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Page 2 of 10 Berger. Mini-invasive Surg 2023;7:24 https://dx.doi.org/10.20517/2574-1225.2023.30

INTRODUCTION
The occurrence of complications after ostomy formation has been described for a long period of time. In
1994, the incidence of peristomal complications was retrospectively described to increase to almost 70%
depending on the type of ostomy and the underlying disease after ten years . The skin is the
[1,2]
predominantly affected location after ileostomy, and hernias were described in about 37% (colostomy) and
16% (ileostomy). Similar data have been published more recently, indicating the absence of any progress
[3]
concerning the incidence of stoma-related problems during the last 30 years. Urostomies are also prone to
[4-8]
develop parastomal hernias to a similar extent . After the formation of an ileal conduit, a parastomal
hernia will occur in up to 30% after observation periods of only four years. Keeping in mind that the
[1,2]
occurrence of parastomal hernia increases continuously with time , these results represent only the
beginning part of the reality. Whereas skin problems can usually be controlled by improved stoma care, if a
hernia is not causing stoma care problems, the parastomal hernia should be prevented or treated by surgical
means. Despite the frequency, there is an almost complete lack of knowledge about what happens with the
patient with a parastomal hernia over time. Without scientific support, it is generally believed that
parastomal hernia is mostly asymptomatic. In 2009, Moreno-Matias et al. described a simple radiological
classification of parastomal hernia, evaluating 75 colostomy patients . Thirty-three patients revealed a
[9]
hernia by clinical examination. Twenty-seven (88%) reported associated symptoms. More detailed results
investigating the quality of life showed that patients with a stoma had a significantly lower quality of life,
which is further reduced when a hernia is present [10-12] .

Risk factors that enhance the rate of parastomal hernia have been extensively described. However, the
results are not completely consistent [6,7,13] . Body mass index and female gender are uniformly defined as
contributing factors. Additionally, increasing age, larger aperture size, and larger waist circumference seem
to play an important role. There is obviously no difference between urological and intestinal ostomies in
this regard. The role of ostomy-associated atrophy of the rectus muscle and the accompanying midline shift
is not clear [14,15] , but it seems to be an interesting factor interfering with the occurrence of parastomal hernia.

In 2013, data from the Danish Hernia Database demonstrated a 13.2% reoperation rate and a 6.3% mortality
rate after parastomal hernia repair. Emergency procedures were identified as the strongest factor correlated
with both reoperation and mortality . However, in 2018, non-operative strategies were recommended due
[16]
to the unsatisfying results of parastomal hernia repair . In a multicenter evaluation of 80 patients, a
[17]
recurrence rate of 55% was established, with 91% of patients with recurrence requiring re-repair.
Additionally, 21% of non-surgical patients crossed over to the surgical group. Based on these findings, the
authors concluded that non-operative treatment may be a better choice. However, to definitely support that
point of view, scientific data about the natural course of parastomal hernia comprising an adequate number
of patients are needed, but up to now, such data are not available.

Realizing the association of parastomal hernia with reduced quality of life, the lack of knowledge about the
natural course, and the high complication rate of elective and especially non-elective repair, it is obvious
that effective prevention and treatment strategies are urgently needed.

PREVENTION
Originally, any surgical measures to prevent the occurrence of parastomal hernia were based on technical
details such as strict transrectal ostomies or extraperitonealization of the stoma loop. However, up to now,
there is no real evidence of whether these modifications are really effective because of the lack of
scientifically adequate data [18,19] . In 2004, Janes et al. described the results of the first randomized study
comparing a simple colostomy with a mesh-augmented colostomy . A lightweight polypropylene mesh
[20]