0–8.3)
15.4 (7.6–26.5)
0 (0–5.5)
9.2 (3.5–19)
38a
NS not specified, C Clinical, CT CT scan, CI confidence interval, N number a
Mean F/U
weakened tissues. Therefore, the sutured fascial repair of parastomal hernias should be performed only in exceptional circumstances, because of the significantly high recurrence rate compared with mesh repairs. The introduction of synthetic mesh has enabled tensionfree repair of parastomal hernias to be performed by a number of different techniques. Synthetic mesh provides initial reinforcement of the abdominal wall with subsequent ingrowth of fibrous tissue into the interstices of the mesh. Mesh can be placed in several different planes in the abdominal wall. The advantage of the on-lay technique is that it avoids laparotomy. The sublay mesh technique and underlay technique position the mesh on the high-pressure side of the abdominal wall and in theory should be more effective in preventing recurrent parastomal hernia formation, although laparotomy is required for both techniques and the underlay technique has been shown to have the added complication of adhesions between the mesh and the bowel [27]. The use of mesh around bowel has the added risk of mesh infection and fistula formation. Despite the theoretical advantages and disadvantages of each method of mesh repair, our study does not indicate that there is an appreciable difference in recurrence or complication rates between these techniques. The heterogeneity of the literature available on parastomal hernia repair makes it difficult to draw firm conclusions regarding optimal surgical management. The majority of reports are retrospective reviews of small series of patients, with variable follow-up. There are no randomised trials comparing one technique to another, and selection of the operation performed is usually based on surgeon preference and fashion. Our analysis of the results of the different mesh techniques does not show a significant difference in terms of recurrence rates of parastomal hernia or complication rates. To date, there have been no randomised clinical trials published to compare different techniques of repairing a parastomal hernia. In the absence
of properly controlled randomised trials, a number of factors should be considered when assessing the published series. The patients included in the published series differ in type of stoma included and indication for initial surgery. A number of factors are known to influence the risk of recurrent hernia formation, such as age, American Society of Anesthesiologists (ASA) score, body mass index, chest disease, malnutrition and smoking [1] and these vary from series to series. Furthermore, most series provide little detail on these risk factors for recurrence, making comparison of outcomes even more difficult. In addition, not all the studies have stated clearly how recurrent hernia formation was defined or detected. Clinical examination is simple, but detecting a small hernia can be difficult, especially in an obese patient. Computed tomography (CT) scanning of the abdominal wall is regarded as the ‘gold standard’, and it has been established that there is a poor correlation between clinical examination and radiological findings [32] when assessing for parastomal hernia formation. Length of follow-up, which affects the recurrence rate, varies from study to study. Finally, definitions of surgical site infection and mesh infection are not usually clearly stated.
Conclusions The quality of the available literature for parastomal hernia repair is poor, and therefore it is difficult to draw robust conclusions as to the best technique of repair. Open nonmesh fascial repair is associated with a higher recurrence rate than open mesh repairs and should be used in specific situations where mesh is contraindicated. There is not enough evidence available to determine which mesh technique (onlay, sublay or underlay) has the best outcome. The reported rate of mesh infection is low and should not preclude the use of mesh in parastomal hernia repairs.
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432 Conflict of interest
Tech Coloproctol (2014) 18:427–432 None.
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