Can ileostomy closure and abdominal wall hernia repair be combined?

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

Patient Selection Criteria

• Combined procedure is appropriate when there is no active infection, inflammation, or intestinal strangulation requiring emergency intervention 1
• Evaluate local tissue conditions, including absence of active infection at either site before proceeding with combined approach 1
• Higher risk patients for hernia development (those with malignancy or diabetes) may particularly benefit from the combined approach with mesh reinforcement 2

Surgical Technique Recommendations

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

  • Use continuous suture technique for fascial closure as it is faster with equivalent outcomes 1
  • Employ mass closure rather than layered closure for speed and equivalent outcomes 1
  • Maintain a suture-to-wound length ratio of at least 4:1 for continuous closure 1
  • Use small bite technique to prevent incisional hernia and wound complications 1

• Mesh selection based on surgical field classification:

  • For clean surgical fields (CDC wound class I) - synthetic mesh is recommended 3, 1
  • For clean-contaminated fields (CDC wound class II) - synthetic mesh can still be used safely 3
  • For contaminated or dirty fields (CDC wound classes III and IV) - primary repair for small defects (<3 cm), biological mesh for larger defects 3

• Consider component separation technique for large midline abdominal wall hernias 3, 1

Antimicrobial Prophylaxis

• For clean cases with no bowel ischemia, short-term prophylaxis is recommended 1, 4
• For cases with intestinal strangulation and/or concurrent bowel resection, 48-hour antimicrobial prophylaxis is recommended 1, 4
• Full antimicrobial therapy is required for cases with peritonitis 3

Potential Complications and Management

• Monitor for stomal stenosis during closure of large abdominal wall defects, as gradual closure techniques may deform the abdominal wall 5
• Prophylactic mesh placement at the ileostomy closure site significantly reduces incisional hernia rates (from 36.1% to 6.4%) without increasing wound infection rates 2
• If primary fascial closure is not possible due to tension, consider progressive closure techniques or temporary abdominal closure with negative pressure wound therapy 6
• When definitive fascial closure cannot be achieved, a skin-only closure is viable with subsequent repair of the eventration at a later stage 3

Risk Factors for Post-Closure Complications

• Patient factors are more predictive of hernia development than surgical technique 7
• Major risk factors for incisional hernia following ileostomy closure:
  • Malignancy (OR: 21.93) 7
  • Diabetes (OR: 20.98) 7
  • Elevated BMI 7
  • Postoperative complications within 30 days 7

Monitoring and Follow-up

• Clinical examination combined with imaging (CT) provides 88.5% concordance for hernia detection 7
• Most hernias develop within 8 months of closure, requiring appropriate follow-up duration 7