Preoperative risk factor modification to reduce the likelihood of PH can be a challenge. The majority of patient characteristics associated with increased risk of PH including sex, age, presence of other hernias, or certain comorbidities are nonmodifiable. Tobacco cessation can be encouraged and efforts can be made to lose weight or optimize diabetes control preoperatively; however, these strategies cannot be employed for emergent procedures warranting ostomy creation.

In an early study, there was a significantly lower rate of PH when the stoma was brought out through the rectus abdominus muscle versus lateral to it [36], but more recent studies have concluded that stoma site, fascial fixation, or closure of the lateral space have no effect on PH formation [10, 12, 18, 19, 37]. A meta-analysis of 1071 colostomy patients showed a lower rate of PH with extraperitoneal colostomy creation compared to intraperitoneal colostomy [38]. The main interest in PH prevention is investigating the role of prosthetic mesh. The use of prophylactic mesh to prevent PH was reported as early as 1986 by Bayer et al. who had no PHs over a 4-year follow-up period in 43 patients who underwent placement of Marlex mesh (Phillips Petroleum Company, Bartlesville, OK) during colostomy creation [39]. Following Bayer’s success, there have since been many observational studies that have evaluated the efficacy and safety of prophylactic mesh placement. Figel et al. demonstrated no mesh complications and no PH recurrences in 16 patients who underwent placement of a bioprosthetic mesh with a median follow-up of 38 months [40]. Gogenur et al. demonstrated no infectious complications, an 8 % rate of minor complications, and an 8 % rate of PH recurrence in 25 patients who had polypropylene mesh placed in the onlay position with a median follow-up of 12 months [41]. A small series of intraperitoneal onlay of polyvinylidene mesh during laparoscopic abdominoperineal resection (APR) showed no mesh-related complications, infections, or PH recurrence at a mean follow-up of 6 months [42]. A study by Nagy et al. evaluated the polypropylene hernia system large device in 14 cases after APR with sigmoid colostomy and noted no PH recurrence in the first postoperative year [43]. Marimuthu et al. studied a polypropylene monofilament mesh with a circle cut in it for the stoma placed preperitoneally without stitches in 18 patients and found no PH at a mean follow-up of 16–17 months. One patient required revision for stoma necrosis on postoperative day one and subsequently developed a wound infection, but no other complications were noted [44]. A prospective study of preperitoneal polypropylene mesh placed in 42 patients with a mean follow-up of 31 months demonstrated a PH incidence of 9.52 % (4/42) [45]. Cost-effectiveness of mesh prophylaxis has also been studied by Lee et al. who looked at mesh prophylaxis in 60-year-olds who underwent APR with end colostomy for rectal cancer and found mesh prophylaxis to be less costly and more effective compared to no mesh for those patients with stage I–III rectal cancer [46]. A multicenter randomized control trial (RCT) by Hauters et al. evaluated 20 patients who underwent laparoscopic and open APR and had an intraperitoneal onlay mesh placed. One patient presented with mild stoma stenosis and one patient (5 %) had a stoma bulge that was confirmed as a PH on CT scan [47]. Another RCT found decreased presence of radiographic PH in patients who had a lightweight intraperitoneal/onlay mesh placed during laparoscopic APR compared to those without mesh (50 versus 93.8 %, p = 0.008) [48]. The three RCTs by Hammond, Janes, and Serra-Aracil have been the most cited papers on the topic of PH prevention. In 2008, Hammond et al. published a RCT of 20 patients undergoing defunctioning stomas with a porcine-derived collagen implant placed in the sublay position in 10 of the patients. With a median 6.5-month follow-up, there were no PHs in the mesh group compared to 30 % (3/10) in the nonmesh group, and there were no complications [49]. Janes et al. evaluated 54 patients undergoing permanent colostomy creation (27 patients with a conventional stoma and 27 with placement of a sublay large-pore light weight polypropylene and polyglactin mesh) and found a lower rate of PH 4.8 % (1/21) in the mesh group compared to 50 % (13/26) in the nonmesh group at 12-month follow-up. There were no infectious complications [50]. A 5-year follow-up study again revealed a lower rate of PH in the mesh group at 13.3 % (2/15) versus 81 % (17/21) in the nonmesh group ( p< 0.001) [9]. The RCT by Serra-Aracil evaluated 54 patients undergoing end colostomy for distal rectal cancer and utilized a sublay lightweight mesh in 27 patients. At a median 29-month follow-up, there were fewer PHs in the mesh group at 14.8 % (4/27) compared with 40.7 % (11/27) in the nonmesh group ( p = 0.03), and the morbidity between the two groups was similar [51]. In 2012, Sajid et al. and Shabbir et al. performed systematic reviews of the RCT literature. Sajid et al. analyzed the three RCTs by Janes, Hammond, and Serra-Aracil encompassing 128 patients who underwent colorectal resections with stoma creation (64 patients in the mesh group versus 64 patients in the nonmesh group), and found an OR of 1.0 (95 % confidence interval [CI] 0.36–3.2, p = 1.0) for developing postoperative complications and an OR of 0.11 (95 % CI 0.05–0.27, p< 0.00001) for developing a PH with the use of mesh [52]. Shabbir et al. reviewed 27 RCTs and excluded all but the same three RCTs as the Sajid paper. This review demonstrated an incidence of PH of 12.5 % (8/64) in the mesh group compared to 53 % (34/64) in the control group ( p< 0.0001). There were no differences in mesh-related complications between the two groups [53]. A similar systematic review that included the same three RCTs but also three prospective observational studies and one retrospective study also found a lower rate of PH in the mesh group at 7.82 % (14/179) versus 55 % (32/58) in the nonmesh group with similar morbidity during a follow-up period ranging 1–83 months [54]. All three systematic reviews concluded that the use of prophylactic mesh at the time of stoma creation can reduce the incidence of PH. A multicenter RCT in the Netherlands known as the PREVENT trial is currently underway and is evaluating whether prophylactic lightweight monofilament polypropylene mesh in a preperitoneal, retromuscular position reduces the incidence of PH formation in patients undergoing elective formation of permanent end colostomies via an open procedure. Follow-up is scheduled for 3 weeks,; 3 months; 1, 2, and 5 years postoperatively [55].

In a series by Moreno-Matias, 27 of the 33 patients (85 %) with clinically detectable PHs had associated symptoms including pain on exertion, interference with irrigation devices, or detachment of the appliance with changes in position [5]. A study of the French federation of ostomy patients found 76 % patients suffered symptoms related to PH including pain, difficulty with appliance fit or leakage [21]. Physical exam can show bulging with a Valsalva maneuver or palpation of a fascial defect [10], but one study demonstrated low interobserver reliability in diagnosing PH based on patient history and clinical examination [56]. Median length of time between the formation of the stoma and the diagnosis of the PH was 44 months (0–331 months) in one study [57].

Imaging can be used as an adjunct to clinical exam in diagnosing PH and, as previously mentioned, may increase the rate of PH detection [5, 10, 23]. However, some PH may not be detected by CT scan [5, 56]. Janes et al. recommended performing CT scans in the prone position and demonstrated good correlation between clinical and radiographic diagnoses when doing so [58]. Contrast can be administered via the stoma to better delineate the anatomy and patency of the bowel. Intrastomal ultrasonography utilizing a 9 MHz probe with rectal setting and render mode enabled the real-time identification of fascia, bowel, rectus muscle, and mesh and had the added benefit of evaluating the patient in the upright and supine positions [59]. As with all ultrasound, diagnostic utility is dependent on availability, operator experience, and equipment quality. Magnetic resonance imaging is rarely needed for PH diagnosis but can be considered in the case of diagnostic uncertainty or in the presence of contraindications to ionizing radiation and should include the diffusion-weighted imaging sequence [60].

Nonoperative management may be attempted pending the patient’s level of discomfort or the severity of the PH complications. Expert consultation with a stoma nurse, if available, can be helpful. A flexible appliance can mold to uneven contours of the skin, and aperture size should leave no more than a 2–3 mm rim around the stoma [61, 62]. Protective skin sealants may improve appliance adhesion and stoma belts may improve appliance security [63]. Similarly, abdominal binders may relieve the discomfort caused by the PH [63].