The concept of proportional reconstruction in parastomal hernia repair: a narrative review

Purpose Parastomal hernia (PSH) is the most common long-term complication after stoma formation and remains one of the greatest challenges in abdominal wall surgery. Although several anatomical classifications and reconstructive techniques have been described, considerable heterogeneity remains in patient selection and surgical management. This narrative review evaluates contemporary evidence on PSH and proposes a practical framework for individualized reconstruction. Methods A structured narrative review of the literature was conducted using PubMed, Embase, and the Cochrane Library. International guidelines, systematic reviews, meta-analyses, randomized controlled trials, and observational studies published between 2000 and 2026 were critically appraised. Evidence was synthesized around four key domains: definition of complexity, quality of life and surgical indications, principles of repair, and advanced abdominal wall reconstruction. Results Current evidence indicates that PSH complexity is multidimensional, reflecting the interaction of anatomical characteristics, patient-related biological factors, and functional impairment. Quality of life should be the principal determinant of the indication for elective surgery, whereas anatomical findings should guide the reconstructive strategy. Mesh reinforcement remains the standard approach for most elective repairs, while advanced abdominal wall reconstruction should be reserved for selected patients with complex disease. Conclusion Complex PSH should be regarded as a multidimensional clinical entity rather than a purely anatomical condition. We propose proportional reconstruction as a conceptual framework in which operative complexity increases only when justified by disease complexity, thereby supporting individualized decision-making and a more rational use of advanced reconstructive techniques.