GUIDELINES ON

PREVENTION AND
TREATMENT OF
PARASTOMAL HERNIAS
2019
 CONTENTS
Clinical Practice Guideline
PAGE
3
CLINICAL PRACTICE GUIDELINE
Methods 4 Implementation by the European Hernia Society (EHS).
Recommendation key 4
Incidence 5 Based on a systematic and comprehensive literature review.
Classification 5
Diagnostics 6 Considers the balance benefits/risk of prevention and the current
Watchful waiting for patients with a non-incarcerated parastomal hernia 6
Specific techniques when constructing a stoma 7 approaches available for diagnostic, treatment and management
Prophylactic mesh 8 of parastomal hernias.
Non mesh repair 9
Laparoscopic repair 9
Open techniques 10
Laparoscopic techniques 10
Mesh types 11

USER TARGET: WORKING GROUP: PATIENTS:

Healthcare Scientists and With a temporary or
professionals surgeons coming a permanent stoma,
(surgeons, general from 14 European or patients expected
practitioners, countries + to have a stoma.
stoma care nurses, the guideline
physiotherapists), development
policymakers within group of EHS.
the European region.

Simons MP, Smietanski M, Bonjer HJ, Bittner R, Miserez M, Aufenacker TJ, Fitzgibbons RJ, Chowbey PK, Tran HM,
Sani R, Berrevoet F, Bingener J, Bisgaard T, Bury K, Campanelli G, Chen DC, Conze J, Cuccurullo D, de Beaux AC,
Eker HH, Fortelny RH, Gillion JF, van den Heuvel BJ, Hope WW, Jorgensen LN, Klinge U, Köckerling F, Kukleta JF,
Konate I, Liem AL, Lomanto D, Loos MJA, Lopez-Cano M, Misra MC, Montgomery A, Morales-Conde S,
Muysoms FE, Niebuhr H, Nordin P, Pawlak M, van Ramshorst GH, Reinpold WMJ, Sanders DL, Schouten N,
Smedberg S, Simmermacher RKJ, Tumtavitikul S, van Veenendaal N, Weyhe D, Wijsmuller AR.

2 GUIDELINES ON PREVENTION AND TREATMENT OF PARASTOMAL HERNIAS WWW.EUROPEANHERNIASOCIETY.EU 3

 METHODS INCIDENCE
• F
 irst-level search: done in February 2016 and included databases of Estimated overall incidence of parastomal hernia:
MEDLINE (through PubMed), CINAHL (through OpenAthens) and CENTRAL • 30% by 12 months
(through Wiley Online Library), with no date or language restrictions.
• 40% by 2 years
The grey literature was searched through OpenGrey (Exalead)
• 50% at longer follow-up
• Second-level screening: The quality of the evidence was assessed using
End colostomy associated with a higher incidence of parastomal hernia,
the Scottish Intercollegiate Guidelines Network (SIGN) checklists and rated
compared to loop colostomy and loop ileostomy.
according to the GRADE approach

• Consensus meeting held in April 2016 in Brussels

• P
 eer review and assessment by two external reviewers in August 2016
according to the AGREE II instrument
CLASSIFICATION
• 5 existing classifications on parastomal hernias
RECOMMENDATION KEY • None have been validated
• Insufficient evidence to favour one classification
STRONG Benefits do or do not outweigh risks and burden.
QUALITY VERY LOW LOW MODERATE HIGH
WEAK Benefits, risks and burden are finely balanced. OF EVIDENCE
NONE No evidence could be found, no recommendation can be made. RECOMMENDATIONS

WEAK: Suggestion to use the European Hernia Society for uniform

reporting.

4 GUIDELINES ON PREVENTION AND TREATMENT OF PARASTOMAL HERNIAS WWW.EUROPEANHERNIASOCIETY.EU 5

 DIAGNOSTICS SPECIFIC TECHNIQUES WHEN CONSTRUCTING A STOMA
No gold standard examination for the detection of parastomal hernias. Statement 1: Insufficient evidence on the comparative risk of parastomal
Diagnosis is challenging, as not reproducible from one observer to another. hernia development after construction of a stoma via the extraperitoneal OR
• Clinical examination the transperitoneal route.
- Sensitivity = 66 – 100%
- Negative predictive value = 75 – 100% QUALITY VERY LOW LOW MODERATE HIGH
• CT scan may result in false positive diagnoses OF EVIDENCE
• Clinical relevance of ultrasonography is not clear
RECOMMENDATIONS
QUALITY VERY LOW LOW MODERATE HIGH
OF EVIDENCE NONE

RECOMMENDATIONS
Statement 2: Insufficient evidence on the comparative risk of parastomal
WEAK: Clinical examination in supine/erect position using Valsalva hernia development after the construction of the stoma at a lateral pararectus
maneuver is necessary for the diagnosis. location OR a transrectus location.
CT scan or ultrasonography may be performed in uncertain cases.
QUALITY VERY LOW LOW MODERATE HIGH
The differential diagnosis between parastomal hernia and stoma prolapse
may require CT imaging.
OF EVIDENCE

RECOMMENDATIONS

NONE

WATCHFUL WAITING FOR PATIENTS WITH A Statement 3: Insufficient evidence on the ideal size of the fascial aperture
NON-INCARCERATED PARASTOMAL HERNIA when constructing a stoma.

No evidence on the benefit of watchful waiting vs surgery

QUALITY VERY LOW LOW MODERATE HIGH
QUALITY VERY LOW LOW MODERATE HIGH OF EVIDENCE
OF EVIDENCE
RECOMMENDATIONS
RECOMMENDATIONS
WEAK: We suggest keeping the size of the fascial aperture as small as
NONE: BUT when making clinical decisions, the surgeon needs to
possible to allow passage of the intestine through the abdominal wall
consider:
without causing ischemia.
- the risks associated with watchful waiting (e.g. strangulation, hernia
enlargement, development of comorbidities) which may increase the
difficulty and risks of subsequent surgery.
- the increased incidence of perioperative complications following
emergency surgery, as well as quality of life parameters.

6 GUIDELINES ON PREVENTION AND TREATMENT OF PARASTOMAL HERNIAS WWW.EUROPEANHERNIASOCIETY.EU 7

 PROPHYLACTIC MESH NON MESH REPAIR
High quality evidence supports the use of a prophylactic mesh during • No high quality evidence on the comparative risk of recurrence following
construction of a permanent end colostomy in elective surgery in reducing parastomal hernia repair with mesh, stoma relocation or suture repair
the incidence of parastomal hernia development. • There is evidence suggestive of a high risk of recurrence following suture
repair
QUALITY VERY LOW LOW MODERATE HIGH • Insufficient evidence on the comparative risk of morbidity following mesh
OF EVIDENCE repair, stoma relocation or suture parastomal hernia repair
• There is evidence suggestive of a low rate of infectious complications for
RECOMMENDATIONS parastomal hernia repair with a synthetic mesh

STRONG: It is recommended to use a prophylactic synthetic non- QUALITY VERY LOW LOW MODERATE HIGH
absorbable mesh when constructing an elective permanent end colostomy OF EVIDENCE
to reduce the parastomal hernia rate.
RECOMMENDATIONS
QUALITY VERY LOW LOW MODERATE HIGH
OF EVIDENCE STRONG: It is recommended not to perform a suture repair for elective
parastomal hernia surgery because of a high risk of recurrence
RECOMMENDATIONS

NO recommendation for the use of a prophylactic mesh for ileostomies or

ileal conduit stomas.
NO recommendations for the use of synthetic absorbable or biological LAPAROSCOPIC REPAIR
meshes.
• Insufficient evidence on the risk of recurrence following laparoscopic versus
open parastomal hernia repair with a mesh
• Insufficient evidence on the morbidity following laparoscopic versus open
parastomal hernia repair with a mesh

QUALITY VERY LOW LOW MODERATE HIGH

OF EVIDENCE

RECOMMENDATIONS

NONE: BUT clinical decision should depend on

- Local resources,
- Patient preferences,
- Surgical experience
- Specific patient conditions (i.e. comorbidities, previous surgeries,
intraperitoneal adhesions and the size of the hernia)

8 GUIDELINES ON PREVENTION AND TREATMENT OF PARASTOMAL HERNIAS WWW.EUROPEANHERNIASOCIETY.EU 9

 OPEN TECHNIQUES MESH TYPES
• Insufficient evidence on the optimal technique for open parastomal hernia • Insufficient evidence on the most effective mesh for parastomal hernia
repair with regard to morbidity or recurrence repair with regard to recurrence or morbidity
• No evidence supporting superiority of biological over synthetic meshes with
QUALITY VERY LOW LOW MODERATE HIGH regard to recurrence or morbidity
OF EVIDENCE
QUALITY VERY LOW LOW MODERATE HIGH
RECOMMENDATIONS
OF EVIDENCE
NONE
RECOMMENDATIONS

NONE

LAPAROSCOPIC TECHNIQUES
The impact of these guidelines on clinical practice is
• Existing evidence favouring the use of a mesh without a hole in preference planned to be assessed through a Web-based survey
to a keyhole mesh for laparoscopic parastomal hernia repair in terms of to be completed by members of the EHS, 2 years after
recurrence publication of this manuscript. Partial or complete adherence
• Insufficient evidence on the safest laparoscopic technique for parastomal to these guidelines by at least 70% of the participants will
hernia repair with regard to morbidity be considered suggestive of adequate implementation.
Participants will be invited to submit comments and
QUALITY VERY LOW LOW MODERATE HIGH suggestions for the planned update of these guidelines.
OF EVIDENCE The results of this survey will be made publicly available.
A 2-year interval for repeated assessment is considered
RECOMMENDATIONS adequate to monitor the level of implementation.

WEAK: For laparoscopic parastomal hernia repair, a mesh without a hole is

suggested in preference to a keyhole mesh.

10 GUIDELINES ON PREVENTION AND TREATMENT OF PARASTOMAL HERNIAS WWW.EUROPEANHERNIASOCIETY.EU 11

EUROPEAN HERNIA SOCIETY
CALLE CASTELLÓ 128
28006 MADRID – SPAIN

T: +34 913 836 000 -EXT 133

EMAIL: SECRETARIATEHS(AT)PACIFICO-MEETINGS.COM

Photo credit: Adobe Stock

PRODUCED IN ASSOCIATION WITH