Incisional and Parastomal Hernia Prevention

  • Sofiane El Djouzi
  • J. Scott Roth


Incisional hernias occur commonly following abdominal operations with an incidence of approximately 10–20% and are the most common complication of laparotomy. Those developing incisional hernia frequently require further operations, either elective or emergent with significant costs to the healthcare system. Those requiring fecal diversion with either colostomy or ileostomy are at risk for development of not only incisional hernia but also parastomal hernia at a rate approaching 50%. Strategies to identify patients at risk for these hernias are required in order to develop preventative treatments. The use of prophylactic mesh has been studied in patients deemed at increased risk for the development of incisional hernia including those undergoing bariatric surgery, abdominal aortic aneurysm repair, and gastrointestinal surgery with significant reductions in incisional hernia rates and rare mesh complications. Similarly, the placement of mesh at the site of a newly created stoma has proven efficacy in the reduction in the incidence of parastomal herniation. Although the ideal technique for placement of prophylactic mesh has not been clearly elucidated, the concept of hernia prevention has the potential to dramatically improve surgical outcomes and enhance quality of life for thousands of patients each year.


  1. 1.
    Saber AA, et al. Occult ventral hernia defects: a common finding during laparoscopic ventral hernia repair. Am J Surg. 2008;195(4):471–3.CrossRefPubMedGoogle Scholar
  2. 2.
    Fischer JP, et al. A risk model and cost analysis of incisional hernia after elective, abdominal surgery based upon 12,373 cases: the case for targeted prophylactic intervention. Ann Surg. 2016;263(5):1010–7.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Verhelst J, et al. Watchful waiting in incisional hernia: is it safe? Surgery. 2015;157(2):297–303.CrossRefPubMedGoogle Scholar
  4. 4.
    Kokotovic D, et al. Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safe. Hernia. 2016;20(2):281–7.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Ochsner JL. Minimally invasive surgical procedures. Ochsner J. 2000;2(3):135–6.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Cleary PD, Greenfield S, McNeil BJ. Assessing quality of life after surgery. Control Clin Trials. 1991;12(4 Suppl):189S–203S.CrossRefPubMedGoogle Scholar
  7. 7.
    Gellert GA. The importance of quality of life research for health care reform in the USA and the future of public health. Qual Life Res. 1993;2(5):357–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Diener MK, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg. 2010;251(5):843–56.CrossRefPubMedGoogle Scholar
  9. 9.
    Fink C, et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg. 2014;101(2):51–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985;72(1):70–1.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Gallup DG, Talledo OE, King LA. Primary mass closure of midline incisions with a continuous running monofilament suture in gynecologic patients. Obstet Gynecol. 1989;73(4):675–7.PubMedGoogle Scholar
  12. 12.
    Bower C, Roth JS. Economics of abdominal wall reconstruction. Surg Clin North Am. 2013;93(5):1241–53.CrossRefPubMedGoogle Scholar
  13. 13.
    Hynes DM, et al. Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial. J Am Coll Surg. 2006;203(4):447–57.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Finan KR, Kilgore ML, Hawn MT. Open suture versus mesh repair of primary incisional hernias: a cost-utility analysis. Hernia. 2009;13(2):173–82.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Israelsson LA, Jonsson L, Wimo A. Cost analysis of incisional hernia repair by suture or mesh. Hernia. 2003;7(3):114–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Shell DHT, et al. Open repair of ventral incisional hernias. Surg Clin North Am. 2008;88(1):61–83. viii.CrossRefPubMedGoogle Scholar
  17. 17.
    Plymale MA, et al. Ventral and incisional hernia: the cost of comorbidities and complications. Surg Endosc. 2017;31(1):341–51.CrossRefPubMedGoogle Scholar
  18. 18.
    Bewick R. Burst abdomen and incisional hernia. Br Med J (Clin Res Ed). 1982;284(6333):1948.CrossRefGoogle Scholar
  19. 19.
    Israelsson LA, Jonsson T. Overweight and healing of midline incisions: the importance of suture technique. Eur J Surg. 1997;163(3):175–80.PubMedGoogle Scholar
  20. 20.
    Basta MN, et al. Predicting incisional hernia after bariatric surgery: a risk stratification model based upon 2161 operations. Surg Obes Relat Dis. 2016;12(8):1466–73.CrossRefPubMedGoogle Scholar
  21. 21.
    Nachiappan S, et al. Prophylactic mesh placement in high-risk patients undergoing elective laparotomy: a systematic review. World J Surg. 2013;37(8):1861–71.CrossRefPubMedGoogle Scholar
  22. 22.
    Millikan KW. Incisional hernia repair. Surg Clin North Am. 2003;83(5):1223–34.CrossRefPubMedGoogle Scholar
  23. 23.
    Poulose BK, et al. Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia. 2012;16(2):179–83.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Israelsson LA, Millbourn D. Prevention of incisional hernias: how to close a midline incision. Surg Clin North Am. 2013;93(5):1027–40.CrossRefPubMedGoogle Scholar
  25. 25.
    Carlson MA, Chakkalakal D. Tensile properties of the murine ventral vertical midline incision. PLoS One. 2011;6(9):e24212.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Nilsson T. The relative rate of wound healing in longitudinal and transverse laparotomy incisions. Animal experiments. Acta Chir Scand. 1982;148(3):251–6.PubMedGoogle Scholar
  27. 27.
    Sahlin S, et al. Monofilament versus multifilament absorbable sutures for abdominal closure. Br J Surg. 1993;80(3):322–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Gurusamy KS, et al. Continuous versus interrupted skin sutures for non-obstetric surgery. Cochrane Database Syst Rev. 2014;2:CD010365.Google Scholar
  29. 29.
    Muysoms FE, Detry O, Vierendeels T, Huyghe M, Miserez M, Ruppert M, Tollens T, Defraigne JO, Berrevoet F. Prevention of incisional hernia by prophylactic mesh-augmented reinforcement of midline laparotomies for abdominal aortic aneurysm treatment: a randomized controlled trial. Ann Surg. 2016;263(4):638–45. Scholar
  30. 30.
    Pans A, et al. Long-term results of polyglactin mesh for the prevention of incisional hernias in obese patients. World J Surg. 1998;22(5):479–82. discussion 482-3.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Strzelczyk JM, Szymanski D, Nowicki ME, Wilczynski W, Gaszynski T, Czupryniak L. Randomized clinical trial of postoperative hernia prophylaxis in open bariatric surgery. Br J Surg. 2006;93(11):1347–60.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Strzelczyk J, et al. The use of polypropylene mesh in midline incision closure following gastric by-pass surgery reduces the risk of postoperative hernia. Langenbeck’s Arch Surg. 2002;387(7–8):294–7.CrossRefGoogle Scholar
  33. 33.
    Abo-Ryia MH, El-Khadrawy OH, Abd-Allah HS. Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against incisional hernia development. Obes Surg. 2013;23(10):1571–4.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    El-Khadrawy OH, et al. Prophylactic prosthetic reinforcement of midline abdominal incisions in high-risk patients. Hernia. 2009;13(3):267–74.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Guttierrez del la Pena C, Medina Achinca C, Domingues-Adame E, Medina Diez J. Primary closure of laparotomies with high risk of incisional hernia using prosthetic material: analysis of usefulness. Hernia. 2003;7(3):134–6.CrossRefGoogle Scholar
  36. 36.
    Caro-Tarrago A, et al. Prevention of incisional hernia in midline laparotomy with an onlay mesh: a randomized clinical trial. World J Surg. 2014;38(9):2223–30.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Carbonell AM, Cobb WS. Safety of prosthetic mesh hernia repair in contaminated fields. Surg Clin North Am. 2013;93(5):1227–39.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Zhong C, Wu B, Yang Z, Deng X, Kang J, Guo B, Fan Y. A meta-analysis comparing lightweight meshes with heavyweight meshes in Lichtenstein inguinal hernia repair. Surg Innov. 2013;20(1):24–31. Scholar
  39. 39.
    Timmermans L, et al. Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia. Ann Surg. 2015;261(2):276–81.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Takagi H, et al. Postoperative incision hernia in patients with abdominal aortic aneurysm and aortoiliac occlusive disease: a systematic review. Eur J Vasc Endovasc Surg. 2007;33(2):177–81.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Adye B, Luna G. Incidence of abdominal wall hernia in aortic surgery. Am J Surg. 1998;175(5):400–2.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Bevis PM, et al. Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery. Br J Surg. 2010;97(10):1497–502.CrossRefPubMedGoogle Scholar
  43. 43.
    Muysoms FE, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1–24.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Gaertner WB, Bonsack ME, Delaney JP. Experimental evaluation of four biologic prostheses for ventral hernia repair. J Gastrointest Surg. 2007;11(10):1275–85.CrossRefPubMedGoogle Scholar
  45. 45.
    den Hartog D, et al. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008;3:CD006438.Google Scholar
  46. 46.
    Sarr MG, et al. A prospective, randomized, multicenter trial of Surgisis Gold, a biologic prosthetic, as a sublay reinforcement of the fascial closure after open bariatric surgery. Surgery. 2014;156(4):902–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Llaguna OH, et al. Does prophylactic biologic mesh placement protect against the development of incisional hernia in high-risk patients? World J Surg. 2011;35(7):1651–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Bali C, et al. A comparative study of sutured versus bovine pericardium mesh abdominal closure after open abdominal aortic aneurysm repair. Hernia. 2015;19(2):267–71.CrossRefPubMedGoogle Scholar
  49. 49.
    Pearl RK. Parastomal hernias. World J Surg. 1989;13(5):569–72.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Israelsson LA. Parastomal hernias. Surg Clin North Am. 2008;88(1):113–25, ix.CrossRefPubMedGoogle Scholar
  51. 51.
    Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg. 2003;90(7):784–93.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Guenaga KF, et al. Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Systematic review and meta-analysis. Acta Cir Bras. 2008;23(3):294–303.CrossRefPubMedGoogle Scholar
  53. 53.
    Luijendijk RW, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392–8.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Janes A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a prosthetic mesh. Arch Surg. 2004;139(12):1356–8.CrossRefPubMedGoogle Scholar
  55. 55.
    Janes A, Cengiz Y, Israelsson LA. Randomized clinical trial of the use of a prosthetic mesh to prevent parastomal hernia. Br J Surg. 2004;91(3):280–2.CrossRefPubMedGoogle Scholar
  56. 56.
    Janes A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study. World J Surg. 2009;33(1):118–21. discussion 122-3.CrossRefPubMedGoogle Scholar
  57. 57.
    Berger D. Prevention of parastomal hernias by prophylactic use of a specially designed intraperitoneal onlay mesh (Dynamesh IPST). Hernia. 2008;12(3):243–6.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Gogenur I, et al. Prevention of parastomal hernia by placement of a polypropylene mesh at the primary operation. Dis Colon Rectum. 2006;49(8):1131–5.CrossRefPubMedGoogle Scholar
  59. 59.
    Marimuthu K, et al. Prevention of parastomal hernia using preperitoneal mesh: a prospective observational study. Color Dis. 2006;8(8):672–5.CrossRefGoogle Scholar
  60. 60.
    Shabbir J, Chaudhary BN, Dawson R. A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation. Color Dis. 2012;14(8):931–6.CrossRefGoogle Scholar
  61. 61.
    Pianka F, et al. Prophylactic mesh placement for the PREvention of paraSTOmal hernias: the PRESTO systematic review and meta-analysis. PLoS One. 2017;12(2):e0171548.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Lopez-Cano M, et al. Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized controlled trial. Hernia. 2012;16(6):661–7.CrossRefPubMedGoogle Scholar
  63. 63.
    Lopez-Cano M, et al. Preventing parastomal hernia using a modified Sugarbaker technique with composite mesh during laparoscopic abdominoperineal resection: a randomized controlled trial. Ann Surg. 2016;264(6):923–8.CrossRefPubMedGoogle Scholar
  64. 64.
    Zhu J, Pu Y, Yang X, Zhang D, Zhao K, Peng W, Xing C. Prophylactic mesh application during colostomy to prevent parastomal hernia: a meta-analysis. Gastroenterol Res Pract. 2016;2016:1694265.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Chapman SJ, Wood B, Drake TM, Young N, Jayne DG. Systematic review and meta-analysis of prophylactiv mesh during primary stoma formation to prevent parastomal hernia. Dis Colon Rectum. 2017;60(1):107–15. Scholar
  66. 66.
    Hammond TM, et al. Parastomal hernia prevention using a novel collagen implant: a randomised controlled phase 1 study. Hernia. 2008;12(5):475–81.CrossRefPubMedGoogle Scholar
  67. 67.
    Fleshman JW, et al. A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies. Dis Colon Rectum. 2014;57(5):623–31.CrossRefPubMedGoogle Scholar
  68. 68.
    Pilgrim CH, McIntyre R, Bailey M. Prospective audit of parastomal hernia: prevalence and associated comorbidities. Dis Colon Rectum. 2010;53(1):71–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of GI/Minimally Invasive SurgeryStritch School of Medicine, Loyola University Medical CenterMaywoodUSA
  2. 2.Center for Minimally Invasive Surgery, Gastrointestinal Surgery, University of KentuckyLexingtonUSA

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