Practice Patterns and Attitudes of Surgeons on the Use of Prophylactic Mesh to Prevent Parastomal Hernia: A Cross-sectional Survey

Information about surgeons’ attitudes toward using prophylactic mesh (PM) for parastomal hernia (PSH) prevention is limited. PURPOSE: A survey was conducted to assess attitudes/beliefs and surgical practice related to PM use for preventing PSH. METHODS: A cross-sectional email survey was conducted during April 2017 among members (surgeons) of the American Hernia Society, European Hernia Society, and International Hernia Collaboration. Survey items included participant demographic characteristics, knowledge about the incidence of PSH, number of permanent stomas created annually, beliefs/opinions (knowledge/interest) regarding the use of PM, and surgical practices (mesh type and position). Data were collected and tallied using SurveyMonkey. Descriptive statistics were used to analyze the data. RESULTS: Of the 5445 emails sent, 497 responses were received, 235 (47.3%) from the United States and 197 (39.6%) from Europe. The majority of participants were general surgeons (371, 74.6%); a small percentage were colorectal surgeons (37, 7.4%). Most respondents (353, 71.0%) reported at least 11 years of surgical experience, with 37.3% reporting >20 years’ experience. The majority of respondents (340, 68.4%) created <15 ostomies per year, more than half (252, 50.7%) consider the incidence of PSH 30% or below, and 107 (22%) use PM. The most common reason for not using mesh was concern about mesh-related complications (141, 41.5%). When asked about type of mesh, most surgeons (153/245, 62.4%) preferred permanent mesh and an open retromuscular approach (97/278, 34.9%).   CONCLUSION: Results of the present survey show ongoing ambiguity regarding the use of PM for PSH prevention. Education to increase awareness about the incidence of PSH and well-designed safety and effectiveness studies of preventive strategies are needed to help surgeons optimize PSH prevention strategies.

As reviews¹ of the subject have shown, a parastomal hernia (PSH) is a very common (occurring in up to 78% of patients with a stoma) and frequently difficult surgical complication to treat. Specific operative techniques for stoma construction, such as extraperitoneal versus transperitoneal bowel exteriorization, lateral pararectus location versus a transrectus location, or size of the fascial aperture in the abdominal wall have been advocated to prevent PSH formation.² However, recently published guidelines² concluded no evidence-based approach is available that prevents PSH with these operative techniques (ie, used when creating an ostomy), and only a suggestion is offered — that is, to keep the size of the fascial aperture as small as possible to allow passage of the intestine through the abdominal wall without causing ischemia. On the other hand, level 1 evidence (meta-analyses of randomized controlled trials²) has shown a PSH can be effectively prevented by inserting prosthetic material during the creation of a permanent end stoma (prophylactic mesh [PM] augmentation). The mesh can be any type of prosthetic material used for reinforcement of the abdominal wall soft tissues (permanent or absorbable synthetic mesh and biologic mesh), an approach promoted since a 2013 narrative review article.³ Indications for PM augmentation can be permanent end stomas (colostomy, ileostomy, or ileal conduit). A recent meta-analysis⁴ of randomized controlled trials that included 451 patients showed the prevention of PSH via PM augmentation when creating an end colostomy reduced the incidence and subsequent repair of PSH without increased wound infections compared with traditional end colostomy formation without mesh (risk ratio [RR] 0.43; 95% confidence interval [CI] 0.26-0.71; P = .0009). Although no recommendation to use PM can be made for ileostomies or ileal conduit stomas or for the use of synthetic absorbable or biological meshes, published guidelines² on prevention and treatment of PSH recommend use of synthetic nonabsorbable mesh to reduce the rate of PSH when creating an elective, permanent end colostomy. Nevertheless, PM augmentation to prevent PSH has not been widely adopted, and views toward PM as evidenced in survey studies^5,6 and commentaries⁷ are cautious.

Failure to use PM augmentation when creating permanent stomas may reflect the evolving complexity of clinical decision making in the 21st century. A recent review⁸ stressed the need to combine critical appraisal of the evidence, patient values and preferences, and surgeon knowledge through shared decision making. Thus, a number of potential reasons may be put forward to explain the reluctant adoption of PM augmentation to prevent PSH. First, not enough high-quality data are available to definitively demonstrate the safety and efficacy of this approach, although the data that exist are strong.^2,4 Second, patient-centered outcomes (ie, values and preferences) regarding PSH prevention with mesh are currently unknown; thus, this important aspect of decision making is unavailable. Third, information is limited regarding barriers to the use of mesh for preventing PSH from the surgeon’s perspective.^5,6 

This study sought to address this third gap in knowledge by designing a survey to determine the prevalence of PM augmentation to prevent PSH in routine surgical practice and gather information about the opinions and practice patterns of surgeons regarding this question. 

Survey. A self-administered survey was designed and reviewed by 5 experienced hernia surgeons who have a particular interest in PSH prevention; they developed the questions based on important topics and controversies related to PSH prevention. A 10-question survey (see Table 1 and Table 1 Continued) was sent via email to surgeons from the American Hernia Society (AHS), European Hernia Society (EHS), and International Hernia Collaboration (IHC) after previous review of the membership lists and approval of the study by the Institutional Review Boards of the different entities. The survey included 4 questions to assess demographic characteristics of respondents (area of surgical specialty, number of years in practice, type of hospital, and country of residence), 2 questions to assess respondent awareness regarding the incidence of PSH associated with an end stoma and number of permanent stomas created yearly, 2 questions to assess opinions and beliefs (knowledge/interest) regarding the use of a PM augmentation to prevent PSH, and 2 questions to determine their surgical practices (mesh type and position) related to PSH prevention. Stomas involving the urinary system were excluded. The survey was designed using SurveyMonkey (https://www.surveymonkey.com). The electronic link to the survey was made available to all members of the AHS, EHH, and IHC and remained active from January 4 to April 11, 2017. Two (2) reminders were sent by email. All responses were anonymous. Descriptive statistics were used to analyze the responses. Survey results provided by SurveyMonkey were analyzed using a Microsoft Office Excel spreadsheet (Microsoft Corporation, Redmond, WA).

Respondent demographics. From a total of 5445 emails sent (1042 from EHS, 888 from AHS, and 3515 from IHC), 497 surgeons responded to the survey for an overall response rate of 9.1% (see Table 2). The majority were general surgeons (371, 74.6%); a small percentage were colorectal surgeons (37, 7.4%). Most respondents (353, 71.0%) reported at least 11 years of surgical experience, with 37.3% reporting >20 years’ experience; 188 (37.8%) were employees of a hospital, 117 (23.5%) were in private practice, and 96 (19.3%) were academic surgeons. The majority of respondents were from the United States (235, 47.3%) or Europe (197, 39.6%). 

Practice and awareness. All but 1 participant answered the question regarding the number of definitive end stomas performed annually. The majority of respondents (340, 68.5%) created <15 ostomies per year, 83 (16.7%) created between 15 and 50/year, 2 (0.4%) created >50/year, and 71 (14.3%) reported creating no end stomas. When asked to estimate the incidence of PSH at 5 years, the highest percentage of respondents (28.4%) responded 30% (see Figure).

Opinions and beliefs. Of the 486 respondents who answered this question, 196 surgeons (40.3%) were familiar with the literature and interested in using PM placement, 107 (22%) were familiar with the literature but would not use PM, and 63 (13%) reported no familiarity with the literature regarding PM augmentation to prevent PSH (see Table 3). Of the 340 responses collected regarding reasons for not using PM placement, the most common (141, 41.5%) was concern about mesh infection or mesh-related complications; 66 (19.4%) reported not being familiar enough with the technique to correctly perform the procedure.

Surgical practice. Questions in this section of the survey were the most frequently unanswered (252 [50.7%] did not answer the question about the type of mesh used, and 219 (44.1%) did not answer the question about how the PM was positioned. As shown in Table 3, most of the surgeons who used PM (153, 62.4%) used a permanent synthetic mesh, followed by biologic mesh (32, 3.1%) and absorbable synthetic mesh (30, 12.2%,). Of the 278 (55.9%) responses regarding positioning of mesh, the most frequently reported was an open retromuscular operative technique (97, 34.9%).

The results of this survey demonstrate the diversity of opinions among surgeons regarding the use of a PM at end stoma formation to prevent PSH. Most responses were received from American and European general surgeons. As such, these results may not be generalizable to surgical specialties other than general surgery, such as colorectal surgery, which accounted for only 7.4% of respondents. Most respondents were experienced surgeons; thus, one can reasonably assume they have the operative skills required to practice evidence-based surgery and decision making.⁹ Consequently, the results of the survey are likely a good general indicator of the practices and beliefs of general surgeons with regard to PM augmentation to prevent PSH formation.

Although a minority of respondents (22%) reported use of PM when creating stomas, the low penetration of this practice was not due to a lack of knowledge; only 13% of respondents were unfamiliar with the published literature (question 7). The main reason identified for not using mesh was concern about potential mesh-related complications. The second most common reason was a lack of familiarity with the technical aspects of mesh placement. Interestingly, the lack of specific procedural reimbursement for PM augmentation was the principal reason for not performing this procedure for 10.6% of respondents. Furthermore, 13% of surgeons were not convinced of the benefits of PM. The survey did not explore why these surgeons were unconvinced. Also of particular interest was the relationship between knowledge about incidence of PSH and what is known from the literature. More than half of respondents (52%) think the incidence of PSH is 30% or below; however, 84% of respondents said they are familiar with literature on PSH prevention, but only 22% of them are already using a PM. This might suggest a potential lack of awareness of the high incidence of PSH described in literature.  

Current survey findings are similar to those previously reported. Parkinson et al⁵ conducted an email survey of the corresponding authors of 200 original articles published in 2 journals, Colorectal Disease and Diseases of the Colon and Rectum, with a response rate of 55%. Of the 111 respondents, 65 (58.6%) were colorectal specialists with at least 10 years in practice. Overall, 17% of respondents said that they had used or had observed the use of PM during the last elective permanent colostomy in which they had participated. Surgeon apprehension for using this device based on a fear of infection and other mesh-related complications or the lack of convincing efficacy data also have been reported.⁶ 

Of the 497 surgeons who responded to the current survey, 107 reported actually using a PM, yet more than 200 responded to questions regarding technical aspects of the procedure. This apparent discordance may have resulted from surgeons expressing their opinions regarding the type mesh to be used and its placement even though they do not practice PM augmentation. The reason behind this discrepancy is not known. Nonetheless, of those who reported using mesh, most chose a nonabsorbable synthetic mesh and an open retromuscular technique, findings that are in agreement with previous reports.⁴

The present results should be interpreted with some limitations. First, the survey tool was self-administered and did not undergo internal or external validation before distribution. Although the survey instrument had not been validated, 5 experienced surgeons drawn from the population of survey recipients reviewed its content. Second, the response rate was <10% (497/5445). However, investigators have shown that response rate-induced bias does not seem to be much of a threat to the validity of questionnaires.¹⁰ Still, the responses may not accurately represent the practice patterns and attitudes of the surgeons surveyed.¹⁰ On the other hand, this is the largest survey of surgeons to date regarding the prevention practices of PSH. Third, the survey was distributed among members of the AHS, EHS, and IHC but did not query surgeons who do not belong to these organizations. A selection bias is likely, because members of these societies have a declared interest in abdominal wall surgery, including the prevention of PSH. Fourth, the apparent discordance from surgeons expressing their opinions regarding the type mesh to be used and its placement even though they do not practice PM augmentation must be considered.

The results of an email survey of surgeons’ attitudes and practices regarding PM augmentation for PSH prevention indicate many general surgeons do not use this preventative strategy because of concerns regarding efficacy and safety, especially with respect to potential mesh-related complications. From a practical point of view, results of the present survey show ongoing ambiguity regarding the use of PM for PSH prevention. Its use remains controversial, and clarification about its effectiveness is still needed. A combination of well- designed safety and effectiveness studies and education is needed to increase awareness of the incidence of PSH and help surgeons implement effective preventative strategies

The authors thank Marta Pulido, MD, for editorial assistance.

Dr. Lopez-Cano is a consultant and speaker for Bard Spain S. A. (Barcelona, Spain), Gore Spain (Madrid, Spain), and B. Braun Surgical (Barcelona, Spain). Dr. Fisher has consulted for Bard Davol (active; Warwick, RI), W. L. Gore and Associates, Inc (active; Flagstaff, AZ), Allergan (not active; Dublin, Ireland), and Tela Bio (not active; Malvern, PA). Dr. Hope is affiliated with CR Bard (Franklin Lakes, NJ), W. L. Gore-Consulting/Research, and Intuitive Speaking.  

Dr. López-Cano is Chief of the Abdominal Wall Surgery Unit, Department of Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. Dr. Harris is Chief of General Surgery, Department of Surgery, University of California, San Francisco, CA. Dr. Fisher is an Assistant Professor of Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA. Dr. Pereira is a general and abdominal wall surgeon, Department of Surgery, Parc de Salut Mar, Experimental and Health Science, Universitat Pompeu Fabra, Barcelona, Spain. Dr. Garcia-Alamino is a methodologist, DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK. Dr. Hope is a Program Director-General Surgery Residency Program, Associate Professor of Surgery-UNC-CH, Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC.

Please address correspondence to: Manuel López-Cano, MD, PhD; email: mlpezcano@gmail.com.