Management of PSH can pose difficulties due to significant rates of recurrence and morbidities of the repair. The current standard of care is mesh repair whenever possible. Although low recurrence rates are reported after synthetic mesh repair, concerns have been raised regarding the safety of synthetic meshes in potentially contaminated fields due to the risk of mesh infection and subsequent removal. Other mesh-related complications include chronic infection, bowel stenosis, erosion of the mesh through the bowel and skin and entero-atmospheric fistulization [4, 11, 12]. These complications led to the development of biologic mesh, which due to its biodegradable nature, has the potential to improve these problems in infected and contaminated fields. The biologic mesh was then introduced for these cases and has become a popular choice for the past few years. Although a promising option, its popularity seized because of a few studies that showed a recurrence rate as high as 31%, when biologic mesh was used in a contaminated field during hernia repair . Recently, the concept of avoiding a synthetic mesh in contaminated cases has been challenged. For instance, Carbonell et al. were able to show acceptable rates of surgical site infection when the synthetic mesh is used in clean-contaminated and contaminated hernia repairs . Synthetic meshes, when used for either an open onlay or retromuscular repair, resulted in low surgical site infections and parastomal hernia recurrence rates [4, 11,12,13,14]. Our study showed no statistical difference in wound complication and hernia recurrence regardless of the type of mesh used.
In a small PSH where a small fascial defect leads to the accumulation of bowel and omentum in a subcutaneous pocket, hernia repair can be often accomplished by a direct surgical approach on the problem. However, patients with very large and recurrent PSH tend to have a greater fascial defect that can only be closed under considerable tension. Stoma relocation involves repositioning the stoma to a new location. At the same time, it involves fixing the hernia at the previous stoma site. Unfortunately, in patients with a history of PSH in the past, there is a significant risk of developing a PSH at the new stoma site. The reported risk was as high as 76% . Similarly, this method also is associated with a risk of hernia recurrence as high as 52% at the previous stoma location . Stoma relocation is usually a last resort when the existing stoma location is substandard and under a lot of tension. If this is the case, then the new stoma should be ideally placed on the opposite side of the abdomen because of the higher reported recurrence rates when the same side is used. Some also recommend using mesh to cover the old and new stoma sites as well as the midline incision to prevent a hernia .
In a study by Riansuwan et al. comparing outcomes after repair of recurrent PSHs between direct repair and stoma relocation, the later was associated with longer operative time and hospital stay . Although they were able to show that the recurrence rate was initially lower in stoma relocation, calculated and longer predicted follow-up time did not show any difference in recurrent rates. This was supported by another study conducted by Baig which demonstrated that stoma relocation with a midline laparotomy was associated with longer operative time and hospital stay and morbidity rates . The complications mentioned in the midline laparotomy were usually related to exposure of the hernia defect, difficulties dissecting dense adhesions caused by prior surgery and enterotomies incurred as a result of adhesiolysis. However, they also found no significant difference regarding recurrence rates . This finding is consistent with our results. Similarly, our study was not able to demonstrate any significant difference regarding wound complication and hernia recurrence rates when direct mesh repair was compared to stoma relocation.
The onlay method of repair has been associated with low morbidity particularly regarding wound and mesh infection rates—1.9% and 2.6% respectively . With this technique, the overall one-year recurrence rate was 17.2% (range 0–20%) . More importantly, the advantage of the onlay repair is the avoidance of performing a laparotomy. This will not only be beneficial to high-risk patients with significant cardiopulmonary comorbidities, but also to patients with substantial intra-abdominal adhesions. Because of these reasons, this technique was utilized for all our patients who underwent mesh repair of the PSH using the lateral peristomal incision.
The onlay method of repair requires extensive skin mobilization to make room for the mesh. This creates a significant dead space, which can result in a seroma formation and ultimately may pose a potential risk for wound and mesh infections. While some view this as a significant disadvantage with the onlay technique, we did not have a substantial problem with this. Our study showed that lateral peristomal incision was associated with shorter operative time and length of hospital stay. However, there was no significant difference regarding wound complications and hernia recurrence when lateral peristomal incision and midline incision were compared.
Interpretation of the results was limited by the retrospective design of the study and the limited number of patients. A larger cohort of patients with longer follow-up and evaluated in a randomized, controlled trial would strengthen the results of this study.