Table 4

Examples from the qualitative data representing the development of the overarching category theme ‘Surgical approach to stoma formation

Surgical approach to stoma formationExtract 1: ‘I would favour using a laparoscopic technique if that was technically possible. The reason being that you can actually confirm the anatomy so you can perform an end colostomy, which I think reduces the risk of parastomal formation and the other complications such as prolapse and retraction. You can actually mobilise the colon to bring it up to the abdominal wall’. (HCP: BRI0022, surgeon, lower GI, RDE)
Extract 2: ‘There is talk, that maybe sometimes laparoscopic surgery they end up with more hernias, but to me I think it’s when they’ve had a full-blown laparotomy and then they have a stoma form. I think they’re probably more at risk because they’ve got double… They appear to have weaker muscles, don’t they?’. (HCP: BRI0003, stoma nurse, BRI)
The section of bowel used to create the stomaExtract 3: ‘It does, you can do end stoma rather than a loop. The loop ones I think we tend to have a lot more trouble with prolapse, retraction and herniation because you have to make a bigger cut to bring up the loop of the colon’. (HCP: BRI0022, surgeon, lower GI, RDE)
Extract 4: ‘An end seems less likely; a loop ileostomy seems more likely to get a parastomal hernia than an end ileostomy. I’m trying to think if colostomies seem less likely to get an earlier-on hernia and more likely to get a later-on hernia’. (HCP: BRI0002, stoma nurse, BRI)
Length of bowel mobilisedExtract 5: interviewer: ‘What do you think about the amount of bowel mobilised? Do you think that would make a difference to parastomal hernias?’.
Respondent: ‘Probably. Yes, you’re probably right, probably more with stoma prolapse or retraction, rather than parastomal hernias. I suppose if you have a prolapsing stoma, it would widen the defect. I don’t know’. (HCP: BRI0009, surgeon, upper GI, BRI)
Premarked stoma siteExtract 6: ‘The stoma site is pre-marked at two sites above and below and left lateral to the umbilicus. Both sites have been tied with a suture’. (Observation CM: BRI0014, end colostomy, laparoscopic, BRI)
Extract 8: interviewer: ‘You also mentioned preoperative marking of the stoma site. Do you think that will make a difference to the parastomal hernia rates?’.
Respondent: ‘It probably doesn’t, it is probably more about having a better site for the patient in terms of a place where they can change it. I suppose sometimes if it is marked in a position that is not ideal for a surgeon it can be more challenging for us. If anything is more challenging you might increase things marginally, but probably not’. (HCP: BRI0022, surgeon, lower GI, RDE)
Route of the stoma through the abdominal wallExtract 9: ‘Technical factors associated with parastomal. So, I suppose one thing to address is whether we do this as a trans-peritoneal, or an extra peritoneal approach. So, years ago, in the ‘60s and ‘70ss, and maybe even more recently, it was quite common for the stomas to be tunnelled, pre-peritoneally, laterally, so essentially what you were doing is you’d have the bowel up laterally against the abdominal wall or the under surface, and then it would come out through the muscles as an extraperitoneal stoma. That may have an impact, I don’t know, that’s never been subjected to a randomised trial comparing it to the trans-peritoneal approach, where the bowel simply just comes through the abdominal wall without tunnelling it. So I think that’s a possible surgical technique factor’. (HCP: BRI0004, surgeon, lower GI, BRI)