Introduction
Parastomal hernia is the most common complication after stoma formation. According to the European Hernia Society (EHS), a parastomal hernia is defined as “an abnormal protrusion of the contents of the abdominal cavity through the abdominal wall defect created during placement of a colostomy, ileostomy, or ileal conduit stoma” [
1,
2]. It is estimated that 30% of patients who undergo stoma creation will develop a parastomal hernia within a year, and about 50% after two or more years of follow-up. A higher incidence is observed in cases of end colostomy, followed by loop colostomy and loop ileostomy [
3]. Commonly known risk factors include age (> 60 years), obesity (body mass index (BMI) > 30 kg/m
2), chronic obstructive pulmonary disease (COPD), malnutrition, use of steroids, emergency surgery, tobacco smoking, postoperative sepsis, and postoperative surgical site infection [
4‐
6]. The predominant symptoms of stomal hernia are pain, bulging, difficulties with stoma device appliance, and skin complications (irritation, erosion). Sporadically, life-threatening situations such as bowel incarceration and strangulation can be observed. Most of these complications can be managed with non-operative measures, with only 30% of patients requiring surgical repair [
6,
7].
The most commonly reported approaches for stomal hernia repair include stoma relocation, fascial repair using sutures, and fascial repair using prosthetic mesh with either open or minimally invasive surgery. At present, suture repair for elective surgery is no longer recommended due to high recurrence rates, except in specific circumstances such as strangulation and contamination of the surgical field, where the use of mesh application should be avoided [
3]. In the last decade, many minimally invasive procedures have been reported in the literature with varying results. In a previous systematic review in 2015, DeAsis et al. investigated the role of laparoscopic surgery in parastomal hernia repair and concluded that the modified Sugarbaker technique demonstrated superior performance compared to other techniques [
8]. Likewise, the sandwich technique showed positive outcomes with low recurrence rates [
9]. In another study published in 2015, Szczepkowski et al. described an alternative approach called hybrid with three-dimensional (3D) meshes with promising results [
10].
Given an increased number of recently published studies comparing the aforementioned techniques, the objective of this study is to update and systematically analyse the current state of research concerning these techniques and assess the potential superiority of one technique over the others.
Discussion
The primary finding of the current systematic review is that the novel approaches, sandwich, and hybrid with 3D meshes, demonstrate superior outcomes in terms of recurrences when compared to the keyhole and Sugarbaker techniques (3.5% and 4.6% versus 24% and 9%, respectively). Notably, the keyhole technique is associated with the highest recurrence rates (24.1%) and postoperative complications (31.3%), consistent with the results of the previous systematic review by DeAsis et al. [
8]. The sandwich technique demonstrates the lowest recurrence rates (3.5%), but it is accompanied by a high rate of postoperative complications (13.2%), followed by the hybrid technique with a recurrence rate of 4.6% and the lowest postoperative complication rates (6.3%). The keyhole technique exhibits the highest recurrence rates but has among the shortest operation times, while the Sugarbaker technique presents an acceptable recurrence (9%) and a moderately increased complication rates (27.6%).
The second noteworthy finding in this updated systematic review is the lower overall recurrence rate compared to the previous meta-analysis in 2015 [
8] In their study in 2015, DeAsis et al. reported an overall recurrence rate of 17.4%, with 10.2% (95% CI:3.9–19.0) for Sugarbaker and 27.9% (95% CI: 12.3–46.8) for keyhole [
8]. These rates were higher than what we observed in our current review, which showed an overall recurrence rate of 13.6% with 24.1% for keyhole and 9% for Sugarbaker. The development and advancement of these techniques in recent years may be partly responsible for the improved outcomes. Recent studies have indicated that fascial closure with interrupted sutures before mesh application is a modification that leads to lower recurrence rates [
15,
19]. Olmi et al. also introduced a modification to the keyhole technique involving fascial closure and stoma fixation in defect edges before applying the mesh. The results of this adjustment in 90 patients led to only 4 recurrences during the follow-up. According to the authors, their adaptations achieved a recurrence rate as low as that of the Sugarbaker technique [
15].
In addition to the aforementioned technique adjustments, recent studies emphasize the essential role of mesh material choice in reducing hernia recurrences. De Asis et al.’s systematic review revealed that many included studies used ePTFE (extended polytetrafluoroethylene) mesh, characterized by its microporous nature and propensity for shrinkage [
8]. However, in studies conducted after 2015, most authors preferred monofilament polyester mesh with a collagen film barrier or 3D funnel-shaped meshes made of polyvilidene fluoride (PVDF) and polypropylene. These materials promote superior tissue-mesh integration, contributing to a reduction in mesh shrinkage, particularly in procedures like the keyhole technique, resulting in decreased recurrences [
10]. Finally, the expertise of specialized surgeons, the evolving understanding of parastomal hernia formation, and the identification of key risk factors for hernia recurrences have all contributed to the optimal results of the last decade.
Despite the lower recurrence rates in our updated review, we have observed significantly higher overall postoperative complication rates compared to those reported by DeAsis et al. (6.4% vs 1.8%) [
8]. This difference primarily arises from our expanded definition of complications. Due to the high variability among studies and the lack of precise data on postoperative complications we chose to categorise any postoperative adverse events, as postoperative complications. Nevertheless, to maximize the impact of our findings we separately recorded specific complications, such as surgical site infections, mesh infections, bowel obstruction, and postoperative ileus, as outlined in the “
Results” section. Consequently, by documenting all adverse events—ranging from postoperative paralytic ileus to cardiopulmonary complications, some of which pertain to the same patient—we increased the postoperative complication rates.
Another noteworthy point is the comparison of the two most prevailing techniques namely the keyhole and Sugarbaker techniques. In our study, we observed a significant difference in recurrence rates, highlighting the superiority of the Sugarbaker technique over the keyhole (9% versus 24.1%). A.M Fleming et al. conducted a recent systematic review of studies comparing only keyhole and Sugarbaker techniques (both open and laparoscopic), but they failed to demonstrate a superiority of one technique over the other. In their initial overall analysis, they observed that the modified Sugarbaker technique had lower recurrence rates compared to the keyhole technique. Nevertheless, in their subgroup analysis (studies after 2015), they observed that both techniques demonstrated similar results in terms of recurrences. According to the authors, several factors may have contributed to this observation, including the evolution of keyhole technique and the development of modern mesh materials. Additionally, there were differences in the study populations between studies conducted before and after 2015, as most studies after 2015 were conducted in Europe, whereas studies before 2015 were mainly conducted in the USA [
52].
Thus, the question that arises is, 'What is the preferable technique for laparoscopic parastomal hernia repair?'. Li Luan et al. designed an algorithm to determine which is the technique of choice for the treatment of recurrent parastomal hernias. Firstly, the authors used laparoscopy to investigate the presence of infection, adhesions, or tumor recurrence. In case of infection, they proceeded to simple suture repair. In the presence of any adhesions, they categorized them as light, medium, and heavy. In the presence of light adhesions with a short bowel loop, they proceeded to keyhole technique, while in the case of a long bowel loop, they preferred the Sugarbaker approach. For medium adhesions and bowel injury they performed onlay mesh repair, but in the absence of bowel injury, they used laparoscopic re do with or without keyhole/Sugarbaker technique. Finally, in the case of heavy adhesions they favored onlay repair. The application of this algorithm resulted in zero recurrences on a mean follow-up of 32.8 ± 3.77 months, encompassing a total of 17 cases [
53]. A similar therapeutic algorithm, as described above, will facilitate future studies in the objective evaluation of the described techniques and clarify their outcomes in distinctive circumstances.
Another issue we need to acknowledge is the role of prophylactic mesh during ostomy creation. Is the principle “prevention is better than cure” applicable in stomal hernia? Current European Hernia Society guidelines strongly recommend the usage of prophylactic mesh during permanent end stoma creation, to decrease the incidence of parastomal hernias [
3]. The initial results of a recent meta-analysis of randomized controlled trials that compared the use or not of prophylactic mesh placement during end colostomy construction ally with the EHS statement [
54]. However, in a subgroup meta-analysis of the studies conducted the last 5 years, the authors failed to detect a statistically significant difference in parastomal hernia prevalence after prophylactic mesh application. As the authors suggest, these results could be attributed to changes in the patient population. Nowadays, patients are more prone to obesity, suffer from many comorbidities and are regularly exposed to neoadjuvant treatments, factors that affect tissue healing mechanisms and predispose to hernia formation. Therefore, although the use of prophylactic mesh may contribute to a decline in hernia formation, this potential benefit needs further investigation [
54].
Moreover, it is fundamental to clarify the potential superiority of extraperitoneal route of stoma creation over the intraperitoneal route. In the 2018 EHS guidelines, authors argued that making a recommendation on this topic was ambiguous due to the lack of randomized controlled trials [
3]. In 2022, Luo et al. conducted to a meta-analysis of randomized controlled trials comparing transperitoneal and extraperitoneal colostomy to analyze the outcomes of each technique. The meta-analysis results showed that extraperitoneal colostomy demonstrated a lower incidence of parastomal hernia and parastomal prolapse, accompanied by higher rates of defecation sensation. Defecation sensation, refers to the stimulation of parietal peritoneum’s nerves that occur during stool passage through the bowel lumen in extraperitoneal colostomy. Patients may occasionally establish a level of defecation control due to abdominal muscle contractions, thereby improving their quality of life. Remarkably, extraperitoneal colostomy appears as a promising technique for hernia prevention. Further controlled studies comparing prophylactic mesh with extraperitoneal colostomy creation are essential to determine the most appropriate prevention method [
55].
Another crucial issue necessitating clarification is the management of concomitant incisional hernias alongside parastomal hernias. Reported incidence rates vary widely, ranging from 13 to 58.3% [
10,
48]. The European Hernia Society classifies parastomal hernias into four types based on defect size and the presence of concomitant incisional hernias [
1]. A comprehensive literature review regarding the most suitable minimally invasive surgical approach in these cases failed to yield specific recommendations. To shed light on this issue, we examined various studies to identify the surgical approaches employed in such cases. Köhler et al. used a second intraperitoneal flat mesh to cover the midline incisional hernia in the hybrid technique [
36]. Other authors employed the same mesh to cover both hernia defects in Sugarbaker and sandwich approaches [
19,
27,
43]. Lambrerht used transversus abdominis muscle release (TAR) combined with the modified Sugarbaker technique for distal incisional hernias, whereas midline incisional hernias required enhanced-view Rives-Stoppa (eRS) technique [
56]. Regarding the recurrence rates, Gameza et al. discovered no significant differences after simultaneously repairing parastomal and concomitant incisional hernias [
46]. The information mentioned above relies on individual centers’ experiences, and there is a noticeable absence of standardized recommendations in this regard. Future studies should encompass a more comprehensive exploration, aiming to evaluate the efficacy of each technique and their applicability in cases involving concomitant incisional hernias.
Several inherent limitations of our study should be acknowledged. This systematic review is mainly limited to observational studies, with the majority being retrospective case series studies. Many of the included studies did not provide sufficient data on parastomal hernia classification, patient characteristics, risk factors for hernia formation and recurrence, urgency of surgery, and criteria for accurately diagnosing hernia recurrence. In addition, morbidity rates were seldom reports and thus the present analysis relied on evaluating pooled complication incidence rates, which lack a clear estimation of severity since relevant Clavien-Dindo scores were not provided. The encountered heterogeneity in terms of study population and outcome reporting makes it challenging to compare the different techniques, and it limits the overall generalizability of the findings presented herein. Further prospective, well-designed trials, with clearly set definitions and uniform outcome reporting are essential for exploring the exact efficacy of each technique and how it fits within the current cadre of minimally invasive approaches for managing parastomal hernias.
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