QS126 - To Separate or Not? Unilateral Anterior Component Separation at Time of Ostomy Reversal

Purpose/Background: The incidence of incisional hernia formation following stoma closure ranges from 25-30% in contemporary studies. The use of mesh at the time of ostomy closure has been described to reduce hernia development. We describe the use of an anterior component separation (CS) on the side of the ostomy reversal to facilitate a tension-free closure. The aim of this study was to assess the outcomes of component separation performed at the time of ostomy closure.

Methods/Interventions: This was an observational study of consecutive patients who underwent ostomy reversal with component separation performed by colorectal surgeons from January 2014 to Oct 2023 at a teaching hospital. Data was captured with a prospectively maintained IRB-approved database and verified by searching all relevant CPT codes. Patient characteristics, intraoperative and postoperative outcomes were analyzed. Technique: when a broad anterior rectus fascial defect is encountered during ostomy reversal, the surgeon dissects laterally over the anterior rectus sheath and external oblique fascia to an area between mid-clavicular and mid-axillary line. The anterior component separation is performed by incising the external oblique fascia for the length of the ostomy defect plus 1-2cm above and below the defect length. This releases the lateral edge anterior rectus sheath at the ostomy site to allow for a tension-free closure of the defect. A closed suction drain is placed laterally to prevent seroma formation and removed prior to discharge.

Results/Outcomes: Of 817 patients who underwent ileostomy or colostomy closure from 2014 to present, 85% (n=698) received closure alone and 15% (n=119) received component separation. Sixty-nine patients underwent ostomy closure and ventral hernia repair with plastic surgery and were therefore excluded, leaving 50 patients who had CS at the site of closure. Of these, the majority underwent loop colostomy closure (n=30, 60%), followed by closure of loop ileostomy (n= 13, 26%), end colostomy (n=5, 10%), and end ileostomy (n=2, 4%). Our baseline demographic data were 54% male, mean age of 60 years, mean BMI of 31 kg/m2, and 62% ASA class 3-4. Indication for ostomy creation included colorectal cancer (n=21, 42%), diverticulitis (n=18, 36%), extracolonic cancer (n=7, 14%) rectourethral fistula (n=3, 6%), and Crohn’s disease (n=1, 2%). Twelve patients (24%) had symptomatic parastomal hernias at time of takedown and the mean time to reversal was 201 days. The mean length of the unilateral component separation was 11.4 cm (range 8-15 cm). Three patients had readmission within 30 days; two for dehydration and one for abdominal wound infection requiring bedside I&D. The mean length of colorectal surgery follow-up was 411 days (range 14-3,400 days), of which no patients had clinically detectable hernias on physical exam at the ostomy site. Seventeen patients (34%) had postoperative CT scans in our database, none of which demonstrated fascial defects at the site of ostomy reversal. Four patients (8%) had ventral hernias on CT scans from prior midline laparotomy that did not require reoperation.

Conclusion/Discussion: We describe the novel use of anterior component separation during ostomy closure. We propose unilateral anterior component separation as an alternative to mesh to prevent ostomy site hernia when a broad fascial defect is encountered during closure.