A colostomy reversal restores the natural passage of stool after a temporary colostomy has been created. The original colostomy diverts the colon through the abdominal wall, forming a stoma, typically allowing the lower bowel to heal following major surgery or illness. The reversal involves closing the stoma and surgically rejoining the ends of the bowel so that waste exits through the rectum. This surgery is usually performed several months after the initial procedure, once the patient has fully recovered and the underlying condition is stable.
A common complication associated with the temporary stoma is the development of a parastomal hernia. This occurs when abdominal contents push through the weakened abdominal muscle wall around the stoma site, creating a bulge. The combined procedure of colostomy reversal with parastomal hernia repair is frequently undertaken to maximize efficiency. Performing both repairs simultaneously minimizes the number of major operations and reduces the patient’s overall exposure to general anesthesia.
Determining Candidacy for Combined Surgery
The decision to proceed with a combined colostomy reversal and hernia repair requires a thorough patient assessment. A mandatory waiting period is required to ensure the bowel has fully healed and the patient has recovered from the initial surgery. This period typically ranges from 8 to 12 weeks for a loop colostomy, but it is often extended to six months or more, especially following a complex procedure like a Hartmann’s reversal.
The patient’s overall health status is reviewed, often using the American Society of Anesthesiologists (ASA) physical status classification system. Pre-existing conditions such as poorly controlled diabetes, obesity, and hypertension are evaluated, as these factors can increase the risk of complications like surgical site infection or anastomotic leak. If the original surgery was for cancer, the patient must have completed any necessary adjuvant treatments, such as chemotherapy, and be free of active disease before the reversal can be scheduled.
Specific criteria for the hernia itself must be met, usually involving hernias that are symptomatic, large, or complex. Advanced imaging, such as a computed tomography (CT) scan, is essential to assess the anatomy of the hernia and the overall abdominal wall integrity. Before the colostomy is reversed, the surgeon must also confirm the health of the remaining rectum or colon stump, often using a contrast enema or endoscopy. This ensures the downstream segment is functional and free of strictures or leaks before the procedure is planned.
The Surgical Process: Reversal and Hernia Repair
The combined surgery begins with the stoma reversal, involving dissecting the bowel free from the abdominal wall where the stoma was created. The surgeon then prepares the two ends of the bowel for reconnection, a step known as creating an anastomosis. For a loop colostomy reversal, this often involves joining the bowel segments, usually performed using surgical staples or sutures.
Once bowel continuity is restored, the integrity of the anastomosis is checked, sometimes using an air or dye test to look for potential leaks. The hernia repair is then performed through the same incision site. The hernia sac is reduced back into the abdominal cavity, and the weakened abdominal wall defect is closed.
Repairing the parastomal hernia typically involves the use of surgical mesh to reinforce the abdominal wall and prevent recurrence. The mesh is placed in a layer of the abdominal wall, often in the retromuscular space behind the main muscle layer. This strategic placement helps to shield the mesh from the contamination risk associated with the adjacent stoma closure site. Specialized techniques, such as the Sugarbaker method, may be employed, which involves lateralizing the bowel and placing the mesh to create a tunnel around the path of the intestine.
Immediate Recovery and Hospital Stay
Recovery from the combined procedure is more intensive than from a simple colostomy reversal due to the added complexity of the abdominal wall reconstruction. Patients can expect a hospital stay often ranging from five to ten days, depending on their overall health and the return of normal bowel function. Patients may temporarily have a nasogastric (NG) tube to decompress the stomach or surgical drains to manage fluid at the repair site.
Pain management is a primary focus, often involving patient-controlled analgesia or epidural catheters for the first few days. The return of bowel function, known as peristalsis, is monitored, beginning with the passage of gas and eventually the first bowel movement. The diet is slowly advanced, starting with clear liquids and progressing to soft, low-fiber foods as the gastrointestinal tract wakes up.
Once discharged, patients receive instructions for wound care at the former stoma site and the abdominal incision. Activity restrictions are strict to protect the newly repaired hernia site and the mesh, requiring the avoidance of heavy lifting or strenuous activity for at least six to eight weeks. Early mobilization through short, frequent walks is encouraged, as it helps stimulate bowel function and reduces the risk of blood clots.
Potential Risks and Long-Term Follow-up
The combined nature of this surgery carries a higher risk profile compared to a reversal alone. One primary risk is an anastomotic leak, which occurs if the newly reconnected bowel does not seal properly, allowing intestinal contents to escape into the abdominal cavity.
Another common risk is surgical site infection (SSI), which is elevated because the procedure involves opening the bowel. This risk is further complicated by the use of mesh for the hernia repair, as an infection in this area may necessitate removal of the mesh and compromise the repair. The most common long-term issue following this combined procedure is hernia recurrence, even with mesh placement.
Long-term follow-up is necessary to monitor for any signs of recurrence or chronic complications. Patients are advised to maintain a healthy weight and adhere to physical restrictions to protect the abdominal wall. Dietary adjustments are needed for several months, focusing on low-residue foods to ease the transition for the reconnected bowel, which may experience urgency or loose stools as it adapts to its restored function.