Prophylactic intraperitoneal mesh placement to prevent incisional hernia after stoma reversal: a feasibility study

Contemporary Outcomes of Elective Parastomal Hernia Repair in Older Adults

Importance

Parastomal hernia is a challenging complication following ostomy creation; however, the incidence and long-term outcomes after elective parastomal hernia repair are poorly characterized.

Objective

To describe the incidence and long-term outcomes after elective parastomal hernia repair.

Design, Setting, and Participants

Using 100% Medicare claims, a retrospective cohort study of adult patients who underwent elective parastomal hernia repair between January 1, 2007, and December 31, 2015, was performed. Logistic regression and Cox proportional hazards models were used to evaluate mortality, complications, readmission, and reoperation after surgery. Analysis took place between February and May 2022.

Exposures

Parastomal hernia repair without ostomy resiting, parastomal hernia repair with ostomy resiting, and parastomal hernia repair with ostomy reversal.

Main Outcomes and Measures

Mortality, complications, and readmission within 30 days of surgery and reoperation for recurrence (parastomal or incisional hernia repair) up to 5 years after surgery.

Results

A total of 17 625 patients underwent elective parastomal hernia repair (mean [SD] age, 73.3 [9.1] years; 10 059 female individuals [57.1%]). Overall, 7315 patients (41.5%) underwent parastomal hernia repair without ostomy resiting, 2744 (15.6%) underwent parastomal hernia repair with ostomy resiting, and 7566 (42.9%) underwent parastomal hernia repair with ostomy reversal. In the 30 days after surgery, 676 patients (3.8%) died, 7088 (40.2%) had a complication, and 1740 (9.9%) were readmitted. The overall adjusted 5-year cumulative incidence of reoperation was 21.1% and was highest for patients who underwent parastomal hernia repair with ostomy resiting (25.3% [95% CI, 25.2%-25.4%]) compared with patients who underwent parastomal hernia repair with ostomy reversal (18.8% [95% CI, 18.7%-18.8%]). Among patients whose ostomy was not reversed, the hazard of repeat parastomal hernia repair was the same for patients whose ostomy was resited vs those whose ostomy was not resited (adjusted hazard ratio, 0.93 [95% CI, 0.81-1.06]).

Conclusions and Relevance

In this study, more than 1 in 5 patients underwent another parastomal or incisional hernia repair within 5 years of surgery. Although this was lowest for patients who underwent ostomy reversal at their index operation, ostomy resiting was not superior to local repair. Understanding the long-term outcomes of this common elective operation may help inform decision-making between patients and surgeons regarding appropriate operative approach and timing of surgery.

Retrorectus mesh reinforcement of ileostomy site fascial closure: stoma closure and reinforcement (SCAR) trial phase I/II results

PURPOSE

Loop ileostomy (LI) is commonly employed during colorectal surgeries to reduce the consequences of anastomotic leak. Unfortunately, LI is associated with a 10-30% incisional hernia (IH) rate after closure. We hypothesized that prophylactic mesh reinforcement during LI takedown would safely prevent subsequent IH formation.

METHODS

This single-center, phase I/II prospective study evaluated adult patients undergoing LI closure after left-sided colorectal cancer procedures. After LI closure, the posterior rectus sheath was mobilized and reapproximated with absorbable suture. A reduced-weight, macroporous, polypropylene mesh (Softmesh, BD) was placed in the retrorectus position to allow 3 cm of overlap and secured with fibrin sealant. The anterior fascia was closed with slowly absorbable suture. CT images obtained for cancer surveillance were reviewed by a radiologist blinded to the study intervention to evaluate for evidence of hernia or surgical site occurrence (SSO).

RESULTS

Twenty patients were included with mean defect and mesh sizes of 11.2 cm² and 64.2 cm², respectively. Mean operative time for LI takedown and mesh augmented closure was 84 min with mesh implantation time being 16.4 min. Two patients were readmitted within 30 days for ileus, no patient required procedural intervention. Over a mean follow-up period of 20 ± 7 months, no SSO or hernias were observed clinically or on CT imaging.

CONCLUSION

In our small series, retromuscular mesh reinforcement of LI closure appears feasible, safe and effective. This mesh reinforcement approach should be further investigated to evaluate its long-term effectiveness.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

INTRODUCTION

The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations.

METHODS

We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis.

RESULTS

Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial.

CONCLUSION

A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

When to use a prophylactic mesh after stoma closure: a case-control study

Purpose

The closure of a stoma is frequently associated with an acceptable morbidity and mortality. One of the most frequent complications is incisional hernia at the stoma site, which occurs in 20%–40% of cases, higher than incisions in other parts of the abdomen. The objective of this study was to identify the risk factors associated with the presentation of incisional hernia after stoma closure, this in order to select patients who are candidates for prophylactic mesh placement during closure.

Methods

An unpaired case–control study was conducted. This study involved 164 patients who underwent a stoma closure between January 2014 and December 2019. Associated factors for the development of incisional hernia at the site of the stoma after closure were identified, for which it was performed a logistic regression analysis.

Results

41 cases and 123 controls were analyzed, with a mean follow-up of 35.21 ± 18.42 months, the mean age for performing the stoma closure was 65.28 ± 14.07 years, the most frequent cause for performing the stoma was malignant disease (65.85%). Risk factor for the development of incisional hernia at the stoma site after its closure was identified as a history of parastomal hernia (OR 5.90, CI95% 1.97–17.68).

Conclusions

The use of prophylactic mesh at stoma closure should be considered in patients with a history of parastomal hernia since these patients present a significantly higher risk of developing a hernia.

Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial

A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.

Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis

Purpose

To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes.

Methods

A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles.

Results

A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04–0.27, p < 0.001, I² = 0%, CI 0–91.40%). No differences in surgical site infections were detected between the groups.

Conclusions

The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-01996-8) contains supplementary material, which is available to authorized users.

Incidence, risk factors and prevention of stoma site incisional hernias: a systematic review and meta-analysis

AIM

Stoma reversal might lead to a stoma site incisional hernia. Recently, prophylactic mesh reinforcement of the stoma site has gained increased attention, supporting the need for accurate data on the incidence of and risk factors for stoma site incisional hernia and 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 the incidence of stoma site incisional hernia after stoma reversal were included. Study quality was assessed with the Newcastle-Ottawa 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 the primary end-point, 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 significantly lower rates of stoma site incisional hernia with prophylactic mesh reinforcement compared with nonmesh controls [6.4% vs 36.1% (P = 0.001); 3% vs 19% (P = 0.04)].

CONCLUSION

Stoma site incisional hernia should not be underestimated as a long-term problem. 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 hernia.

Stomal Closure: Strategies to Prevent Incisional Hernia

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.

Incidence of and risk factors for stoma-site incisional herniation after reversal

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.

Prophylactic meshes in the abdominal wall

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.

Incisional hernia prevention and use of mesh. A narrative review

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

Use of biologic mesh at ostomy takedown to prevent incisional hernia: A case series

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The placement of biologic mesh at ostomy takedown is a safe technique.

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Biologic mesh use at ostomy takedown may prevent the development of incisional hernia.

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Biologic mesh placed in a retrorectus fashion has prevented incisional hernia in patients with significant risk factors.

Introduction

Incisional hernias are a relatively common occurrence after ostomy takedown with a incidence of 30–35%. The use of biologic mesh offers a means to bolster the stoma incision site with a lower risk of infection than synthetic mesh.

Methods

This study represents a retrospective chart review of six patients who underwent stoma takedown and had biologic mesh placed in the retrorectus position during repair from March 2015 until March 2016.

Results

There has been a zero-rate of hernia occurrence for the six patients who underwent stoma takedown. No incisional hernias were noted on physical exam with follow up ranging from 11 to 25 months.

Conclusion

We conclude that placement of biologic mesh is a safe and effective way of preventing incisional hernias at stoma sites.

Incidence, recurrence and risk factors of hernias following stoma reversal

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.

Incidence of Port-Site Hernias: A Survey and Literature Review

BACKGROUND

The impact of laparoscopy on the prevalence of incisional hernias remains unclear. The aim of this study is to determine (1) surgeon perceptions of port-site hernias (PSHs), (2) the true incidence of PSH.

MATERIALS AND METHODS

A survey on PSH was given to determine the surgeon-reported rate of PSH. A literature review was performed for studies with a primary outcome of PSH. Studies were evaluated using checklists, and scores were used to compare risk of bias. Risk of bias was graphed against PSH incidence.

RESULTS

From 38 surgeons surveyed, the surgeon perceived rate of PSH was a median (range) of 0.5% (0% to 5%) for ports ≤5 mm, 5% (0.1% to 20%) for ports extended, and 5% (0.1% to 40%) for ports ≥10 mm. Thirty studies showed a PSH rate from 0% to 39.3%. Higher quality studies reported higher rates of PSH.

CONCLUSIONS

Surgeons underestimate the incidence of PSH, but high-quality literature suggests that it may be nearly 40%.

The incidence of incisional hernias following ileostomy reversal in colorectal cancer patients treated with anterior resection

INTRODUCTION The aim of this study was to identify the rate of incisional hernia formation following ileostomy reversal in patients who underwent anterior resection for colorectal cancer. In addition, we aimed to ascertain risk factors for the development of reversal-site incisional hernias and to record the characteristics of the resultant hernias. MATERIALS AND METHODS Using a prospectively compiled database of colorectal cancer patients who were treated with anterior resection, we identified individuals who had undergone both ileostomy formation and subsequent reversal of their ileostomies from January 2005 to December 2014. Medical records were reviewed to record descriptive patient data about risk factors for hernia formation, operative details and any subsequent operations. Computed tomography reports were reviewed to identify the number, site and characteristics of incisional hernias. RESULTS A total of 121 patients were included in this study; 14.9% (n = 18) developed an incisional hernia at the ileostomy reversal site; 17.4% (n = 21) at a non-ileostomy site and 6.6% (n = 8) developed both. The reversal-site hernias were smaller both in width and length compared with the non-ileostomy-site hernias. Risk factors for the development of reversal-site incisional hernias were higher body mass index (BMI), lower age, open surgery, longer reversal time and a history of previous hernias. We did not detect a difference in the size of the incisional hernias that developed in patients with these specific risk factors. CONCLUSIONS Incisional hernias are a significant complication of ileostomy reversal. Further evaluation of the use of prophylactic mesh to reduce the incidence of incisional hernias may be worthwhile.

Retrospective observational study on the incidence of incisional hernias after reversal of a temporary diverting ileostomy following rectal carcinoma resection with follow-up CT scans

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.

Incisional reinforcement in high-risk patients

Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.