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Berger. Mini-invasive Surg 2023;7:24 https://dx.doi.org/10.20517/2574-1225.2023.30 Page 5 of 10

techniques, or using robotic approaches. Additionally, the application of the mesh can differ widely. There
exists the possibility of placing the mesh in an onlay, sublay (retromuscular), and intraperitoneal position.
Furthermore, flat meshes can be incised to perform the keyhole technique in these positions. Another
[38]
alternative is the Sugarbaker technique , originally described for open surgery, with adequate lateralization
of the stoma loop can be used. This technique was very early adopted laparoscopically [39,40] . In the meantime,
[41]
the minimal-invasive extraperitoneal “Sugarbaker technique” has been introduced , which is highly
suitable for robotic use .
[42]
The literature contains a lot of case reports demonstrating the authors’ own techniques or modifications of
preexisting approaches. However, major series of well-standardized procedures are scarce. Nonetheless,
some reviews aimed to elucidate the effectivity of the different techniques. Hansson et al. described the
superiority of the Sugarbaker technique compared to the keyhole technique. Our own experience, after four
years of laparoscopic Sugarbaker repair, revealed unacceptable recurrence rates [37,40] . When analyzing the
patients suffering from recurrence, we found that the recurrence always occurred laterally, and the previous
fascial defect was also located more lateral to the stoma site. We concluded that the lateralized stoma-related
bowel preventing direct contact of the mesh with the abdominal wall does not stabilize it. So, the defect can
grow over time, leading to a recurrence. To address this, we found that the combination of the keyhole
technique to stabilize the lateral abdominal wall with the Sugarbaker technique, which covers the medial
part and can overlap the midline if necessary, should be effective, which proved to be true, as shown in
Figures 2-4.

In the meantime, the sandwich technique has also been proposed for parastomal hernia after urostomies .
[11]
Due to the complexity of the sandwich technique, the chimney technique was adapted for therapeutic
purposes [30,43] , as shown in Figure 1. Originally, the chimney technique was mainly performed as a hybrid
procedure. After laparoscopic adhesiolysis, the stoma was excised, the parastomal defect was closed after
resection of the hernia sac, and the 3-dimensional mesh was pulled over the mobilized stoma-related bowel
and replaced intra-abdominally. The mesh could be fixed laparoscopically. The technique can be used in
open surgery as well with augmentation of the median line. Sometimes, the 3-dimensional mesh was incised
to avoid excision of the stoma and closed laparoscopically, which has been described anecdotally. To avoid
incision of the Dynamesh IPST, today, a preincised structure with enforced incision lines is commercially
®
®
available (Dynamesh IPST R).
A recent nationwide analysis after a median observation time of 39 months demonstrated the superiority of
the sandwich and chimney techniques in comparison to Sugarbaker, keyhole, or other approaches . The
[44]
recurrence rates are summarized in Table 1. The details of this nationwide study clearly demonstrate the
main problems associated with parastomal hernia repair. During a ten-year period, 235 patients with
parastomal hernia have been operated on in nine hospitals, which means two to three patients per year per
hospital. The overall complication rate amounted to 26.3%. The authors concluded that the recurrence rates
are unacceptably high while the patient load is very low. I would like to add that the complication rate is
also unacceptably high.

A Danish nationwide analysis before and after the centralization of parastomal hernia repair to five centers,
which took seven years, demonstrated an increasing amount of patients, a reduction of emergency cases,
and improved outcomes of emergency cases after centralization . So, it is absolutely clear that the repair of
[45]
parastomal hernias should be performed by specialized surgeons in specialized centers providing an
adequate caseload.