Page 30 - Read Online

Page 4 of 10 Berger. Mini-invasive Surg 2023;7:24 https://dx.doi.org/10.20517/2574-1225.2023.30

®
Figure 1. Intra-abdominal view of the chimney technique for prophylaxis of parastomal hernia with the Dynamesh IPST with a 4 cm
funnel in a patient with terminal sigmoidostomy. The mesh is fixed by resorbable tacks (blue ones) using a double crown

technique, possible shrinkage of the mesh will not increase the diameter of any keyhole but only shorten the
length of the funnel. Therefore, with a longer funnel, 4 cm, the procedure should be even more effective,
and this structure should be recommended. In a recent review, this technique for prophylaxis and therapy
of parastomal hernia and the relevant literature are described in more detail and compared with the
[30]
alternative keyhole technique .
After the described promising results of observational studies, a well-designed RCT is already finished in
Finland using the 3-dimensional implant known as the chimney trial. Therefore, according to the study,
[31]
this technique should be called the “chimney technique” and clearly differentiated from the keyhole
approach. The one-year results have been demonstrated at the annual meeting of the European Hernia
Society. At that time point, the hernia rate was 2/60 (3%) in the mesh group and 30/62 (48%) in the control
group. The diagnosis was established by CT. So, the ethics committee finished the study due to the highly
significant benefit of the implant. The publication of the definitive findings from the chimney trial is eagerly
anticipated this year and will revolutionize the field of parastomal hernia prophylaxis.

A further approach to evaluate the role of prophylaxis is through a well-designed registry or major cohort
study that exactly documents the surgical details of stoma formation . This would allow for a better
[32]
evaluation of less used techniques, such as SMART (Stapled Mesh StomA Reinforcement Technique) , in
[33]
comparison to the keyhole and chimney technique. Despite the not completely clear conclusions, the use of
a prophylactic synthetic mesh will significantly reduce the lifetime costs for patients with end colostomy
[34]
due to rectal cancer!

REPAIR
Generally, the parastomal hernia is not only a mechanical but also, more important, a biochemical problem,
similar to incisional hernias . Similar changes of the extracellular matrix have also been described in
[35]
patients developing a parastomal hernia . Therefore, the obvious conclusion is the necessity of a
[36]
permanent augmentation of the abdominal wall because the scar will not be stable enough to prevent a
hernia. Clinically, it has been clearly shown that suture-based repairs of parastomal hernia are associated
with a high recurrence rate . Mesh-based repairs can be performed by open surgery, laparoscopic
[37]