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Climent et al. Mini-invasive Surg 2018;2:45 I http://dx.doi.org/10.20517/2574-1225.2018.62 Page 9 of 13

[65]
depending on whether a hernia is diagnosed clinically (48.1%) or radiologically (80%) . The fact that
[65]
many ileostomies are temporary may lead to less incidence of long-term herniation . Risk factors for
the development of parastomal hernia are obesity, raised intra-abdominal pressure (chronic constipation,
[69]
ascites, chronic cough), corticosteroid use, increased age, wound sepsis [66-69] , malnutrition, smoking ,
diameter of the trephine and its location and emergency surgery without preoperative assessment by a
[66]
stoma therapist .
Current treatment options include non-operative management, if the parastomal hernia is asymptomatic
or stoma relocation and repair of the fascial defect with or without mesh. Primary fascial repair has
been associated with high recurrence, from 50% to 75% [66,69] . Despite the fact that fewer recurrences are
described with stoma relocation on the other side of the abdomen wall, there is a significant risk of an
incisional hernia at the site of the original stoma and in addition, this technique could be limited if there
[65]
are multiple previous surgeries . The repair of fascial defect with mesh has been widely described with
different techniques, placing the mesh on the top of the fascia of the rectus sheath (onlay), between the
rectus abdominis muscle and posterior rectus sheath (sublay), and intraabdominal (underlay), fixed on to
the peritoneum, which could be by open or laparoscopic approach. The onlay technique consists in the
insertion of a polypropylene ring mesh around the stoma, avoiding a laparotomy, which may be convenient
in high-risk patients. However, there is a high risk of recurrence and the infection rate is quite significant,
[66]
12.5% , requiring the removal of the mesh. The sublay mesh technique and the underlay mesh technique
have been associated with less recurrence compared to the onlay technique, likely because the mesh is
[69]
placed on the high-pressure side of the abdominal wall . Unfortunately, there are minimal long-term data
on the effectiveness of sublay mesh technique. The two most popular underlay techniques are the slit mesh
Keyhole technique and the Sugarbaker technique. Both involve hernia sac reduction, adhesiolysis, and
appropriate mesh fixation. The Sugarbaker approach involves the bowel being exteriorized through the side
of the mesh creating a tunnel between the abdominal wall and the prosthesis, in the Keyhole approach the
bowel is inserted through a hole placed in the centre of the mesh. The Sugarbaker technique was modified
from the original version to prevent recurrent hernias, and an overlap of 3-5 cm between the mesh and
[70]
the adjacent fascia around the trephine opening is now mandatory . The largest Sugarbaker and Keyhole
[71]
cohorts are published by Hansson et al. in two different studies describing a recurrence of 37% after
[71]
[70]
the Keyhole technique compared to a recurrence rate of 6.6% in the group of Sugarbaker technique .
Authors justify these results because the mesh material used, polytetrafluoroethylene (ePTFE), has a
tendency to shrink, which widens the slit in the mesh and consequently results in a hernia recurrence.
[68]
DeAsis et al. found also better results for the Sugarbaker technique but with a not insignificant risk
of recurrence of 10.2%. Expanded ePTFE meshes are the most common prostheses described in the
literature to deal with laparoscopic intraperitoneal hernia repair because there is less risk of adhesions to
the bowel [68,70] compared to polypropylene mesh. However, the hydrophobicity of ePTFE and the lack of
ingrowth of fibrocollagenous tissue into the prosthesis make it vulnerable to infection, so it is mandatory
[71]
to avoid the use of mesh in a contaminated field . Some authors have suggested the use of hybrid mesh
types, with an inert mesh material such as polyvinylidene fluoride with a small amount of polypropylene
[72]
on the parietal side, inducing ingrowth and incorporation .

In order to prevent a parastomal hernia, some groups have suggested the use of mesh placed prophylactically
[73]
in the sublay position at the time of stoma creation . A recent metanalysis of 10 randomized trials, analysing
649 patients in total, found that mesh reduced the rate of parastomal hernia repair by 65%, with a low rate of
[74]
infection . Nevertheless, the use of prophylactic mesh is still controversial and there is no clear consensus
[66]
regarding it’s use .
Other stoma complications
Stoma prolapse is defined as bowel intussusception, which protrudes through the stomal orifice [Figure 3].
Traditionally it has been described the use of sugar for helping in the manual reduction because it benefits