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A clinical and radiological assessment of incisional hernias following closure of temporary stomas
Abstract
Aims:
The rate of incisional hernia at stoma closure sites is unclear. This study aimed to describe this rate in patients with closed stomas who had definitive post-operative imaging of their abdominal wall.
Methods:
A retrospective review of patients who had undergone stoma reversal and had a CT or MRI scan of the abdomen ≥2 months following reversal was performed. A radiologist, blinded to the original radiological report and clinical results, reviewed all scans for abdominal wall herniation. This was correlated to documented clinical findings.
Results:
Fifty-nine patients were included: 49 loop ileostomy and 10 end colostomy reversals. CT scans were performed for 57 patients and MRI for two. The median time from closure to imaging was 10 months (range 3-32 months). The combined clinical and radiological hernia rate was 34% (20/59). Imaging alone produced a rate of 31% (18/59). The clinical rate of hernia detection was 14% (8/59). Using the rate of clinical herniation as the detection standard, imaging had a low positive predictive value (33%, 6/18) but a high negative predictive value (95%, 39/41). Four patients required surgical repair of their stoma site hernia (20%, 4/20).
Conclusions:
One in three patients undergoing stoma closure developed an incisional hernia. One in five of those with a hernia underwent surgical repair. Definitive imaging may provide an early surrogate marker for late clinically relevant hernias. Consideration of methods to prevent stoma closure site hernias should be considered.
... The incidence of incisional hernia (IH) was shown to be 1.8% in Chow's review and 7% in Bhangu's review [50], while observational studies that were specifically designed to evaluate IH after stoma closure reported that the rate of IH was as high as 11.7-34% [50][51][52][53]. These observational studies applied computed tomography (CT) and ultrasound (US) to detect hernia, which might explain the huge difference in the rate of IH in these observational studies in comparison to the reviews. ...
... The incidence of incisional hernia (IH) was shown to be 1.8% in Chow's review and 7% in Bhangu's review [50], while observational studies that were specifically designed to evaluate IH after stoma closure reported that the rate of IH was as high as 11.7-34% [50][51][52][53]. These observational studies applied computed tomography (CT) and ultrasound (US) to detect hernia, which might explain the huge difference in the rate of IH in these observational studies in comparison to the reviews. ...
... These observational studies applied computed tomography (CT) and ultrasound (US) to detect hernia, which might explain the huge difference in the rate of IH in these observational studies in comparison to the reviews. However, in some studies, only the incidence of clinical hernia (hernia diagnosed without the help of CT and US) rate was analyzed; it was reported to be 11.9-14% [50,53], which was still higher than the rate shown in the reviews. The reoperation rate among patients with IH was reported to be 51% in Bhangu's review, which meant that this group of patients had to undergo at least three operations during the entire course of treatment for rectal cancer. ...
Defunctioning stomas are frequently used by colorectal surgeons after unsatisfactory anastomosis. The primary purpose of constructing a defunctioning stoma is to prevent an anastomotic leakage or to alleviate the detrimental consequences of it. However, the construction of defunctioning stomas is not free and is associated with adverse impacts on the patient. Stoma-related complications can develop in different stages and can impair a patient’s quality of life. Furthermore, one in every four to six defunctioning stomas turns into a non-closure stoma. Since no definite indications for the creation of a defunctioning stoma are available, surgeons have to carefully weigh their benefits against their adverse effects. Thus, the precise selection of patients who should undergo the creation of a defunctioning stoma is of great importance, and an alternative method for preventing anastomotic leakage is needed.
... Patients with incisional hernia can present with discomfort and pain [3], and may develop cosmetic problems [4]. The reoperation rate for repair of incisional hernia at a stoma closure site has been reported to range from 4 to 20% [5,6]. ...
... Most reports of hernia formation after stoma closure included a mixture of ileostomy and colostomy closure cases in their analyses [5,10,11]. There are few reports with large numbers of subjects on incisional hernia formation solely after ileostomy closure [1,2]. ...
... Many other reports have also described the usefulness of radiological examination for hernia detection. Bhangu et al. [5] reported that the detection rate of incisional hernia was 14% by clinical findings alone, 31% by radiological findings, and 34% by combined clinical and radiological findings. Cingi et al. [10] reported that the hernia detection rate was 26% by clinical findings and 48% by CT findings. ...
Purpose
Incisional hernia is a major complication after stoma closure and can cause uncomfortable symptoms. In this study, we evaluated the risk factors for hernia formation with the aim of reducing the incidence of incisional hernia.
Methods
A total of 134 oncology patients underwent closure of a temporary loop ileostomy between May 2004 and December 2013. The incidence of incisional hernia was determined by routine follow-up computed tomography scanning every 6 months. The relationships between patients’ characteristics, including age, sex, obesity, diabetes mellitus, surgical site infection, chronic obstructive pulmonary disease, hypertension, hypoalbuminemia, smoking, and presence of a midline hernia and the occurrence of incisional hernia were retrospectively evaluated.
Results
The median follow-up time was 47 months (range 8–130). Hernias occurred in 23.9% of patients (32/134). The median time to detection of hernias was 8 months (range 2–39). The Chi-squared test revealed significant differences in obesity (P = 0.0003), hypertension (P = 0.0057), and incisional hernia history (P = 0.0000) between patients with and without incisional hernia. Multivariable analysis and univariate analysis revealed that hypertension and the presence of midline incisional hernia were risk factors for incisional hernia.
Conclusions
Hypertension and the presence of a midline incisional hernia were the major risk factors for incisional hernia after loop ileostomy closure. These risk factors can be addressed before planning surgery.
... Eight studies reported on risk factors for development of SSIH (Table S2) [3][4][5][30][31][32]45,52]. In univariate analysis, Brook et al. [5] found a significantly higher BMI in patients who developed SSIH compared with patients without SSIH (mean 28.4 kg/m² vs 24.7 kg/m²). ...
... In univariate analysis, Brook et al. [5] found a significantly higher BMI in patients who developed SSIH compared with patients without SSIH (mean 28.4 kg/m² vs 24.7 kg/m²). Bhangu et al. [30] found no significant differences in age or gender for patients with SSIH versus no SSIH. Moreover, no difference in MIH between patients with and without SSIH was found (50% vs 41%, P = 0.51). ...
... To investigate potential underestimation, the overall incidence of SSIH from the 11 studies with SSIH as the primary outcome was calculated (17.7%, range 1.7%-36.1%) [4,5,[30][31][32]37,45,46,48,51,52]. These rates indeed support the hypothesis that the overall incidence of hernia from all included studies (6.5%), as from those only reporting on SSIH as a secondary outcome (3.6%), is an underestimation. ...
Aim
Stoma reversal might lead to stoma site incisional hernias. Recently, prophylactic mesh reinforcement of the stoma site has gained increased attention, supporting the need for accurate data on stoma site incisional hernia incidence and risk factors to identify high‐risk patients. The aim of this study was to assess incidence, risk factors, and prevention of stoma site incisional hernias.
Method
Embase, MEDLINE, Web of Science, Cochrane, and Google Scholar databases were searched. Studies reporting stoma site incisional hernia incidence after stoma reversal were included. Study quality was assessed with the Newcastle‐Ottowa Scale and Cochrane risk‐of‐bias tool. Data on incidence, risk factors, and prophylactic mesh reinforcement were extracted.
Results
Of 1440 articles found, 33 studies comprising 4679 reversals were included. The overall incidence of incisional hernia was 6.5% (range:0‐38%, median follow‐up:27.5 (17.54‐36) months). Eleven studies assessed stoma site incisional hernia as primary endpoint, showing an incidence of 17.7% (range:1.7‐36.1%, median follow‐up:28 (15.25‐51.70) months). Body mass index, diabetes, and surgery for malignant disease were found to be independent risk factors, as derived from eight studies. Two retrospective comparative cohort studies showed significant lower stoma site incisional hernia rates with prophylactic mesh reinforcement as compared to non‐mesh controls (6.4% versus 36.1% [p=0.001];3% versus 19% [p=0.04]).
Conclusion
The problem of stoma site incisional hernias as long‐term problem should not be underestimated. Body mass index, diabetes, and malignancy seem to be potential risk factors. Currently, limited data are available on the outcomes of prophylactic mesh reinforcement to prevent stoma site incisional hernias.
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... Around half the hernias detected required repair. We have also previously published a very similar study to that of Saeed et al., analysing postoperative surveillance imaging from 59 stoma closures [4]. We again found that the rate of herniation was one in three, and that one in five patients with a hernia required surgical repair. ...
... In contrast to the authors' statement, however, this was not the first prospective study evaluating long-term function longitudinally. In the Dutch total mesorectal excision trial, anorectal, sexual and urinary function were evaluated preoperatively and at several time points up to 5 years [2][3][4][5][6]. In this study patients were randomized to total mesorectal excision with or without short-course radiotherapy (5 9 5 Gy). ...
... In this study patients were randomized to total mesorectal excision with or without short-course radiotherapy (5 9 5 Gy). We found that anorectal and urogenital dysfunction were mainly caused by surgical (nerve) damage, but with a significant additional role of radiotherapy [2][3][4]. ...
We read with interest the article by Saeed et al on the incidence of hernia at the site of temporary loop ileostomy closure(1) . Although at one year follow-up they did not visualise any case of a hernial sac, 37% (16/43) had either muscle atrophy or a defect. It should be noted that the post-operative surveillance computed tomography (CT) scans used were not optimised to detect hernia formation, in contrast to some previously published studies(2) . No patient was reported as requiring surgical repair of a hernia at the stoma closure site. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.
... Regardless of its direct effect, it influences the discussion of suture materials and preventive measures such as mesh reinforcement. These are called for because the incidence of IH is as high as 34%, and the affected patients frequently are subjected to a subsequent hernia repair operation [3]. Other reported risk factors for IH formation at the stoma site include obesity, diabetes mellitus, chronic obstructive lung disease and arterial hypertension [4]. ...
... The overall rate of incisional hernias at the stoma site after reversal operation at our institution was 15.7%. This lies at the [3,4,[8][9][10]. Striving for a more precise analysis, a subgroup of patients with ileostomy reversal after low anterior resection for rectal cancer with systematic oncological followup including regular CT scans was studied. ...
Background
The closure of a stoma site has a high incidence of incisional hernia (IH) development, reaching 30% in some studies. Location and defect size in the abdominal wall depend on the type of stoma formed, most commonly a loop ileostomy or terminal sigmoid colostomy.
Methods
The retrospective single-centre study includes all consecutive patients who underwent stoma reversal between 2010 and 2016 at the Department of Visceral, Transplant and Thoracic Surgery in Innsbruck. Patient characteristics and follow-up examinations were evaluated for IH at both the stoma reversal site and at any other surgical access sites.
Results
A total of 181 patients (49% female, 51% male) had a stoma reversal operation. A parastomal hernia was present in 5% (n = 9). Follow-up data was available for 140 patients (77%). A postoperative IH at the stoma reversal site developed in 15.7% (n = 22) and in 18.6% (n = 26) at other surgical wounds to the abdominal wall during a median follow-up of 136 weeks. The combination of a preoperative parastomal hernia and a postoperative IH was observed in 2.8% (n = 5). Parastomal herniation, male sex, body mass index over 25, arterial hypertension and concomitant ventral hernia were associated with IH formation at the stoma reversal.
Conclusion
The rate of IH at the stoma reversal site was lower than expected from the literature, whereas the rate of IH at other surgical wounds to the abdominal wall was within the expected range.
... In this instance, both patients and clinicians may closely monitor the progression of the incisional hernias. Studies in this review that used radiographic follow-up found a greater number of incisional hernias at both the stoma site and midline incision [5,6,9,14,18]. In addition, in the studies that aimed to assess the impact of radiographic follow-up, the use of radiography proved to be more efficient than clinical assessment alone for the identification of incisional hernias [5,6]. ...
... Studies in this review that used radiographic follow-up found a greater number of incisional hernias at both the stoma site and midline incision [5,6,9,14,18]. In addition, in the studies that aimed to assess the impact of radiographic follow-up, the use of radiography proved to be more efficient than clinical assessment alone for the identification of incisional hernias [5,6]. Although the use of radiography for follow-up may not be feasible, its effectiveness and role warrants further investigation. ...
... In this instance, both patients and clinicians may closely monitor the progression of the incisional hernias. Studies in this review that used radiographic follow-up found a greater number of incisional hernias at both the stoma site and midline incision [5,6,9,14,18]. In addition, in the studies that aimed to assess the impact of radiographic follow-up, the use of radiography proved to be more efficient than clinical assessment alone for the identification of incisional hernias [5,6]. ...
... Studies in this review that used radiographic follow-up found a greater number of incisional hernias at both the stoma site and midline incision [5,6,9,14,18]. In addition, in the studies that aimed to assess the impact of radiographic follow-up, the use of radiography proved to be more efficient than clinical assessment alone for the identification of incisional hernias [5,6]. Although the use of radiography for follow-up may not be feasible, its effectiveness and role warrants further investigation. ...
... However, delaying the findings of trials denies patients and clinicians early evidence on which to base treatment decisions. Imaging assessment of hernias carries two benefits: (1) it allows for standardisation of hernia detection (especially for computed tomography), and (2) it may allow for early identification of late clinically relevant hernias, and thus early delivery of trial results [25]. Finally, thorough provision for assessment of quality of life (including pain) and cost-effectiveness should be assessed and ensured. ...
... bham.ac.uk) These wounds act as a frequent and controlled model for complex and contaminated wounds, where incisional hernia may occur in up to 30 % of patients [25,28]. Patients undergoing re-laparotomy (e.g. ...
Purpose:
Incisional hernia is a common long-term complication after laparotomy. This study investigated whether prophylactic mesh reinforcement of laparotomy reduced the rate of incisional hernia, with emphasis on trial design and quality.
Methods:
A systematic review of published literature was performed for studies comparing incisional hernia presence following conventional closure or prophylactic mesh reinforcement. Studies were assessed using the Cochrane Risk of Bias Tool, the Jadad score and the Newcastle Ottawa Scale (NOS). The primary endpoint was incisional hernia, assessed by meta-analysis.
Results:
Seven studies [four randomised controlled trials (RCTs) and three prospective trials] included 588 patients; 262 received mesh reinforcement. All studies included elective patients at high risk of incisional hernia. Six incorporated a polypropylene mesh and one a biologic mesh. Four studies were judged high quality by NOS and two of four RCTs were at low risk of bias, although overall outcome assessment from all studies was either poor or mediocre. Mesh significantly reduced the rate of incisional hernia [odds ratio (OR) 0.15, p < 0.001]; the same effect was seen in RCTs only (OR 0.17, p < 0.001). A borderline increase of seroma seen with a fixed effect model (OR 1.82, p = 0.050) was not seen with a random effect model (OR 1.86, p = 0.210, I (2) = 45 %).
Conclusion:
Mesh reinforcement of laparotomy significantly reduced the rate of incisional hernia in high-risk patients. However, poor assessment of secondary outcomes limits applicability; routine placement in all patients cannot yet be recommended. More evidence regarding the rates of adverse events, cost-benefits and quality of life are needed.
... However, stoma closure procedures are also at risk of complications like incisional hernias, which have a variable incidence depending on the different studies available, oscillating between 0 and 48% with a presentation median of 7%. This variability can be explained by the method of diagnosis (physical examination vs. diagnostic imaging) and follow-up time [2][3][4]. ...
Background
This study aims to identify which risk factors are associated with the appearance of an incisional hernia in a stoma site after its closure. This in the sake of identifying which patients would benefit from a preventative intervention and thus start implementing a cost-effective protocol for prophylactic mesh placement in high-risk patients.
Methods
A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. Studies reporting incidence, risk factors, and follow-up time for appearance of incisional hernia after stoma site closure were included. A fixed-effects and random effects models were used to calculate odds ratios’ estimates and standardized mean values with their respective grouped 95% confidence interval. This to evaluate the association between possible risk factors and the appearance of incisional hernia after stoma site closure.
Results
Seventeen studies totaling 2899 patients were included. Incidence proportion between included studies was of 16.76% (CI95% 12.82; 21.62). Out of the evaluated factors higher BMI (p = 0.0001), presence of parastomal hernia (p = 0.0023), colostomy (p = 0,001), and end stoma (p = 0.0405) were associated with the appearance of incisional hernia in stoma site after stoma closure, while malignant disease (p = 0.0084) and rectum anterior resection (p = 0.0011) were found to be protective factors.
Conclusions
Prophylactic mesh placement should be considered as an effective preventative intervention in high-risk patients (obese patients, patients with parastomal hernia, colostomy, and end stoma patients) with the goal of reducing incisional hernia rates in stoma site after closure while remaining cost-effective.
... Tilney et al. [13] reported that the probability of recurrent incisional hernia after ileostomy was 3.7%, and the probability of recurrent incisional hernia after colostomy was 14.6%. Other related reports pointed out [14,15] that at least 30% of SSIH occurred within 2 years, and their discomfort symptoms would gradually worsen, and eventually more than half of the patients needed to undergo surgery, and the risk is significantly higher than other patients with abdominal incisional hernia. Therefore, it is particularly important to truly understand the incidence of SSIH and its risk factors. ...
Purpose
Stoma site incisional hernia (SSIH) is a common complication, but its incidence and risk factors are not well known. The objective of this study is to explore the incidence and risk factors of SSIH and build a predictive model.
Methods
We performed a multicenter retrospective analysis on the patients who underwent enterostomy closure from January 2018 to August 2020. Patient's general condition, perioperative, intraoperative, and follow-up information was collected. The patients were divided into control group (no occurrence) and observation group (occurrence) according to whether SSIH occurred. Univariate and multivariate analysis were used to evaluate the risk factors of SSIH, following which we constructed a nomogram for SSIH prediction.
Results
One hundred fifty-six patients were enrolled in the study. The incidence of SSIH was 24.4% (38 cases), of which 14 were treated with hernia mesh repair, and the others were treated with conservative treatment. Univariate and multivariate analysis showed that age ≥ 68 years (OR 1.045, 95% CI 1.002 ~ 1.089, P = 0.038), colostomy (OR 2.913, 95% CI 1.035 ~ 8.202, P = 0.043), BMI ≥ 25 kg/m2 (OR 1.181, 95% CI 1.010 ~ 1.382, P = 0.037), malignant tumor (OR 4.838, 95% CI 1.508 ~ 15.517, P = 0.008) and emergency surgery (OR 5.327, 95% CI 1.996 ~ 14.434, P = 0.001) are the independent risk factors for SSIH.
Conclusions
Based on the results, a predictive model for the occurrence of SSIH was constructed to screen high-risk groups of SSIH. For patients at high risk for SSIH, how to deal with the follow-up and prevent the occurrence of SSIH is worth further exploration.
... Incisional hernias are described as "abdominal wall defects, with or without a bulge, around postoperative scars, observable or palpable by clinical examination or imaging" by the European Society of Radiology [1]. When clinical and imaging (CT or MRI) assessments were combined rather than clinical or radiological screening alone, a higher incidence of incisional hernias was found [2]. The development of a hernia at the site of an earlier ileostomy or colostomy is an unnoticed, delayed adverse effect of enterostomy reversal [3]. ...
Background: Systemic problems, mesh infections, and hernia recurrence have all been related to wound infections that appear after a hernia repair. Objective: To assess the risks factor after surgical site infection with and without mesh incisional hernia. Methodology: The study was a Prospective interventional study which was conducted in Department of Colorectal Surgery Bangabandhu Sheikh Mujib Medical University from April, 2019- September, 2020 using a semi-structured questionnaire through face to face interview. Data were analysed using a computer programme SPSS 24.0 version. Result: The mean age of no mesh group was 55.83±8.42 years while the mesh group was 53.29±9.81 years. A majority of male patients in both, no mesh (70.8%) and mesh (66.7%), groups. The mean BMI of no mesh group was 25.13±5.49 while the mesh group was 26.98±4.46. 3 patients at 4th week and 1 patient at 3rd month had infection in no mesh group. And, 7 patients at 4th week, 2 at 3rd month and 1 patient at 6th month had infection in the mesh group. There was no difference statistically between no mesh and mesh groups (p=0.094, p=0.472 and p=0.280 at 4th week, 3rd month and 6th month, respectively. Conclusion: Obesity, tobacco use, and diabetes mellitus are the three main patient comorbidities that can be modified and are substantially linked to postoperative surgical site infection in hernia surgery. Weight reduction, quitting smoking, and diabetes management are all part of preoperative optimization.
... Incisional hernias are defined as ''abdominal wall defects, with or without a bulge, around post-operative scars, perceptible or palpable by clinical examination or imaging'' according to the European Society [6]. Combining clinical and imaging (CT or MRI) assessment to identify incisional hernias provided a higher rate than clinical or radiological detection alone [7]. ...
Background: Stomal site incisional hernia is a common complication following ostomy closure. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. The effectiveness of prophylactic mesh placement at the time of stoma closure is unknown because of fear of mesh infection and subsequent wound complications. Purpose: To compare the results obtained by placing synthetic mesh in the stoma site during closure with conventional technique without mesh to prevent incisional. Patients and Methods: Prospective interventional study had been designed to compare the outcome of permanent synthetic mesh placement at the time of ostomy closure. Total 45 patients were selected purposively who were candidates for ostomy closure and presented at the Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU) from April 2019 to September 2020 and divided into two groups (no mesh and mesh). In the mesh group, permanent synthetic mesh (ProleneTM – Polypropylene) was placed. Primary outcome, incisional stomal hernia was assessed at regular follow-up for one year along with associated morbidities. Results: The primary outcome of this study i.e. incisional hernia (stomal site) was observed among 1 (4.8%) patients at 4th week, 3 (14.3%) at 3rd month, 7 (33.3%) at 6th month and 8 (38.1%) at 12th month follow-up in no mesh group. And, only 1 patient at 6th month and 12th month follow-up had hernia in the mesh group (Figure 3). There was no difference statistically between no mesh and mesh groups at 4th week and 3rd month but significant difference found at 6th and 12th month follow-up (p=0.280, p=0.344, p=0.033 and p=0.017, respectively). Conclusion: Prophylactic placement of permanent polypropylene mesh during ostomy closure placement significantly reduced the rate of incisional hernia without any additional morbidity. Placement of mesh was found to be both safe and effective.
... Interestingly, 28% of overall incisional hernias were located at the stoma site. The rate of stoma-site herniation observed in this study was slightly lower than that observed in recent studies that focused specifically on this problem and reported an incidence of 30-35% [16][17][18][19]. However, this result is certainly underestimated because we only used a clinical diagnosis. ...
Background
Surgical management of Hinchey III and IV diverticulitis involves Hartmann’s procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. These procedures were evaluated in four randomized controlled trials. Early results from these trials demonstrated similar rates of complications but higher rates of colonic restoration after PRA than HP. Long-term follow-up has not been reported to date. The aim of this study was to analyze long-term outcomes and quality of life (QoL) in patients previously enrolled in a prospective randomized trial comparing HP and PRA for generalized peritonitis due to perforated diverticulitis (DIVERTI trial).Study designFollow-up data were available for 78 of 102 patients. Demographic data, incisional hernia rate, need for additional surgery related to the primary procedure, and QoL were recorded.ResultsThe overall survival rate was 76% and did not differ between the two groups. Incisional hernia was reported in 21 (52%) patients in the HP arm and in 11 (29%) patients in the PRA arm (p = 0.035). The HP arm demonstrated significantly lower SF-36 physical and mental component scores. The mean general QoL (EQ-VAS) and mean EQ-5D index scores were better after PRA than after HP, but this difference was not statistically significant. The results of GIQLI, which measures intestine-specific QOL, did not differ between the two groups.Conclusions
This follow-up study with a median follow-up time of > 9 years among living patients indicates that PRA for perforated diverticulitis is associated with fewer long-term complications and better QoL than HP. PRA significantly reduced the incisional hernia rate and the need for reoperation. Long-term survival was not jeopardized by the PRA approach. Future studies are needed to address the utility of protective stoma.
... This latter percentage could have been even higher if the imaging had included a dynamic sequence, with the patient making a Valsalva manoeuvre. In addition, performing an abdominal ultrasound during a physical exploration could increase sensitivity for diagnosing an IH [24]. ...
Background: Stoma site incisional hernias after ileostomy closure are complex hernias that can be associated with abdominal pain, discomfort, and a diminished quality of life. The aim of this study was to determine the incidence of incisional hernia (IH) following temporary ileostomy reversal in patients undergoing colorectal surgery, and the risk factors associated with its development.
Methods: This was a prospective, single-centre, cohort study of patients undergoing ileostomy reversal between January 2010 and December 2016. Comorbidities, operative characteristics, comparison between early and late ileostomy closure and postoperative complications were analysed.
Results: A total of 202 consecutive patients were prospectively evaluated (median follow-up 46 months; range: 12-109). Stoma site incisional hernia occurred in 23% of patients (n = 47), diagnosed by physical examination or imaging tests. The reasons for the primary surgery were colorectal cancer (n = 141, 69.8%), inflammatory bowel disease (n = 14, 6.9%), emergency surgery (n = 35, 17.3%), and other conditions (n = 12, 5.9%). Secondary outcomes: a statistically significant risk factors for developing an IH was obesity (higher BMI) (OR 1.15, 95% CI: 1.05-1.26) p = .003).
Conclusions: 23% of patients developed surgical site IH, a higher BMI being the only risk factor found to be statistically significant in the development of an incisional hernia.
... Over the years, the need for complex reoperation accumulates, which patients might choose not to undergo until in extremis or until their daily symptoms become too severe; nearly half of patients who develop an incisional hernia at a closed stoma site ultimately require subsequent surgical repair. 4 Studying contaminated wound closure (failure) is challenging due to the heterogeneity of wound size and underlying pathology. 5 Stoma closure sites can be considered a controlled model for the study of contaminated wound healing. ...
Background:
Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site.
Methods:
In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964.
Findings:
Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43-0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26-0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60-1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54-1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events.
Interpretation:
Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias.
Funding:
National Institute for Health Research Research for Patient Benefit and Allergan.
... Two factors should be noted with regard to the incidence of stoma site hernia. Firstly, that the long-term risk is not known and secondly, that clinical examination alone is shown to have a lower detection rate of incisional hernia post stoma closure when compared to clinical imaging (14,15). Therefore, studies focusing on only clinical examination may be underestimating the prevalence, as radiological detected herniae may become symptomatic over time and may be missed in studies with a short follow-up period. ...
Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or “purse-string” closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.
... In these patients, smaller asymptomatic incisional her- nias may have been missed. This could have led to an underestimation of the true incisional hernia rate 2,24 . ...
Background
Stoma reversal is often considered a straightforward procedure with low short‐term complication rates. The aim of this study was to determine the rate of incisional hernia following stoma reversal and identify risk factors for its development.
Methods
This was an observational study of consecutive patients who underwent stoma reversal between 2009 and 2015 at a teaching hospital. Patients followed for at least 12 months were eligible. The primary outcome was the development of incisional hernia at the previous stoma site. Independent risk factors were assessed using multivariable logistic regression analysis.
Results
After a median follow‐up of 24 (range 12–89) months, 110 of 318 included patients (34·6 per cent) developed an incisional hernia at the previous stoma site. In 85 (77·3 per cent) the hernia was symptomatic, and 72 patients (65·5 per cent) underwent surgical correction. Higher BMI (odds ratio (OR) 1·12, 95 per cent c.i. 1·04 to 1·21), stoma prolapse (OR 3·27, 1·04 to 10·27), parastomal hernia (OR 5·08, 1·30 to 19·85) and hypertension (OR 2·52, 1·14 to 5·54) were identified as independent risk factors for the development of incisional hernia at the previous stoma site. In addition, the risk of incisional hernia was greater in patients with underlying malignant disease who had undergone a colostomy than in those who had had an ileostomy (OR 5·05, 2·28 to 11·23).
Conclusion
Incisional hernia of the previous stoma site was common and frequently required surgical correction. Higher BMI, reversal of colostomy in patients with an underlying malignancy, stoma prolapse, parastomal hernia and hypertension were identified as independent risk factors.
... In particular, the risk factors for the development of a hernia at the former stoma site have not yet been analyzed to a sufficient degree. Previous reviews identified incisional hernia rates following stoma reversal in the range of 0 to 48% [3][4][5]. ...
Purpose:
The incidence of incisional hernia (IH) at ileostomy closure site has not been sufficiently evaluated. Temporary loop ileostomy is routinely used in patients after low anterior resection for rectal cancer. The goal of this study was to compare the IH rates of standard suture skin closure and purse-string skin closure techniques.
Patients and methods:
Patients undergoing ileostomy reversal and follow-up CT scan at the University Hospital Frankfurt between January 2009 and December 2015 were retrospectively analyzed regarding IH and associated risk factors. Patients received either direct stitch skin closure (group DC) or purse-string skin closure (group PS).
Results:
In total, 111 patients underwent ileostomy reversal in the aforementioned period. In 88 patients, a CT scan was performed 12-24 months after ileostomy reversal for cancer follow-up. Median follow-up was 12 months. Median time interval between ileostoma formation and closure was 12 (± 4 SD) weeks. In 19 of 88 patients (21.5%), an IH was detected. The incidence of IH detected by CT scan was significantly lower in the PS group (n = 7, 12.9%) compared to the DC group (n = 12, 35.2%, p = 0.017).
Conclusions:
This retrospective study shows an advantage of the purse-string skin closure technique in ileostomy reversals. The use of this technique for skin closure following ileostomy reversals is recommended to reduce the IH rates. Randomized controlled trials are needed to confirm these findings.
... More than one-third of patients with IH are symptomatic, with pain and discomfort at the hernia site resulting in a limitation of activity, possible obstruction, and overall decreased quality of life (3). One study reported hernioplasty to be required in 6%-15% of IH cases to relieve symptoms of strangulation or obstruction (4). ...
Introduction:
Although laparoscopic surgery uses relatively small incisions, incisional hernia after surgery is not uncommon. However, the incidence of incisional hernia and its risk factors are not well known. The purpose of our study was to investigate risk factors for incisional hernia after laparoscopic colorectal cancer surgery.
Methods:
The study group consisted of 212 patients who underwent laparoscopic colorectal cancer surgery at Hiroshima Prefectural Hospital between November 2008 and October 2013. Diagnosis of incisional hernia was performed by postoperative CT. The visceral fat area (VFA) and subcutaneous fat area at the level of the umbilicus were calculated using an image analysis system. For statistical analysis, Fisher's exact test or Student's t-test were used for univariate analysis, and logistic regression analysis was used for multivariate analysis. The cut-off value for risk factors was calculated from the receiver-operator curve.
Results:
Incisional hernia was observed in 18 patients (8.5%). On univariate analysis, female sex (P = 0.04), older age (P = 0.02), subcutaneous fat area (P < 0.01), VFA (P = 0.02), and BMI >25 kg/m2(P < 0.01) were significant risk factors for incisional hernia. The predictive cut-off values were as follows: age, 72 years; subcutaneous fat area, 110 cm2; VFA, 110 cm2; and albumin concentration, 3.9 g/dL. On multivariate analysis, a VFA >110 cm2(P < 0.01) and female sex (P = 0.01) were retained as independent risk factors for incisional hernia.
Conclusion:
After laparoscopic colorectal cancer surgery, a higher VFA and female sex are independent risk factors for incisional hernia.
... The feasibility study aimed to recruit 90 patients over 12 months, the results for which are reported in this paper. The sample size for the full Phase III study was based on detecting a 40% reduction in the 2-year clinical hernia rate (from 25% [2][3][4]14] to 15% with the biological mesh) with 90% power (a = 0.05) and with a built-in drop-out rate of 15%, which requires 790 patients (395 per arm). ...
Abstract
Aim
Hernia formation occurs at closed stoma sites in up to 30% of patients. The Reinforcement of Closure of Stoma Site (ROCSS) randomized controlled trial is evaluating whether placement of biological mesh during stoma closure safely reduces hernia rates compared with closure without mesh, without increasing surgical or wound complications. This paper aims to report recruitment, deliverability and safety from the internal feasibility study.
Method
A multicentre, patient and assessor blinded, randomized controlled trial, delivered through surgical trainee research networks. A 90-patient internal feasibility study assessed recruitment, randomization, deliverability and early (30 day) safety of the novel surgical technique (ClinicalTrials.gov registration number NCT02238964).
Results
The feasibility study recruited 90 patients from the 104 considered for entry (45 to mesh, 45 to no mesh). Seven of eight participating centres randomized patients within 30 days of opening. Overall, 41% of stomas were created for malignant disease and 73% were ileostomies. No mesh-specific complications occurred. Thirty-one postoperative adverse events were experienced by 31 patients, including surgical site infection (9%) and postoperative ileus (6%). One mesh was removed for re-access to the abdominal cavity, for reasons unrelated to the mesh. Independent review by the Data Monitoring and Ethics Committee of adverse event data by treatment allocation found no safety concerns.
Conclusion
Multicentre randomization to this trial of biological mesh is feasible, with no early safety concerns. Progression to the full Phase III trial has continued. ROCSS shows that trainee research networks can efficiently develop and deliver complex interventional surgical trials.
... 2 One of the most common late complications of reversal is the development of a stomal hernia, with an incidence ranging from 0 to 48%. 1 Patients may be asymptomatic, or experience pain, intermittent bowel obstruction and reduced quality of life, with up to 20% of patients requiring surgical repair. 3 Predicting those patients at higher risk of hernia after reversal of ileostomy may influence surgical technique when closing the abdominal wall defect and overlying skin wound. Accepted risk factors for incisional hernia include age, female gender, obesity, and comorbid state 4 and smoking. ...
Background:
Incisional hernia at the ileostomy site occurs in 0-48% of patients undergoing loop ileostomy closure. Risk factors for ileostomy-site hernia are not currently well understood. We explored the predictive value of patient and clinical factors for ileostomy-site hernias.
Method:
Loop ileostomy reversals undertaken between 1st January 2009 and 31st December 2013 were retrospectively evaluated. Preoperative patient data (BMI, age, gender, blood pressure, diabetes), surgical variables (preoperative ileostomy marking, intraoperative management (suture type, closure method), postoperative complications (≤30 days), approach, urgency, and chemotherapy, hospital stay, stoma closure interval, follow-up duration) were collected. Patients were followed up by clinical examination and postoperative imaging.
Results:
193 loop ileostomy reversals were identified. Operative indications included: colorectal cancer (n = 102, 52.8%); inflammatory bowel disease (n = 47, 24.3%); diverticulosis (n = 20, 10.4%); assorted indications (n = 19, 9.8%); and inflammatory fistulae (n = 5, 2.6%). Median duration of clinical follow-up was 20.5 months (0-69). Hernia occurred in 26 patients (13.5%), detected at a median of eight months post-reversal. Radiological follow-up occurred in 72% of patients and, as a reference standard, in 100% of patients diagnosed with a hernia. Concordance between clinical and radiological findings was 88.5%. Postoperative complications predicted higher hernia risk. BMI and preoperative blood pressure were significant hernia predictors. Differences in the type of suture material to close the defect (absorbable vs. non-absorbable) and stoma skin closure method (primary vs. secondary intention healing) were non-predictive of hernia.
Conclusion:
Whilst BMI and patient comorbidity are the major hernia predictors, variability in surgical practice does not constitute a significant risk factor for ileostomy-site incisional hernia.
... The PRISMA flow diagram is shown in addendum 3 (Key Question A). Fifteen records were included in the qualitative analysis [3][4][5][6][50][51][52][53][54][55][56][57][58][59][60]. ...
The material and the surgical technique used to close an abdominal wall incision are important determinants of the risk of developing an incisional hernia. Optimising closure of abdominal wall incisions holds a potential to prevent patients suffering from incisional hernias and for important costs savings in health care.
The European Hernia Society formed a Guidelines Development Group to provide guidelines for all surgical specialists who perform abdominal incisions in adult patients on the materials and methods used to close the abdominal wall. The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and methodological guidance was taken from Scottish Intercollegiate Guidelines Network (SIGN). The literature search included publications up to April 2014. The guidelines were written using the AGREE II instrument. An update of these guidelines is planned for 2017.
For many of the Key Questions that were studied no high quality data was detected. Therefore, some strong recommendations could be made but, for many Key Questions only weak recommendations or no recommendation could be made due to lack of sufficient evidence.
To decrease the incidence of incisional hernias it is strongly recommended to utilise a non-midline approach to a laparotomy whenever possible. For elective midline incisions, it is strongly recommended to perform a continuous suturing technique and to avoid the use of rapidly absorbable sutures. It is suggested using a slowly absorbable monofilament suture in a single layer aponeurotic closure technique without separate closure of the peritoneum. A small bites technique with a suture to wound length (SL/WL) ratio at least 4/1 is the current recommended method of fascial closure. Currently, no recommendations can be given on the optimal technique to close emergency laparotomy incisions. Prophylactic mesh augmentation appears effective and safe and can be suggested in high-risk patients, like aortic aneurysm surgery and obese patients. For laparoscopic surgery, it is suggested using the smallest trocar size adequate for the procedure and closure of the fascial defect if trocars larger or equal to 10 mm are used. For single incision laparoscopic surgery, we suggest meticulous closure of the fascial incision to avoid an increased risk of incisional hernias.
... The PRISMA flow diagram is shown in addendum 3 (Key Question A). Fifteen records were included in the qualitative analysis [3][4][5][6][50][51][52][53][54][55][56][57][58][59][60]. ...
... CT scan shows contrast filled bowel loops passing through the right femoral canal, medial to the femoral vessels (arrow) vertical incisions and abdominal distension. CT enables distinguishing wound hematoma from early wound dehiscence in acute postoperative phase when clinical examination is difficult (Fig. 5) [15,16]. ...
Diagnosis of abdominal wall hernia is often a clinical problem, especially in occult or in obese patients. Multidetector CT is an accurate method of detecting various types of abdominal and diaphragmatic hernias. It clearly demonstrates the anatomical sites of hernial sac, its contents and possible complications.
Abdominopelvic hernias are common clinical entities composed of a wide variety of congenital, traumatic, and iatrogenic etiologies. Any weakness in the body wall may result in hernia of cavity contents with concomitant risks of morbidity and mortality. Presentations may be specific, palpable body wall mass/bulge, or vague, nonspecific pain through bowel obstruction. This document focuses on initial imaging of the adult population with signs of symptoms prompting suspicion of abdominopelvic hernia. Imaging of the abdomen and pelvis to evaluate defects is essential for prompt diagnosis and treatment. Often CT and ultrasound are the first-line modalities to quickly evaluate the abdomen and pelvis, providing for accurate diagnoses and management of patients. MRI protocols may be useful as first-line imaging studies, especially in patients with orthopedic instrumentation. Although often performed, abdominal radiographs and fluorographic procedures may provide indirect evidence of hernias but are usually not indicated for initial diagnosis of hernia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Background & Aims: Enterostomy reversal and fascial defect cause weakness in the abdominal wall and may lead to formation of incisional hernia. Literature says that placement of synthetic mesh in dirty/contaminated wound causes high chances of surgical site infection (SSI) and mesh related complications. This dogma is now challenged. Present study was conducted to evaluate outcome of the placement of synthetic non-absorbable mesh after enterostomy closure in terms of SSI and incisional hernia.
Materials & Methods: This prospective case-control study was conducted in the department of General surgery Netaji Subhash Chandra Bose (NSCB) medical college, Jabalpur, between 1st December 2018 to 30th September 2020. All patients of age >18 years with ileostomy/colostomy undergoing enterostomy reversal were included. Outcomes noted for wound infection/dehiscence, mesh related complications, its removal, and development of incisional hernia.
Results: Total 60 patients were included in this study. Out of which, 30 (23 loop ileostomy, 5 double barrel ileostomy, and 2 colostomy) were taken as the case; where polypropylene mesh was placed (9 sublay and 21 onlay). 30 others (28 loop ileostomy, 1 double barrel ileostomy, and 1 colostomy) were taken as control where mesh was not placed after stoma closure. SSI was significantly lower in mesh placed group than non-mesh placed group (16.6% vs. 40%; P=0.019). Use of mesh was associated with slightly better outcomes but not significant in terms of rate of wound dehiscence (3.3% vs. 6.7%; Z=0.59; P=0.554) and incisional hernia (0 vs 6.7%; p= 0.492) in mesh and non-mesh groups, respectively. Mesh removal for chronic infection was not required in any case.
Conclusion: Placement of permanent synthetic polypropylene mesh at the site of enter ostomy closure for prevention of incisional hernia can be done safely without fear of having increased risk of SSI and need of mesh removal.
Parastomal hernia (PSH) development is one of the dreaded and potentially inevitable complications following stoma creation. A myriad of surgical repair techniques exist including open or minimally invasive with either laparoscopic or robotic-assisted approaches and involve variations in primary, mesh, and extraperitoneal repair methods. In this chapter, we detail our approach to PSH repair.
Surgery for abdominal wall hernias continues to evolve. Surgical techniques have advanced significantly, and additional adjunct procedures to prevent and or repair burst abdomen have become more common. General surgeons have various maneuvers in their armamentarium ranging from plain closure to placing mesh to reinforce or reconstruct tissue planes by transferring native tissue. Over the last few years, the emphasis has been directed towards the prevention of incisional hernias during the index surgery by utilizing prophylactic mesh replacement (PMR). This chapter will explore the need for adjunct prophylactic procedures to prevent abdominal wall hernias and to prevent or repair burst abdomens.
Purpose
Incisional hernia following closure of loop ileostomy is a common problem. Assessment of the proportion of this complication is limited by small sample size and inconsistent reporting. The aim of this review was to provide an estimate of the proportion of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported proportion.
Methods
A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled proportion estimates. Meta-regression models were formed to explore potential heterogeneity.
Results
42 studies with 7166 patients were included. The pooled estimate of the proportion of incisional hernia after ileostomy closure was 6.1% (95% confidence interval, CI 4.4–8.3%). Proportion estimates for higher quality studies and studies reporting on incisional hernia as primary outcome were 9.0% (95% CI 6.3–12.7%) and 13.1% (95% CI 8.8–19.1%). Significant between-study heterogeneity was identified (P < 0.001, I² = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies affected the proportion.
Conclusion
The proportion of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported proportion.
Background:
Closure of complex and contaminated abdominal wounds is challenging and carries risks, including wound dehiscence and incisional hernias. Hernia formation at closed stoma sites occurs in up to 30% of patients. Use of biological meshes in these situations may provide a safe method of reducing these complications, especially long-term incisional hernias.
Method:
The Reinforcement of Closure of Stoma Site (ROCSS) study is a phase III multicentre randomised controlled trial (RCT), with an internal feasibility study. The primary objective of ROCSS is to assess whether a biological mesh (collagen tissue matrix) reduces the incidence of clinically detectable stoma closure site hernias at two years compared to standard closure techniques. Patients will be randomised in a 1:1 ratio to either standard suture (non-mesh) closure, or closure with an intra-abdominal biologic mesh reinforcement. Patients and outcome assessors are masked to treatment allocation. ROCSS aims to recruit 560 patients, with an option to recruit to 790 patients to increase power. The primary outcome measure is the occurrence of clinically detectable hernias years two years post randomisation. The secondary outcome measures are the radiological hernia rate at one year, incidence of symptomatic hernia, the surgical complication/re-intervention rate, quality of life, post-operative pain, and cost-benefit analysis.
Discussion:
ROCSS is a multicentre RCT assessing the placement of a biological mesh at the site of stoma closure on clinical hernia rate. Our hypothesis is that reinforcing the stoma closure site with a collagen mesh is superior to the standard technique in reducing the risk of herniation at 2 years. These findings could influence future closure of stomas and other complex and/ or contaminated abdominal wounds in settings around the world. This article is protected by copyright. All rights reserved.
Background:
Reversal of an enterostomy results in a high rate of incisional hernia at the ostomy site. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. We present the outcomes of a series of prophylactic mesh reinforcements with retromuscular, large-pore polypropylene at the time of enterostomy reversal.
Methods:
Retrospective review of all ostomy reversals was performed. All cases with placement of synthetic mesh reinforcement were identified from a prospectively maintained, hernia database. Primary endpoints were surgical site occurrence (SSO), surgical site infection (SSI), and hernia occurrence.
Results:
Ostomy reversal was performed in 359 patients; 91 were reinforced with mesh and 268 without mesh. Colostomy reversal was performed in 56.5% and ileostomy in 43.5%. The mesh group had a greater BMI and a greater incidence of COPD, but groups were otherwise similar. A midline incisional hernia was present in 45% of the mesh group vs 4.5% in the controls. Incidence of SSO and SSI were similar for mesh and control groups (21 vs 22.8%; P = 0.82 and 20 v 19.8%; P = 1.000; respectively). Superficial SSI was less with mesh (8 vs 16.4%; P = 0.039). Tncidence of a hernia developing at the stoma site was decreased markedly with mesh (1.% vs 17.2%; P < 0.001), as was the occurrence of a midline hernia (6% v 19%; P = 0.004). Mesh was placed across the midline prophylactically in 29.7% of cases, which decreased midline hernia formation from 24.1% to 4% (P = 0.019).
Conclusions:
Retromuscular placement of permanent synthetic mesh at the time of enterostomy reversal is effective in preventing development of incisional hernia without increased risk of SSO or SSI.
Anastomotic leak after low anterior resection for rectal cancer is a dreaded complication. Diversion stoma helps tiding over this crisis and it is routinely practised in most centres, especially in post chemoradiotherapy setting. But a diversion stoma has got its own problems. In this study, we attempt to use the triple test as a predictor of anastomotic integrity and thereby avoid a diverting stoma, and patients undergoing low anterior resection after neoadjuvant chemoradiotherapy were spared the trouble of a diverting stoma if the on table triple test was negative. Two hundred such consecutive patients were prospectively followed up in the postoperative period. The incidence of anastomotic leak and the factors predicting the same were analysed in this group of patients. The incidence of anastomotic leak in our study was 7%, which is much less when compared to published literature. The triple test was a reliable predictor of the integrity of anastomosis and if the test is negative, a diverting stoma can be avoided. Age more than 60 years and end-to-end anastomosis were found to be associated with increased incidence of leak, and patients with a negative triple test need not routinely undergo diversion stoma after a low anterior resection even in post chemoradiotherapy setting.
Background
To determine the incidence and risk factors for stoma site (SSH) and incisional (IH) hernias following stoma reversal as well as their recurrence following repair.
Methods
A cohort of VA Surgical Quality Improvement Program patients undergoing stoma reversal from 2002 to 2014 were evaluated at a single institution. Variables were selected a priori and evaluated by univariate analyses.
Results
Of 114 stoma reversals, 63 utilized a midline approach. The incidence of SSH and IH was 9.6% and 31.7% over a median follow-up of 5.7 (0.5–14) and 4.0 (0.1–14) years, respectively. Five SSH and 10 IH were repaired with no recurrences. Myofascial release and superficial surgical site infections (SSI) were associated with SSH while body mass index, preoperative radiotherapy, American Society of Anesthesiologists classification ≥3, operative duration ≥2.5 h and deep SSIs were associated with IH.
Conclusions
Incisional hernia incidence after stoma reversal is high for both the stoma site and midline. Risk factors differ for each hernia type. A low recurrence rate exists in short term follow-up following repair of a hernia occurrence.
Summary
The incidence and risk factors of stoma site and midline incisional hernias following stoma reversal were investigated. Incidence of stoma site hernia is approximately 1 in 10 while midline incisional hernia incidence is approximately 1 in 3. Factors associated with the development of each hernia type differ. In short-term follow-up, recurrence following repair of each type of hernia occurrence is low.
Background:
There is a high incidence of incisional hernias in specific high-risk patient populations. For these patients, the prophylactic placement of mesh during closure of the abdominal wall incision has been investigated in several prospective studies.
Objective:
This article aims to summarize and synthetize the currently available evidence on prophylactic meshes in a narrative review.
Materials and methods:
Systematic reviews were performed on the use of prophylactic meshes in different indications: midline laparotomies, stoma reversal wounds, and permanent stoma.
Results:
High-quality data from randomized trials shows that prophylactic synthetic non-absorbable mesh implantation is safe and effective, both in prevention of incisional hernias after midline laparotomies and during construction of an elective end colostomy. It should be considered in patients with a high risk for incisional hernia development, such as those receiving open abdominal aortic aneurysm, obesity, or colorectal cancer surgery. It is strongly recommended for construction of an elective permanent end colostomy. For midline laparotomies, both the retromuscular and onlay positions of a prophylactic mesh seem equally effective and safe. For parastomal hernia prevention, only the retromuscular prophylactic mesh and its use for end colostomies has been proven to be effective and safe. No data support the choice of a biological mesh or a synthetic absorbable mesh over a non-absorbable synthetic mesh, even in clean-contaminated surgical procedures. No data yet support the standard use of prophylactic mesh when closing the wound during closure of a temporary stoma.
Conclusion:
Prophylactic mesh implantation should be the standard of care during construction of an elective end colostomy and will become the standard of care for midline laparotomies in patients at high risk of incisional hernias.
Background
There is a high incidence of incisional hernias in specific high-risk patient populations. For these patients, the prophylactic placement of mesh during closure of the abdominal wall incision has been investigated in several prospective studies.
Objective
This article aims to summarize and synthetize the currently available evidence on prophylactic meshes in a narrative review.
Materials and methods
Systematic reviews were performed on the use of prophylactic meshes in different indications: midline laparotomies, stoma reversal wounds, and permanent stoma.
Results
High-quality data from randomized trials shows that prophylactic synthetic non-absorbable mesh implantation is safe and effective, both in prevention of incisional hernias after midline laparotomies and during construction of an elective end colostomy. It should be considered in patients with a high risk for incisional hernia development, such as those receiving open abdominal aortic aneurysm, obesity, or colorectal cancer surgery. It is strongly recommended for construction of an elective permanent end colostomy. For midline laparotomies, both the retromuscular and onlay positions of a prophylactic mesh seem equally effective and safe. For parastomal hernia prevention, only the retromuscular prophylactic mesh and its use for end colostomies has been proven to be effective and safe. No data support the choice of a biological mesh or a synthetic absorbable mesh over a non-absorbable synthetic mesh, even in clean–contaminated surgical procedures. No data yet support the standard use of prophylactic mesh when closing the wound during closure of a temporary stoma.
Conclusion
Prophylactic mesh implantation should be standard of care during construction of an elective end colostomy and will become standard of care for midline laparotomies in patients at a high risk of incisional hernias.
Aims:
Incisional hernia (IH) is a recognized complication of open and laparoscopic visceral surgery, with reported rates of 10-50% in adult surgical literature. There is a paucity of data relating to incisional hernias in children. The aim of our study was to analyze the incidence and treatment of IH in children.
Methods:
Retrospective review of all patients admitted for incisional hernia repair at a tertiary pediatric surgical centre in the UK more than a 7-year period was performed. Data collected included age at initial surgery, time to IH repair, and type of IH repair and postoperative complications.
Results:
Twenty one patients (14 male) underwent IH repair during the study period. The incidence of IH among children who had primary abdominal surgery in our institution less than the age of 6months was 2.3%. Median age at repair was 7.9months (range: 18days-5years). Median time from primary surgery to diagnosis of IH was 2months (range 0day-3years), with 81% (17/21) diagnosed within 1year of the preceding abdominal procedure. The most common pathology necessitating the primary operative procedure was necrotising enterocolitis (n=9) in babies of gestational age less than 30weeks. The highest rates of IH were noted in infants following closure of stoma (7.5%) and pyloromyotomy (2.52%). Primary closure was undertaken in all cases. Two children had recurrence of IH, one of which underwent surgical repair.
Conclusions:
Incidence of IH in children is low but significant. IH was most commonly diagnosed following closure of stoma for NEC in this study.
Background:
Wounds resulting from the closure of temporary stomas have a high risk of developing an incisional hernia (IH) with incidences around 30 % in studies designed to investigate this outcome. A temporary diverting ileostomy (TDI) is often used in patients after low anterior resection (LAR) for rectal cancer.
Methods:
The OSTRICH study is a retrospective cohort study of rectal cancer patients who had a LAR with a reversed TDI and at least one CT scan during follow-up. Two radiologists independently evaluated all abdominal CT scans to diagnose IH at the ileostomy wound and additionally, IH at the laparotomy site.
Results:
From the oncological database of rectal cancer patients treated from 2003 till 2012 (n = 317) a cohort of 153 patients that fulfilled the inclusion criteria was identified. Rectal cancer resection was performed by laparoscopy in 53 patients (34.6 %) and by laparotomy in 100 patients (65.4 %). A total of 17 IH (11.1 %) was diagnosed at the former stoma site after a mean follow-up of 2.6 years. Of these, 8 IH were in patients who had a laparoscopic LAR (15.1 %) and 9 IH in patients who had an open LAR (9.0 %) (Fisher's exact test; p = 0.28). IH on the other abdominal wall incisions was reported in 69 patients (45.1 %). Of these, 10 patients underwent laparoscopic rectal surgery (18.9 %) and in 59 patients had open rectal surgery (59.0 %) (Fisher's exact test; p < 0.0001).
Conclusion:
We found a lower number of incisional hernias (11.1 %) after reversal of ileostomies than expected from the literature. In contrast to the findings at the ileostomy site, a very high frequency of IH (59.0 %) after LAR by laparotomy was found, which was significantly higher than after laparoscopic LAR.
Although incisional hernia (IH) is a common complication of abdominal surgery, the incidence rate and risk factors are not well known. The objectives of this study are to determine the incidence rate of IH following colorectal cancer surgery and to describe the associated risk factors.
Between 2005 and 2010, patients who underwent surgery to treat colorectal cancer were examined. The diagnosis of IH was performed by CT scan, and the visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus were calculated using a 3D-image analysis system. Survival analysis was used to assess the incidence and risk factors of IH.
A total of 626 patients (326 open, 300 laparoscopic) were included in this study, with median follow-up of 54 (range 2-97) months. Forty patients were diagnosed with postoperative IH, and the cumulative, 5-year incidence of IH was 7.3 %. Univariate analysis revealed that age, body mass index, waist circumference, hip circumference, open laparotomy, wound infection, VFA, and SFA were significantly associated with incidence of IH. Multivariate analysis revealed that age [hazard ratio (HR) 1.043 (1.005-1.083), p = 0.027], open laparotomy [HR 4.410 (1.018-19.095), p = 0.047], and SFA [HR 1.013 (1.004-1.022), p = 0.005] were significant risk factors for developing IH.
Higher age and SFA, along with open surgery, are risk factors for developing IH.
Introduction:
Evidence is needed to justify whether investment in an internationally agreed core outcome set for inguinal hernia surgery is needed. This study aimed to assess outcome reporting from randomised controlled trials (RCTs) and meta-analyses in inguinal hernia surgery.
Methods:
RCTs and meta-analyses comparing surgical technique or mesh type for primary inguinal hernia repair were systematically identified. Verbatim details, type, frequency and definition of clinician-observed and -assessed outcomes were summarised. Patient-reported outcome measures (PROMs) were analysed for instrument validity and frequency of domain reporting.
Results:
40 RCTs (10,810 patients) and 7 meta-analyses (17,280 patients) were identified. No single PROM was reported by all studies. There were 58 different clinician-observed outcomes, with recurrence (n = 47, 100%), wound infection (n = 33, 70.2%), haematoma (n = 31, 77.5%) and seroma formation (n = 22, 46.8%) being most frequently reported. All studies measured patients' views, although only 12 (30.0%) used validated instruments. The SF36 was the most commonly used multi-dimensional valid PROM (n = 7), and a visual analogue scale assessing pain (n = 32) was the most frequently used unidimensional scale. Non-validated questionnaires assessed 25 other aspects of patients' health. Two meta-analyses defined recurrence and three chronic pain although neither ensured that included RCTs adhered to the definitions.
Conclusions:
Outcome reporting from RCTs concerning inguinal hernia repair is inconsistent and poorly defined, limiting meta-analyses, which themselves do not control for the differing definitions of assessed outcomes. This study justifies investment in a standardised core outcome set for inguinal hernia surgery, to improve outcome reporting and evidence synthesis.
The automated volume scanning system (AVSS) has been applied in breast diseases, but its use in incisional hernias has not been reported. In this study, conventional handheld B-mode ultrasound (HHUS) and AVSS examined a total of 122 hernia defects in 78 patients. The results from two modalities were then compared with surgical findings for the purpose of assessing the diagnostic value of AVSS. Statistics showed that surgeries identified 38 small, 23 medium and 17 large incisional hernias. The results of AVSS completely agreed with surgical findings; however, HHUS misidentified nine large hernias as medium and seven medium hernias as large. AVSS proved to be more accurate than HHUS in measuring the length and width of the hernia. It also outperformed HHUS in both detecting the incisional hernias (91.8% vs. 78.7%, p = 0.00) and determining hernia contents (89.3% vs. 68.0%, p = 0.00). Moreover, the coronal images AVSS obtained clearly displayed the shapes of the hernias, with 46 being regular and 32 irregular. Overall, AVSS can be used as a promising diagnostic modality for incisional hernias.
The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.
The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias.
A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done.
Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%-33.9%) and for midline incisional hernias was 44.1% (range 8.7%-58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two.
Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.
Background:
Stomal site incisional hernia is a common complication following ileostomy closure. The effectiveness of prophylactic mesh placement at the time of stomal closure is unknown because of fear of mesh infection and subsequent wound complications. The present study investigated whether prophylactic mesh placement reduces the rate of incisional hernia after ileostomy closure without increasing wound complications. The study was based on retrospective review of consecutive ileostomy closures undertaken at a tertiary referral center between January 2007 and December 2011. Hernias were identified through clinical examination and computed tomography.
Results:
Eighty-three cases of ileostomy closure were reviewed; 47 patients received mesh reinforcement, and 36 underwent non-mesh closure (controls). In total, 16 (19.3 %) patients developed incisional hernia, 13 (36.1 %) of which occurred in the control group; 3 (6.4 %), in the mesh group [odds ratio (OR): 8.29; 95 % confidence interval (CI) 2.14-32.08; p = 0.001]. Incisional hernia repair was performed in 3 (23 %) patients in the control group; no hernias in the mesh group required surgery. There was no significant difference in wound infection rates between mesh (2 patients, 4.3 %) and control (1 patient, 2.8 %) groups. No mesh infection was found. Multivariate analysis demonstrated that malignancy (OR: 21.93, 95 % CI 1.58-303.95; p = 0.021) and diabetes (OR: 20.98, 95 % CI 3.23-136.31; p = 0.001) independently predicted incisional herniation, while mesh reinforcement prevented hernia development (OR: 0.06, 95 % CI 0.01-0.36; p = 0.002).
Conclusions:
Mesh placement significantly reduced the incidence of incisional hernia following ileostomy closure, but without increasing complication rates. This technique should be strongly considered in patients at high risk of hernia development.
Incisional hernia at the site of stoma closure is an under-reported problem, having been recently shown to occur in up to 30 % of patients. This technical note describes a technique for the placement of intraperitoneal biological mesh to prophylactically reinforce stoma closure sites. Seven consecutive patients underwent mesh placement as part of a pilot study. Following closure of the stoma through a trephine incision, 6 anchoring sutures were placed between the peritoneum/deep fascia and the edges of the mesh circumferentially. The mesh was delivered into the peritoneal cavity and parachuted up against the abdominal wall, and the sutures tied. If closure was performed through a midline laparotomy, the anchoring sutures were placed in a similar fashion through the midline incision. The fascia above the mesh and soft tissues was then closed. The mesh was successfully placed in all 7 patients. Follow-up at 30 days showed one superficial wound infection. An ultrasound scan of this patient revealed that the mesh was still in place and that the infection did not breach the fascia. No other early adverse events occurred. Prophylactic biological mesh reinforcement of stoma closure sites is technically feasible and safe in the short term. Longer-term results from a prospective randomised trial are needed, including clinical and radiological assessment for hernia rates, to establish what if any are the realisable benefits of this technique.
Parastomal hernia with a reported incidence of up to 50% is a major problem after ostomy formation. Hernias at the closure site may be a problem after the closure of the enterostomy. In this study, in addition to physical examination, we used ultrasonography (USG) in order to find the true incidence of ostomy closure site and laparotomy incisional hernias.
We examined patients with closed enterostomy sites by both physical examination and USG for the detection of hernias. Risk factors for hernia formation, such as age, gender, body mass index (BMI), ostomy type, and surgical site infections, were determined.
The evaluation of 31 patients with ostomies resulted in a 32% incidence of closed ostomy site hernias when patient medical history, physical examination, and ultrasonographic examination were used together. With physical examination and USG, incisional hernias at the laparotomy incision were found in 58% of cases. USG was able to detect hernias which were not clinically evident at the ostomy closure site and the laparotomy wound. BMI, age, gender, ostomy type, and surgical site infection did not have a significant effect on hernia formation.
Ostomy closure site and laparotomy incisional hernias are important clinical problems with a high incidence after ostomies are closed. Closure of the enterostomy site should be regarded as a hernia repair rather than a simple fascial closure. USG is a valuable clinical tool in combination with physical examination for the detection of minor defects.
The prevalence of and risk factors for incisional hernias among temporary stoma wounds have implications for clinical practice.
Retrospective cohort study.
University tertiary care hospital.
All adult patients with a stoma closed between January 1, 2000, and August 1, 2004. Of 150 living patients, 111 (74.0%) were included for analysis after follow-up at the outpatient clinic.
The main outcome was incisional hernia in a temporary stoma wound, defined as a defect within the musculature and fascia detected by ultrasonographic examination. Risk factors for incisional hernias and the diagnostic validity of clinical symptoms and palpation during the Valsalva maneuver were determined.
After a median follow-up of 35 months (range, 5-77 months), hernia prevalence was 32.4%. Among patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of less than 30, hernia prevalence was 25.8%; among patients with a body mass index of 30 or higher, hernia prevalence was 59.1%. Palpation demonstrated the highest sensitivity (58.3%). One in 6 patients had discomfort at the temporary stoma site and no palpable defect but showed an incisional hernia on ultrasonographic examination. Obesity was the sole significant risk factor identified in this study (odds ratio, 5.53; 95% confidence interval, 1.72-17.80). The presence of a stoma in situ for less than 6 months showed a trend toward being a risk factor (odds ratio, 2.38; 95% confidence interval, 0.96-5.99).
Incisional hernias occur in 1 of 3 temporary stoma wounds, and a body mass index of 30 or higher is a risk factor.
Biologic grafts for hernia repair are a relatively new development in the world of surgery. A thorough search of the Medline database for uses of various biologic grafts in hernia shows that the evidence behind their application is plentiful in some areas (ventral, inguinal) and nearly absent in others (parastomal). The assumption that these materials are only suited for contaminated or potentially contaminated surgical fields is not borne out in the literature, with more than 4 times the experience being reported in clean fields and the average success rates being higher (93% vs 87%). Outcomes prove to be highly dependent on material source, processing methods and implant scenarios with failure rates ranging from zero to more than 30%. Small intestinal submucosa (SIS) grafts have an aggregate failure rate of 6.7% at 19 months whereas acellular human dermis (AHD) grafts have a failure rate of 13.6% at 12 months. Chemically cross-linked grafts have much less published data than the non-cross-linked materials. In particular, the search found 33 articles for SIS, 32 for AHD, and 13 for cross-linked porcine dermis. Furthermore, the cumulative level of evidence for each graft material was fairly low (2.6 to 2.9), and only 1 material (SIS) had level 1 evidence reported in any hernia type (inguinal and hiatal). Together, biologic grafts have published evidence showing success rates better than 90% overall and more than 2000 years of cumulative implant time. Improvements in materials, techniques, and patient selection are likely to improve these numbers as this field of surgery matures.
Loop ileostomies are used currently in surgical practice to reduce the consequences of distal anastomotic failure following colorectal resection. It is often assumed that reversal of a loop ileostomy is a simple and safe procedure. However, many studies have demonstrated high morbidity rates following loop ileostomy closure. The aims of this systematic review were to examine all the existing evidence in the literature on morbidity and mortality following closure of loop ileostomy.
A literature search of Ovid, Embase, the Cochrane database, Google Scholar and Medline using Pubmed as the search engine was used to identify studies reporting on the morbidity of loop ileostomy closure (latest at June 15th 2008), was performed. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital-related outcomes, post-operative bowel-related complications, and other surgical and medical complications.
Forty-eight studies from 18 countries satisfied the inclusion criteria. Outcomes of a total of 6,107 patients were analysed. Overall morbidity following closure of loop ileostomy was found to be 17.3% with a mortality rate of 0.4%. 3.7% of patients required a laparotomy at the time of ileostomy closure. The most common post-operative complications included small bowel obstruction (7.2%) and wound sepsis (5.0%).
The consequences of anastomotic leakage following colorectal resection are severe. However, the consequences of stoma reversal are often underestimated. Surgeons should adopt a selective strategy regarding the use of defunctioning ileostomy, and counsel patients further prior to the original surgery. In this way, patients at low risk may be spared the morbidity of stoma reversal.
Sphincter-saving surgery for the treatment of middle and low rectal cancer has spread considerably when total mesorectal excision became standard treatment. In order to reduce leakage-related complications, surgeons often perform a derivative stoma, a loop ileostomy (LI), or a loop colostomy (LC), but to date, there is no evidence on which is the better technique to adopt.
We performed a systematic review and meta-analysis of all randomized controlled trials until 2007 and observational studies comparing temporary LI and LC for temporary decompression of colorectal and/or coloanal anastomoses. Clinically relevant events were grouped into four study outcomes: general outcome measures: dehydratation and wound infection GOM construction of the stoma outcome measures: parastomal hernia, stenosis, sepsis, prolapse, retraction, necrosis, and hemorrhage closure of the stoma outcome measures: anastomotic leak or fistula, wound infection COM, occlusion and hernia functioning of the stoma outcome measures: occlusion and skin irritation.
Twelve comparative studies were included in this analysis, five randomized controlled trials and seven observational studies. Overall, the included studies reported on 1,529 patients, 894 (58.5%) undergoing defunctioning LI. LI reduced the risk of construction of the stoma outcome measure (odds ratio, OR = 0.47). Specifically, patients undergoing LI had a lower risk of prolapse (OR = 0.21) and sepsis (OR = 0.54). LI was associated with an excess risk of occlusion after stoma closure (OR = 2.13) and dehydratation (OR = 4.61). No other significant difference was found for outcomes.
Our overview shows that LI is associated with a lower risk of construction of the stoma outcome measures.
The creation of a loop ileostomy is considered suitable to protect a distal anastomosis in colorectal surgery. This technique is, however, associated with failure, complications and even mortality. The aim of this study was to quantify retrospectively the morbidity associated with an ileostomy and its subsequent closure.
One hundred and nineteen patients with a temporary loop ileostomy, created between January 2000 and July 2007 were retrospectively analysed from a review of patient records.
All ileostomies were closed after a median period of 106 days (interquartile range: 69-174 days). Stoma-related morbidity occurred in 23 (19%) patients. After ileostomy closure, 16 major complications were seen in 14 (12%) patients and 43 minor complications occurred in 25 (21%) patients. Sixty-three patients (53%) had neither stoma-related morbidity or peri- or postoperative complications after stoma closure.
Protective loop ileostomy was found to be associated with a high morbidity. This raises the question of the mode of identifying the specific patients with a low anastomosis who should be provided an ileostomy for protection, set against the potential complications of the formation and closure of the ileostomy.
A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality.
A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005.
Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer (n = 160, 49%), ileal pouch-anal anastomosis (n = 114, 35%), diverticular disease (n = 25, 8%), Crohn's colitis (n = 4, 1%) and other conditions (n = 22, 7%). Overall mortality was 2.5% (n = 8) and morbidity was 22.8% (n = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%). Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n = 65, P = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality (n = 46, P < 0.001).
Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.
A personal retrospective series of 100 consecutive colostomy closures performed between 1968 and 1978 is reviewed. Serious intraabdominal complications occurred in three patients. The total complication rate in this series was 29%. There were no deaths and no faecal fistulae. However, wound infection occurred in 22 patients.
This study summarizes the clinical results after 61 operations including diverting stomas in 56 patients. 29 transverse colostomies and 32 loop ileostomies were constructed over a 2-year period. Two thirds of the operations were performed on acute indications. The patients were followed up with regard to closure rate and complications up until the end of 1985. Within this period there was a closure rate of 38% and a stoma-related complication rate of 21% without any significant difference between the two different groups of stomas. The complications following ileostomy appeared to be more serious than those after transverse colostomy.
The choice of a defunctioning stoma in restorative resection of rectal carcinoma is unclear. Traditionally, the loop colostomy has been preferred.
All patients with either a defunctioning loop ileostomy or colostomy treated by a single surgeon (MS) were studied. The morbidity of stoma construction and closure, as well as problems experienced in the intervening period, were entered on a database.
No significant difference in the morbidity of closure was noted when loop ileostomy was compared to loop colostomy. Although a trend favouring loop ileostomy was noted when interval morbidity was examined, this difference was not statistically significant.
Loop colostomy and ileostomy are both effective in defunctioning the distal colon following a restorative resection for rectal carcinoma. There is some morbidity associated with both but when a stoma is constructed, loop ileostomy is preferable. The loop ileostomy is generally easier to manage and is not associated with a greater rate of complications (in its construction and closure) than the loop colostomy.
Parastomal herniation is a common complication after stoma formation. The incidence can be reduced by using an extraperitoneal technique, limiting the size of the trephine to 1.5-2.0 cm or by strengthening with a mesh. If an intraperitoneal technique is used the intestine should be brought out through the rectus muscle. Generally, the symptoms are easily controlled with a support belt. Various techniques have been advocated for surgical repair. Fascial repair alone should no longer be performed owing to an unacceptably high recurrence rate, but should be combined with a prosthetic mesh. Relocation of the stoma should be performed for primary repairs.
The consequences of leakage from low colorectal or coloanal anastomoses are reduced by the use of a loop stoma to divert the faecal stream. Controversy continues as to whether loop ileostomy (LI) or loop transverse colostomy (LTC) is the optimal method of defunctioning such anastomoses.
Patients requiring defunctioning following anterior resection and total mesorectal excision were randomized to receive either LI or LTC. Comparison was made between the groups regarding the difficulty of stoma formation and closure, the recovery after stoma closure and stoma-related complications. The minimum follow-up after stoma closure was 6 months (median 36 months).
Between October 1995 and August 1999, 70 patients were randomized (LTC 36, LI 34) of whom 63 underwent stoma closure (LTC 31, LI 32). There were no significant differences in the difficulty of formation or closure, or in the postoperative recovery between the groups. However, there were ten complications related directly to the stoma in the LTC group: faecal fistula (one patient), prolapse (two), parastomal hernia (two) and incisional hernia during follow-up (five). None of these complications occurred in the LI group.
In this randomized study, the frequency of herniation before or after colostomy closure supports the choice of LI as a method of defunctioning a low anastomosis. Both methods appear to provide satisfactory protection for the low anastomosis.
Parastomal hernia following formation of an ileostomy or colostomy is common. This article reviews the incidence of hernia, the technical factors related to the construction of the stoma that may influence the incidence, and the success of the different methods of repair.
A literature search using the Medline database was performed to locate English language articles on parastomal hernia. Further articles were obtained from the references cited in the literature initially reviewed.
Parastomal hernia affects 1.8-28.3 per cent of end ileostomies, and 0-6.2 per cent of loop ileostomies. Following colostomy formation, the rates are 4.0-48.1 and 0-30.8 per cent respectively. Site of stoma formation (through or lateral to rectus abdominis), trephine size, fascial fixation and closure of lateral space are not proven to affect the incidence of hernia. The role of extraperitoneal stoma construction is uncertain. Mesh repair gives a lower rate of recurrence (0-33.3 per cent) than direct tissue repair (46-100 per cent) or stoma relocation (0-76.2 per cent).
The incidence of parastomal hernia is between 0 and 48.1 per cent, depending on the type of stoma and length of follow-up. No technical factors related to the construction of the stoma have been shown to prevent herniation. If repair is required, a prosthetic mesh technique should be considered. Further randomized clinical trials (particularly of extraperitoneal stoma construction) are needed.
A temporary loop ileostomy is constructed to protect a distal colonic anastomosis. Closure is usually performed not earlier than 8-12 weeks after the primary operation. During this period, stoma-related complications can occur and enhance the adverse effect on quality of life. The aim of this study was to evaluate the length of time between ileostomy construction and closure, to quantify stoma-related morbidity and to examine the potential advantages of early ileostomy closure.
Sixty-nine patients with a temporary, protective loop ileostomy (constructed between January 1996 and December 2000) were retrospectively analysed. The analysis was done by reviewing the medical records and the notes of the stoma care nurse.
Sixty ileostomies (87%) were closed after a median period of 24 weeks (range 2-124 weeks). Stoma-related complications occurred in 29 of the 69 patients (42%), and 11 patients (18%) had complications after ileostomy closure.
The length of time between ileostomy construction and closure was substantially longer than initially planned. Earlier ileostomy closure (preferably even during the initial admission) could reduce the frequently occurring stoma-related morbidity in these patients and thus improve quality of life.
Parastomal hernia represents a major surgical challenge. There is no uniform definition of parastomal hernia, and the true rate is therefore difficult to establish, although it is probably higher than 30%. Many surgical techniques have been tried to prevent and treat parastomal hernia; but despite these efforts, herniation continues to be a problem. The only method that has reduced the rate of parastomal hernia in a randomized trial is the use of a prophylactic prosthetic mesh. A large-pore low-weight mesh with reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the primary operation significantly reduces the rate of parastomal hernia. Recurrence rates after surgical treatment of parastomal hernia are high unless mesh is used. Relocation of the stoma, with prophylactic mesh in a sublay position at the new site and sublay mesh repairing the incisional hernia at the primary site, is the standard method for treating parastomal hernia in our department.
Parastomal hernia is a common complication after stoma formation. The objective of the study was to see whether placing prophylactic preperitoneal mesh could reduce the incidence of parastomal hernia.
Patients having elective bowel surgery requiring permanent stoma were included in this study. The time required for mesh insertion, day of stoma function, and early complications were recorded. Follow up was at 6 weeks, 3-monthly for the first year and at 6-monthly intervals thereafter.
Eighteen patients fulfilled the inclusion criteria and were followed up for 6-28 months (mean 16.05). The time taken for mesh placement was 12-22 min (mean 14). One patient had to have revision surgery on day 1 for stomal necrosis - the mesh was left in situ in that instance. This patient developed superficial laparotomy wound infection. During the follow up, no patients developed parastomal hernia, stomal prolapse, stenosis, retraction, fistula or obstruction.
The early results, in this group of patients, show that prophylactic polypropylene mesh insertion at the time of permanent stoma formation is encouraging and long-term results are awaited.
Parastomal hernia continues to be an important clinical problem with a reported incidence of up to 50 percent. In studies using computerized tomography in selected cases for detection of parastomal hernia, physical examination alone was underestimating the true incidence. Also after closure of the enterostomy, the ostomy site could still be a potential area of herniation. In this study in addition to physical examination, we used computerized tomography to determine the true incidence of parastomal hernia and ostomy closure site hernias.
We examined patients with enterostomies and with closed enterostomy sites both with physical examination and computerized tomography for the detection of hernias, hernia content, and relation to rectus muscles. Risk factors for hernia formation, such as age, gender, body mass index, associated medical problems, and surgical site infections, were determined.
Evaluation of 23 patients with ostomies resulted in 52 percent incidence of parastomal hernia, whereas the addition of tomography examination gave a corrected incidence of 78 percent. In a second subset of 23 patients with closed ostomies, although 26 percent of the patients were found to have ostomy site hernias with physical examination alone, this incidence increased to 48 percent when combined with computerized tomography. The potential risk factors for hernia formation, such as body mass index, surgical site infection, and ostomy site whether pararectus or transrectus, were not proven to have a significant role in this study.
Parastomal hernia and closed ostomy site incisional hernias have a high incidence, and computerized tomography has been shown to be a valuable diagnostic tool.
The purpose of this study is to measure abdominal wall myopathic histologic and mechanical changes during incisional herniation and its effect on incisional hernia repairs.
Unloaded skeletal muscles undergo characteristic atrophic changes, including change in fiber type composition, decreased cross-sectional area, and pathologic fibrosis. We hypothesize that these atrophic changes decrease muscle elastic properties and may contribute to the high laparotomy wound failure rate observed following incisional hernia repair.
A rat model of chronic incisional hernia formation was used. Failing midline laparotomy incisions developed into incisional hernias. Controls were uninjured and sham laparotomy (healed) groups. Internal oblique muscles were harvested for fiber typing, measurement of cross-sectional area, collagen deposition, and mechanical analysis. Mesh hernia repairs were performed on a second group of rats with chronic incisional hernias or acute anterior abdominal wall myofascial defects.
The hernia group developed lateral abdominal wall shortening and oblique muscle atrophy. This was associated with a change in the distribution of oblique muscle fiber types, decreased cross-sectional area, and pathologic fibrosis consistent with myopathic disuse atrophy. These muscles exhibited significant decreased extensibility and increased stiffness. The healed (sham) laparotomy group expressed an intermediate phenotype between the uninjured and hernia groups. Recurrent hernia formation was most frequent in the chronic hernia model, and hernia repairs mechanically disrupted at a lower force compared with nonherniated abdominal walls.
The internal oblique muscles of the abdominal wall express a pattern of changes consistent with those seen in chronically unloaded skeletal muscles. The internal oblique muscles become fibrotic during herniation, reducing abdominal wall compliance and increasing the transfer of load forces to the midline wound at the time of hernia repair.
The present study evaluated outcomes of patients undergoing proximal diversion using either a loop ileostomy or loop colostomy following distal colorectal resection for malignant and non-malignant disease.
A literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1966 and 2006, comparing loop ileostomy and loop colostomy to protect a distal colorectal anastomosis. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since 2000, higher quality papers, those reporting on 70 or more patients, and those reporting outcomes following colorectal cancer resections.
Seven studies, including three randomised controlled trials, satisfied the inclusion criteria. Outcomes of a total of 1,204 patients were analysed, of whom 719 (59.7%) underwent defunctioning loop ileostomy. High stoma output was more common following ileostomy formation (OR = 5.39, 95% CI: 1.11, 26.12, P = 0.04), but wound infections following their reversal were significantly fewer (OR = 0.21, 95% CI: 0.07, 0.62, P = 0.004). Overall complications were less frequent for ileostomy patients in the subgroup of high quality studies (OR = 0.22, 95% CI: 0.08, 0.59, P = 0.003).
The results of this meta-analysis suggest that ileostomy may be preferable to colostomy when used to defunction a distal colorectal anastomosis. Wound infections following stoma reversal were reduced, as were overall stoma-related complications and incisional hernia following stoma reversal for ileostomy patients in high quality studies.
To evaluate morbidity related to the use of a protective stoma in rectal resection for cancer.
Seventy-two patients undergoing anterior rectal resection for cancer combined with a protective stoma (1993-2005) were included. Loop ileostomy was applied in 61 patients, loop colostomy in 10, and end ileostomy in one. Data regarding the primary operation were recorded prospectively, and stoma complications retrospectively.
Five patients (7%) developed stoma complications immediately after the primary operation, and 14/70 (20%) following hospital discharge. The stoma was closed in 62 (86%) patients after median 4 (range 1-11) months. Five patients (8%) developed complications in hospital after closure. Two patients (3%) died, one of ileal anastomotic leak and one of myocardial infarction. Five patients (8%) had late complications after closure. A total of 19 patients (26%) developed stoma related complications. Eight (11%) of these were reoperated. Premature stoma closure was necessary in two additional patients. Nine patients (13%) ended up with a permanent stoma. Fourteen (19%) patients developed signs of rectal anastomotic failure, six (8%) of whom needed reoperation. One died.
Significant morbidity is related to the use of defunctioning stomas. A protective stoma cannot always prevent serious complications of a rectal anastomotic leak, and a proportion of the patients will not have the stoma closed.
Incisional hernia at the site where a patient had previously had a stoma has not been clearly studied. The aim of this study is to determine the incidence and associated factors that may lead to an incisional hernia related to the reversal of an intestinal stoma.
An analysis was made of 70 cases of intestinal reconnection. All patients received Cefotaxime or Ceftazidime during anaesthesia induction and two more doses at 1-8 h in the post-operative period. In all of the cases, closure of the stoma site was effected as a primary closure using no. 1 polyglycolic acid continuous suture. There followed wound lavage with iodopovidone, and the skin was closed with simple sutures using polypropylene 3/0. No drain was left in situ in any of the cases. The study considered the following aspects: demographic characteristics of the study group; illnesses giving rise to the need for stoma formation; the stoma site itself; clinical aspects, including body mass index (BMI); the incidence of incisional hernia; and any complications involving the surgical wound.
At this hospital, the cause of requiring treatment with stoma formation was diverticular disease of the colon principally, and the age of the patients varied from 36 to 87 years (median 61). The incidence of incisional hernia at the stoma site was 22 cases (31.4%), presenting equally in both sexes and with greater frequency under the following circumstances: during the first year of follow-up and in patients with concomitant illnesses, principally diabetes. Local complications involving the surgical wound occurred in six cases (8.5%).
The incidence of incisional hernia at the stoma site was found to be 31.4% in this study, which is a high incidence of hernias with simple repair.
Parastomal hernias can be prevented or repaired using synthetic mesh; however, reported complications include infection, fibrosis and potential bowel erosion. The study aim was to assess the safety, feasibility and potential efficacy of using a prophylactic collagen implant.
Twenty patients undergoing defunctioning stomas were randomised to a conventional procedure or reinforcement with the implant. Follow-up included regular symptom questionnaires, clinical examination, stoma site ultrasound, and serum inflammatory markers.
Ten patients (four males; mean BMI 26.3) had a conventional stoma, and ten (three males; mean BMI 26.3) received the implant. At a median of 6.5 months follow-up, a parastomal hernia was clinically evident in three of ten patients without the implant, and in none of ten patients with the implant. There were no clinical complications, ultrasound evidence of chronic seromas or serological evidence of a systemic inflammatory response.
Xenogeneic collagen has been demonstrated to aid soft tissue reinforcement. In this study, in contrast to published data relating to the use of conventional synthetic mesh, there were no complications related to infection or the implant's proximity to the bowel. This trial demonstrates that the implant is safe, feasible to use and has the potential to prevent parastomal herniation.
Are biologic grafts effective for hernia repair?: a systematic review of the literature
- Ritchie Rd Altizer
- Am
Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 2009;16(1):26e37.