Can ileostomy closure and mesh placement be combined?

Ileostomy Closure and Mesh Placement: Safety and Efficacy

Ileostomy closure and mesh placement can be safely combined, with prophylactic mesh reinforcement significantly reducing the risk of stomal site incisional hernia without increasing wound complications. 1

Evidence for Combined Approach

• Prophylactic mesh placement at the time of ileostomy closure significantly reduces the incidence of incisional hernia formation (6.4% with mesh vs. 36.1% without mesh) 1
• No significant difference in wound infection rates has been observed between mesh (4.3%) and non-mesh (2.8%) groups during ileostomy closure 1
• Recent data shows that biosynthetic mesh placement during ileostomy closure results in very low hernia rates (1.7% at 1-year follow-up) 2
• Retromuscular mesh reinforcement during loop ileostomy takedown appears feasible, safe, and effective with no surgical site occurrences or hernias observed over a 20-month follow-up period 3

Optimal Mesh Selection and Placement

• Various mesh types can be considered for prophylactic reinforcement during ileostomy closure:

  • Non-absorbable synthetic mesh (polypropylene) 3
  • Slowly absorbable biosynthetic mesh (poly-4-hydroxybutyrate) 2
  • Biological meshes in contaminated fields 4

• The retromuscular (sublay) position is the preferred placement technique for mesh reinforcement during ileostomy closure 3, 5

  • This position places the mesh between the rectus muscle and posterior rectus sheath 5
  • Allows for adequate overlap (recommended 3 cm beyond the defect margins) 3

Risk Factors and Patient Selection

• Patients at higher risk for incisional hernia after ileostomy closure who would benefit most from prophylactic mesh include:
  • Those with malignancy (OR: 21.93) 1
  • Patients with diabetes (OR: 20.98) 1
  • Patients with other risk factors for hernia development should be considered for prophylactic mesh reinforcement 4

Technical Considerations

• Primary fascial closure should be attempted when possible before mesh reinforcement 5
• The posterior rectus sheath should be mobilized and reapproximated with absorbable suture before mesh placement 3
• Mesh should be secured with minimal fixation (fibrin sealant is one option) to reduce tissue trauma 3
• The anterior fascia should be closed with slowly absorbable suture after mesh placement 3

Potential Complications and Management

• Most common complications after mesh placement during ileostomy closure include:

  • Seroma formation (8.6%) 2
  • Superficial surgical site infections (6%) 2
  • Deep surgical site infections (1.7%) 2

• Serious complications requiring intervention are rare (2.6%), with mesh removal needed in only about 1% of cases 2

Cautions and Contraindications

• While mesh is beneficial for colostomy closure, there is some evidence suggesting increased parastomal hernia rates with mesh reinforcement in permanent ileostomies (different from temporary ileostomy closure) 6
• In cases of significant contamination or active infection, consider delaying mesh placement or using biological or biosynthetic alternatives 4

Long-term Outcomes

• Prophylactic mesh placement during ileostomy closure improves quality of life measures over time 2
• The need for subsequent hernia repair is significantly reduced with prophylactic mesh placement (0% vs. 23% without mesh) 1

By implementing prophylactic mesh reinforcement during ileostomy closure, surgeons can significantly reduce the risk of incisional hernia formation without increasing wound complications, ultimately improving patient outcomes and reducing the need for subsequent hernia repairs.