Invited commentary on European Hernia Society Guidelines on prevention and treatment of parastomal hernias

Even if the development of sphincter-saving surgery has increased, the residual rate of abdominoperineal resection of the rectum is still up to 20%. Furthermore, almost all patients undergoing a low anastomosis have a protective stoma. Stoma creation is a procedure which general and colorectal surgeons are often faced with. Although considered relatively easy, this step takes place usually at the end of a challenging operation, when attention may be flagging.

Parastomal hernia is a common complication and surgical repair is often followed by recurrence. So, the guidelines on prevention and treatment of parastomal hernias proposed by the European Hernia Society are welcomed. The task force was constituted by invited European experts from 14 different countries.

Most of the 12 questions determined by the group could not be answered with a high level of proof owing to lack of studies of enough good quality. A good example is the impossibility to make recommendations for the choice between transperitoneal and extraperitoneal route, and through or lateral to the rectus muscle when creating an end colostomy. However, one of the important conclusions of these guidelines is the high-quality evidence which supports the use of a prophylactic mesh during construction of a permanent end colostomy. In this situation, a prophylactic mesh placement, preferably in a retro muscular position, is safe and reduces the incidence of parastomal hernia development. A second message is that there is no superiority of biologic mesh compared to synthetic non-absorbable mesh. No higher risk of infectious complications has been shown in the literature, information confirmed in two recent meta-analyses. This recommendation has a clear financial implication.

In conclusion, these guidelines should be read by all general and colorectal surgeons, even if one can agree that studies of good quality are still required before making recommendations to all the questions raised by stoma formation.

On behalf of the European Society of Coloproctology.

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Correspondence to E. Tiret.

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Tiret, E. Invited commentary on European Hernia Society Guidelines on prevention and treatment of parastomal hernias. Hernia 22, 205 (2018).

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