Can ileostomy closure and abdominal wall hernia repair be performed together?

Combined Ileostomy Closure and Abdominal Wall Hernia Repair

Ileostomy closure and abdominal wall hernia repair can be safely performed together as a combined procedure in most patients, which reduces the need for multiple surgeries and decreases overall morbidity. 1

Surgical Considerations for Combined Approach

• The combined procedure is feasible when there is no active infection, inflammation, or intestinal strangulation requiring emergency intervention 2, 1
• Prophylactic mesh reinforcement at the time of ileostomy closure significantly reduces the incidence of stomal site incisional hernia (6.4% with mesh vs. 36.1% without mesh) without increasing wound complications 3
• Patient factors rather than surgical technique are the main predictors of hernia development after ileostomy closure, with obesity (higher BMI) being a significant risk factor (OR 1.15,95% CI: 1.05-1.26) 4, 5

Surgical Technique Recommendations

• For midline abdominal wall hernia repair combined with ileostomy closure:

  • Use continuous suture technique for fascial closure as it is faster than interrupted sutures with no difference in hernia or dehiscence rates 2
  • Employ mass closure rather than layered closure for speed and equivalent outcomes 2
  • Maintain a suture-to-wound length ratio of at least 4:1 for continuous closure 2
  • Use small bite technique to prevent incisional hernia and wound complications 2

• For mesh selection and placement:

  • Synthetic mesh is recommended for hernia repair when there is no gross enteric spillage 1
  • Consider component separation technique for large midline abdominal wall hernias 2
  • Biological meshes may be considered in contaminated fields where component separation alone is not feasible 6

Potential Complications and Prevention

• Stomal stenosis can occur during gradual closure of abdominal wall defects with an ostomy in place; careful evaluation of stomal patency throughout the repair process is essential 7
• Incisional hernia at the ileostomy site occurs in up to 23% of patients following loop ileostomy closure without mesh reinforcement 5
• Risk factors for hernia development include:
  • Obesity (higher BMI) 4, 5
  • Diabetes 3
  • Malignancy 3
  • Postoperative complications 4

Antimicrobial Prophylaxis

• For clean cases with no bowel ischemia, short-term prophylaxis is recommended 2
• For cases with intestinal strangulation and/or concurrent bowel resection, 48-hour antimicrobial prophylaxis is recommended 2
• Consider antimicrobial-coated sutures to reduce surgical site infection risk 2

Algorithm for Decision Making

1. Assess patient factors:

   • BMI (obesity increases hernia risk) 5
   • Presence of diabetes or malignancy 3
   • Overall nutritional status 6

2. Evaluate local tissue conditions:

   • Absence of active infection at either site 1
   • Quality of surrounding tissue 6
   • Size of hernia defect 2

3. Choose appropriate surgical technique:

   • For small to moderate hernias with healthy tissue: combined procedure with synthetic mesh 1, 3
   • For large hernias: consider component separation with or without mesh reinforcement 2
   • For contaminated fields: biological mesh may be preferred 6

4. Implement proper closure technique:

   • Continuous suture with slowly absorbable monofilament material 2
   • Small bite technique with SL/WL ratio of at least 4:1 2
   • Prophylactic mesh placement at ileostomy site 3