Reply to "Can we avoid rectus abdominis muscle atrophy and midline shift after colostomy creation?".

markdownabstractWe read with interest the letter to the editor by Stephenson et al regarding our article “Abdominal rectus muscle atrophy and midline shift after colostomy creation.” Any attempt to decrease the risk of parastomal herniation should be applauded, because its incidence of greater than 50% remains unacceptably high. Transrectus vs pararectal stoma placement has been subject to discussion for quite some time, is retrospective in nature, and thus the level of evidence is low. The most recent Cochrane review concludes that the poor quality of the included evidence did not allow a robust conclusion. In addition, no difference could be discovered after we pooled all studies, which comprised a total number of 761 patients. Furthermore, the authors describe in their letter that they could not observe a midline shift in their trial; however, as we mention in our study, we could only determine the true midline by using the I-Space, a CAVE-like virtual reality system and V-scope software, so we are interested as to how the authors determined a midline without these tools. Applying new techniques to prevent this complication seems highly relevant, because the impact of parastomal hernia on the quality of life of patients should not be underestimated (unpublished results). Placement of the stoma lateral to the rectus muscles could possibly decrease the rate of parastomal hernia, as is suggested by the retrospective study of Stephenson et al. The intercostal nerves are less segmented lateral to the stoma and could be easier to detect and preserve. Randomized, controlled trials, however, are needed to evaluate the effect of this technique. A possible technique for parastomal hernia prevention is the use of primary mesh augmentation. A meta-analysis focusing on primary mesh augmentation showed a decrease in parastomal hernia with a risk ratio of 0.23. Interestingly, no mesh infections were reported in any of the randomized controlled trials, but the use of prosthetic material in potentially contaminated areas are still a subject of debate. Possibly, the long-term results of the PREVENT trial could give us more information regarding this prevention method.