The Nordic parastomal hernia paradox: A regional survey of prophylaxis and repair

BACKGROUND AND AIMS: To evaluate current preferences and practices as well as institutional policies regarding parastomal hernia (PSH) prevention and repair among Nordic surgeons. METHODS: A cross-sectional, web-based survey was distributed to consultant-level surgeons and senior trainees across Denmark, Finland, Norway, and Sweden, assessing demographics, prophylaxis practices, and repair preferences. RESULTS: A total of 191 surgeons responded, of whom 98% practiced in academic or regional hospitals and 50% had >10 years of specialist experience. Among the 166 respondents (87%) who performed permanent end colostomies, only 28% currently used prophylactic mesh, while 53% had never used it, and 19% had discontinued prior use. Prophylactic adoption varied markedly by country: Finland (81%) versus Denmark (0%). Primary barriers were belief in acceptable non-mesh outcomes (42%) and complication fears (40%). Among current mesh users, the intraperitoneal funnel (Chimney) technique was most prevalent (54%). For PSH repair (n = 111), laparoscopic Sugarbaker was the most frequently performed (41%) and preferred (34%) technique. Robotic Pauli emerged as the second most preferred approach (20%), and robotic-assisted repair was used by 17% of repair-performing surgeons, but preferred by 39% of hernia/abdominal wall reconstruction (AWR) specialists. Open surgery was used by 50% but preferred by only 20%, reflecting a marked preference-utilization gap. One-third of respondents (36%) believed more patients should be offered elective PSH repair, with significant country-level variation: 65% of Swedish surgeons favored more repairs, while 42% of Danish surgeons favored fewer repairs. CONCLUSION: A substantial implementation gap in PSH prophylaxis persists across the Nordic region, driven by surgical culture rather than evidence. In contrast, repair practice is shifting decisively toward robotic retromuscular techniques, led by specialists. The perceived need for more elective repairs, particularly given the high mortality (up to 29%) of emergency repair, supports adopting centralized referral pathways-modeled on the Danish experience-to improve regional outcomes.