, Volume 22, Issue 2, pp 379–384 | Cite as

Preventing parastomal hernia with modified stapled mesh stoma reinforcement technique (SMART) in patients who underwent surgery for rectal cancer: a case–control study

  • A. E. CandaEmail author
  • C. Terzi
  • C. Agalar
  • T. Egeli
  • C. Arslan
  • C. Altay
  • F. Obuz
Original Article



Parastomal hernia is a frequent complication of an abdominal wall stoma. Surgical repairs have high complication and recurrence rates. Several different techniques have been suggested to prevent parastomal hernia during stoma creation. The aim of the present case–control study was to evaluate the efficacy of modified Stapled Mesh stomA Reinforcement Technique (SMART) for prevention of parastomal hernia compared with conventional colostomy formation in patients who underwent open or laparoscopic rectal resection and end colostomy for cancer.

Methods and materials

Between January 2014 and May 2016, all consecutive patients who underwent open or laparoscopic resection and end colostomy for primary or recurrent rectal cancer were identified from a prospectively collected database. Since January 2014, one surgeon in our team has routinely offered modified SMART procedure to all patients who are candidates for permanent terminal colostomy. In the SMART group patients, while creating an end colostomy, we placed a standard polypropylene mesh in the retromuscular position, fixed and cut the mesh by firing a 31- or 33-mm-diameter circular stapler and constructed the stoma. In the control group, a stoma was created conventionally by a longitudinal or transverse incision of the rectus abdominis sheath sufficiently large for the colon to pass through.


Twenty-nine patients underwent parastomal hernia prophylaxis with modified SMART and 38 patients underwent end-colostomy formation without prophylaxis (control group). Groups were similar in terms of age, sex and underlying conditions predisposing to herniation. Median follow-up time is 27 (range 12–41) months. Nineteen patients (28.4%) developed parastomal herniation. In the SMART group, 4 patients (13.8%) developed parastomal herniation which is significantly lower than the control group in which 15 patients (39.5%) developed parastomal herniation (p = 0.029). We did not observe mesh infection, stenosis, erosion or fistulation in the SMART group. One patient in the control group underwent surgical correction of stoma stricture, another patient underwent surgery for stoma prolapse and four patients underwent surgery for parastomal herniation.


New systemic reviews and meta-analysis support parastomal hernia prevention with the use of a prophylactic mesh. Until more evidence is available, prophylactic mesh should be routinely offered to all patients undergoing permanent stoma formation. SMART is easy to use, safe and effective for paracolostomy hernia prophylaxis.


Parastomal hernia Mesh Prophylaxis Stapler SMART 



We thank Cathel Kerr, PhD, from Edanz Group ( for editing a draft of this manuscript.

Compliance with ethical standards

Conflict of interest

AEC declares no conflict of interest. CT declares no conflict of interest. CA declares no conflict of interest. TE declares no conflict of interest. CA declares no conflict of interest. CA declares no conflict of interest. FO declares no conflict of interest.

Ethical approval

The study was reviewed and approved by the institutional research and ethics committee (Dokuz Eylul University, 2807-GOA).

Human and animal rights

This article does not contain any studies with animals performed by any of the authors.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Informed consent

Considering the design of our study, patient consent was not required.

Supplementary material

Video 1. Parastomal hernia prophylaxis by SMART technique in a male patient who underwent laparoscopic abdominoperineal resection for locally advanced rectal cancer. (WMV 53919 kb)


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Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryDokuz Eylul University School of MedicineIzmirTurkey
  2. 2.Department of RadiodiagnosticsDokuz Eylul University School of MedicineIzmirTurkey

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