dr. Amer Odobašić

1. A.Odobašić
University Clinical Center Tuzla - Bosnia and Herzegovina
Mediterranean Society of Coloproctology
XI Biennial Congress of the MSCP; Thessaloniki, Greece, May 4 - 5, 2018.
Parastomal hernias:
How to prevent, when and how to repair?
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2. Conflict of interest
Author declare that this lecture has not been published in
whole or in part elsewhere; the manuscript is not currently
being considered for publication in any another journal;
Author has been personally and actively involved in
substantive work leading to the manuscript, and will hold
themselves responsible for its content. Author declare that he
has no conflict of interest.
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3. OSTOMY - STOMA
surgically created opening
between the intestines and
the abdominal wall
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4. Types of intestinal ostomies
Duration:
Temporary
Permanent
Anatomical location:
Jejunostomy
Ileostomy
Colostomy...
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5. Types of intestinal ostomies
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6. 6

7. PERMANENT END COLOSTOMY
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8. Specific complications of ostomy
•Skin excoriation
•Prolapse
•Bleeding
•Retraction
•Stenosis
•PARASTOMAL HERNIA (PSH) ........
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9. Parastomal Hernia-the Achilles Heel of a Permanent Colostomy
Suk-Hwan Lee
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10. Incidence of PSH
•The true incidence of PSH is difficult to assess
and varies widely depending on:
•the length of follow-up
•the type of ostomy...
•Loop colostomy - 0 to 30,8%
•End colostomy – 0 to 48,1%
•Loop ileostomy – 0 to 6,2%
•End ileostomy – 1,8 to 28,3%
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11. Risk factors for PSH formation
•Smoking
•Obesity
•Diabetes
•Malnutrition
•Immunosuppression
•Patients with conditions that chronically increase
intra-abdominal pressure, including cough and
COPD
•Advanced liver disease with ascites...
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12. Diagnostic
•Physical examination
•Ultrasonography (US)
•Computed tomography
(CT scan)
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13. Parastomal hernia: clinical and radiological definitions. A Jänes, L Weisby, LA Israelsson.
Hernia, 2010
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14. Classification of PSH
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15. 15

16. European Hernia Society classification of parastomal
hernias
M. Smietanski • M. Szczepkowski • J. A. Alexandre • D. Berger •K. Bury • J. Conze • B.
Hansson • A. Janes • M. Miserez • V. Mandala•Montgomery • S. Morales Conde • F.
Muysoms
Hernia (2014) 18:1–6
The classification proposal is based on the PSH defect size (small
is 5 cm) and the presence of a concomitant incisional hernia
(cIH). Four types were defined:
• Type I, small PSH without cIH;
• Type II, small PSH with cIH;
• Type III, large PSH without cIH;
• Type IV, large PSH with cIH.
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17. Surgical treatment of PSH
Simple Fascial Repair - high recurrence rates ranging
from 10 to 76%
Stoma Translocation - with recurrence rates of 33% to
76%
Mesh repair – recurrence rates less than 20% for both
synthetic and biologic meshes
Onlay mesh placement, retromuscular mesh placement,
open intraperitoneal mesh placement with either the
keyhole or Sugarbaker technique
Laparoscopic mesh placement – Keyhole technique,
Sugarbaker, Sandwich technique....
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18. Position of mesh
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19. Sugarbaker repair
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20. 20

21. Keyhole repair
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22. 22

23. Dr. Berger’s Sandwich technique for mesh fixation. (A) The fixation of the first mesh. This
technique is similar to Keyhole technique; (B) the fixation of the second mesh. The lower
edge can be pulled into the anterior gap of the bladder and fixed to the pubic arcuate
ligament; (C) the fixation of the second mesh. The mesh covers the lateral bowel loop (5–10
cm). The technique is similar to Sugarbaker technique.
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24. Surgical techniques for parastomal hernia repair: a systematic
review of the literature
• BME Hansson et al. Annals of Surgery, 2012
• Primary outcome was recurrence after at least 1-year follow-up.
Secondary outcomes were mortality and postoperative morbidity.
• Thirty studies were included with the majority retrospective. Suture
repair resulted in a significantly increased recurrence rate when
compared with mesh repair (odds ratio [OR] 8.9, 95% confidence
interval [CI] 5.2-15.1; P < 0.0001). Recurrence rates for mesh repair
ranged from 6.9% to 17% and did not differ significantly. In the
laparoscopic repair group, the Sugarbaker technique had less
recurrences than the keyhole technique (OR 2.3, 95% CI 1.2-4.6; P =
0.016).
• The use of mesh in parastomal hernia repair significantly reduces
recurrence rates and is safe with a low overall rate of mesh infection.
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25. Prophylactic mesh use during primary stoma formation
to prevent parastomal hernia
B Cornille, S Pathak, IR Daniels, NJ Smart Royal Devon and Exeter NHS Foundation
Trust, UK. Ann R Coll Surg Engl 2017; 99: 2–11
• METHODS A systematic search was performed using PubMed,
Embase™ and the Cochrane Library to identify randomised controlled
trials that analysed placement of prophylactic mesh versus no mesh
at time of initial surgery. Meta-analysis was performed using random
effects methods.
• RESULTS A total of 506 studies were identified by our search strategy.
Of these, 8 studies were included, involving 430 patients (217 mesh
vs 213 no mesh). Prophylactic mesh placement resulted in a
significantly lower rate of PSH formation (42/217 [19.4%] vs 92/213
[43.2%]) with a combined risk ratio of 0.40 (95% confidence interval
[CI]: 0.21–0.75, p=0.004). Placement of prophylactic mesh did not
result in increased peristomal complications (15/218 [6.9%] vs
16/227 [7.0%]) with a combined risk ratio of 1.0 (95% CI: 0.49–2.01,
p=0.990).
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26. • CONCLUSIONS Prophylactic placement of mesh at primary
stoma formation may reduce the incidence of PSH, without
an increase in peristomal complications.
• However, the overall quality of the randomised controlled
trials included in the meta-analysis was poor, and should
prompt caution regarding the applicability of the findings of
the individual studies and the meta-analysis to every-day
practice.
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27. 27

28. StMesh stomA Reinforcement Technique (SMART) in the prevention of
parastomal hernia: a single-centre experience
Z. Q. Ng, P. Tan, M. Theophilus, Hernia June 2017, Volume 21, Issue 3, pp 469–475
• The aim of this retrospective analysis was to evaluate the outcomes of
Stapled Mesh stomA Reinforcement Technique (SMART) in terms of
parastomal hernia occurrence rate and mesh-related complications.
• METHODS All patients operated with an abdominal perineal resection
or Hartmann’s procedure with SMART from November 2013 to March
2016 were included. Patient demographics, operative details and stoma-
related symptoms were collected. Patients were examined clinically by
the medical team and also reviewed independently by a specialist stoma
care nurse for signs of stoma-related complications. As part of
oncological follow-up, CT scans were available for review for evidence of
parastomal herniation.
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29. • RESULTS 14 patients (mean age 76 years) were included in the
analysis. All the SMART cases were successfully completed with no
intraoperative or immediate post-operative complications.
• No cases of mesh-related complications such as infection,
immediate stomal prolapse, stenosis, retraction, stomal
obstruction, mesh erosion or fistulation were observed. No mesh
removal was required.
• There were two cases of parastomal hernia detected on CT scan.
Both cases have remained asymptomatic no intervention was
required at this stage. Median follow-up was 24 months.
• CONCLUSION Our medium-term experience has demonstrated
the efficacy of SMART in the reduction of parastomal hernia
occurrence. With appropriate learning curve, parastomal hernia
can be prevented.
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31. Preventing parastomal hernias with systematic
intraperitoneal specifically designed mesh
• Raquel Conde-Muíño, José-luis Díez, Alberto Martínez, Francisco Huertas,
Inmaculada Segura and Pablo PalmaB . BMC SURGERY 2017, 17:41
• METHODS Data were prospectively recorded. A specifically
designed mesh made of polyvinyl fluoride with central conduit
(Dynamesh IPST®) was fixed using an intra-peritoneal onlay
technique. Safety was evaluated by means of surgical data and
frequency of mesh-related complications, efficacy by the rate
of parastomal hernias.
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32. • RESULTS Thirty-four patients were included in the study. Three
of them died before a year of follow up (not related to the
stoma), so they were excluded. The other 31 patients (11
women and 20 men) were prospectively followed up after
different pathologies resulting in a permanent colostomy.
Twelve months after surgery CT-Scan imaging revealed two
(6.4%) parastomal hernias, one of them already clinically
suspected. During the follow up, 29% of the patients (n = 9)
developed another type of hernia (incisional, inguinal or both).
In five patients (16.1%) a light stomal retraction of the
otherwise slightly prominent ostomy was observed. Median
clinical follow-up was 17.5 months (range 12–34).
• CONCLUSIONS Prophylactic parastomal mesh placement might
be a safe and effective procedure with a potential to reduce the
risk of parastomal hernia. Routine use of this technique should
be further analysed.
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34. Prophylactic Mesh Placement During Formation of an
Endcolostomy Reduces the Rate of Parastomal Hernia
Short-term Results of the Dutch PREVENT-Trial
Henk-Thijs Brandsma, Birgitta M. E. Hansson, Theo J. Aufenacker, Dick van Geldere,
Felix M. V. Lammeren, Chander Mahabier, Peter Makai.
Annals of Surgery. 2017;265(4):663-669.
METHODS: Augmentation of the abdominal wall with a retro-
muscular lightweight polypropylene mesh was compared with
the traditional formation of a colostomy. In total, 150 patients
were included. The incidence of a PSH, morbidity, mortality,
quality of life, and cost-effectiveness was measured after 1 year
of follow-up.
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35. • RESULTS: There was no difference between groups regarding
demographics and predisposing factors for PSH. Three out of
67 patients (4.5%) in the mesh group and 16 out of 66
patients (24.2%) in the nonmesh group developed a PSH (P =
0.0011).
• CONCLUSION: Prophylactic augmentation of the abdominal
wall with a retromuscular lightweight polypropylene mesh at
the ostomy site significantly reduces the incidence of PSH
without a significant difference in morbidity, mortality,
quality of life, or cost-effectiveness.
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36. Instead ofConclusion
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37. European Hernia Society guidelines on prevention and treatment of
parastomal hernias
S. A. Antoniou · F. Agresta · J. M. Garcia Alamino · D. Berger · F.
Berrevoet · H.-T. Brandsma · K. Bury · J. Conze · D. Cuccurullo · U. A.
Dietz · R. H. Fortelny · C. Frei-Lanter · B. Hansson · F. Helgstrand · A.
Hotouras · A. Jänes · L. F. Kroese · J. R. Lambrecht · I. Kyle-Leinhase ·
M. Lopez-Cano · L. Maggiori · V. Mandalŕ · M. Miserez · A.
Montgomery · S. Morales-Conde · M. Prudhomme · T. Rautio · N.
Smart · M. Śmietański · M. Szczepkowski · C. Stabilini · F. E. Muysoms
• Hernia (2018) 22:183–198
• Background International guidelines on the prevention and
treatment of parastomal hernias are lacking. The European Hernia
Society therefore implemented a Clinical Practice Guideline
development project.
• Methods The guidelines development group consisted of general,
hernia and colorectal surgeons, a biostatistician and a biologist,
from 14 European countries.
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38. RESULTS End colostomy is associated with a higher incidence of parastomal
hernia, compared to other types of stomas. Clinical examination is
necessary for the diagnosis of parastomal hernia, whereas computed
tomography scan or ultrasonography may be performed in cases of
diagnostic uncertainty.
Currently available classifications are not validated; however, we suggest
the use of the European Hernia Society classification for uniform research
reporting. There is insufficient evidence on the policy of watchful waiting,
the route and location of stoma construction, and the size of the aperture.
The use of a prophylactic synthetic non-absorbable mesh upon
construction of an end colostomy is strongly recommended.
So far, there is no sufficient comparative evidence on specific techniques,
open or laparoscopic surgery and specific mesh types. However, a mesh
without a hole is suggested in preference to a keyhole mesh when
laparoscopic repair is performed.
CONCLUSION An evidence-based approach to the diagnosis and
management of parastomal hernias reveals the lack of evidence on several
topics, which need to be addressed by multicenter trials. Parastomal hernia
prevention using a prophylactic mesh for end colostomies reduces
parastomal herniation. Clinical outcomes should be audited and adverse
events must be reported. 38

39. •With such a high incidence of PSH and recent success
with mesh repair, much attention has been given to
prophylactic mesh placement at the time of primary
stoma formation.
•Parastomal hernia prevention using a prophylactic mesh
for end colostomies reduces parastomal herniation
•Various techniques can be compared only through
prospective randomized controlled trials (RTCs).
•Hernia prevention with prophylactic mesh placement at
the time of stoma creation may be the continued focus
of future research.
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