Reconstructive Strategies for Abdominal Wall Defects in Patients With Stomas: A Systematic Review of Mesh and Flap Techniques.
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An abdominal wall hernia occurs when there is a defect or weakness in the abdominal wall musculofascial layer. Patients with ostomies are at particular risk of developing parastomal hernia because stoma creation necessarily traverses the abdominal wall, creating a structural weak point. In high-risk patients, including those with prior abdominal surgery, prior mesh infection, recurrent parastomal hernia, or large soft-tissue defects, hernia repair often requires complex reconstruction. Mesh-based repairs reduce hernia recurrence rates; however, limitations persist in settings of infected mesh fields, recurrent parastomal hernias, or extensive soft-tissue defects requiring tissue coverage beyond mesh reinforcement alone. This systematic review evaluates reconstructive approaches for abdominal wall defects in stoma patients, comparing mesh-only versus mesh with flap repairs, focusing on hernia recurrence, wound healing, and infection outcomes. Following PRISMA guidelines, comprehensive searches of PubMed, ScienceDirect, and the Cochrane Library were undertaken to identify studies published between January 2015 and July 2025. Boolean operators and Medical Subject Headings (MeSH) terms combining 'stoma,' 'abdominal wall,' and 'reconstruction' yielded 1,947 articles. After duplicate removal, 1,785 unique records were screened. Eligible studies included randomized controlled trials (RCTs), observational studies, and case series with at least five patients, reporting outcomes of mesh with or without flap reconstruction in adult patients undergoing abdominal wall repair in the setting of a stoma, which encompasses parastomal hernia repair, wound breakdown, and complex abdominal wall reconstruction with concomitant stoma management. Exclusions included case reports, reviews, pediatric-only, and abstract-only studies. Screening and data extraction were performed independently by two reviewers, with discrepancies resolved by consensus. Thirteen papers met inclusion criteria. The PRISMA 2020 flow diagram documented study selection. Included studies comprised retrospective cohorts, case-controlled analyses, and database studies (sample sizes up to 9,000 patients). Patients frequently had malignancy, obesity, prior abdominal surgery, or prior mesh infection as risk factors. Mesh reinforcement, whether prophylactic or used in delayed reconstruction, consistently reduced parastomal hernia incidence. Flap reconstructions, including autologous tissue flaps and component separation, were effective in complex cases involving large defects or recurrent hernias. Techniques such as Stapled Mesh Stoma Reinforcement Technique (SMART) and Stapled Transabdominal Ostomy Reinforcement with Retromuscular Mesh (STORRM) demonstrated feasibility with low recurrence rates in high-risk patients. Both mesh-only and combined mesh-flap approaches demonstrated low complication rates and preserved stoma function, supporting their safety and effectiveness in appropriately selected patients. Both mesh-only and mesh-plus-flap reconstruction are effective and safe for abdominal wall defect repair in stoma patients. Mesh reinforcement reduces hernia recurrence, while flap techniques offer added benefit in complex cases characterized by large defects, recurrent parastomal hernias, or compromised tissue. Well-powered, prospective comparative studies are needed to establish definitive evidence-based guidelines.