Incisional mesh hernioplasty following spontaneous stoma closure: A case report

Abstract

BACKGROUND

Loop stoma is usually used to divert the fecal stream, with the aim of protecting the downstream anastomosis or allowing sufficient time for the repaired perforation site to heal. It is usually reversed once the purpose of its creation is served. Spontaneous stoma closure is a rare phenomenon, and its mechanism remains unclear. The factors contributing to this phenomenon encompass stoma retraction and the healing process of enterocutaneous fistula.

CASE SUMMARY

We present a case of mesh hernioplasty after the spontaneous closure of a transverse loop colostomy. This is the third case of spontaneous closure of loop colostomy and the first reported case of mesh hernioplasty following the spontaneous stoma closure in the English literature.

CONCLUSION

Spontaneous stoma closure is rare. Long-term follow-up is recommended to detect the development of incisional hernia at an early stage.

Key Words: Colostomy; Incisional; Mesh hernioplasty; Retraction; Spontaneous closure; Case report

Core Tip: Spontaneous stoma closure is a rare phenomenon, and its mechanism remains unclear. The factors contributing to this phenomenon encompass stoma retraction and the healing process of enterocutaneous fistula. We present a case of incisional mesh hernioplasty after spontaneous closure of a transverse loop colostomy. This is the first reported case in the English literature of mesh hernioplasty following spontaneous stoma closure. Although spontaneous stoma closure may avoid a second operation, clinicians should pay attention to the long-term complications such as incisional hernia formation.

INTRODUCTION

With the advancement of surgical techniques and promotion of the injury control concept, the use of enterostomy has increased significantly. Temporary enterostomy, as a necessary procedure in some specific clinical scenarios, is applied in malignant diseases, such as low-rectal cancer with anal preservation, and benign diseases[1]. It always requires additional surgery to close after the desired period of time, be it primary repair of stoma or resection followed by anastomosis[2]. In the United States, 725000 to 1 million people have undergone stoma surgery. In China, the number of people with permanent stomas has exceeded 1 million with an annual increase of 100000[3,4]. Common complications following enterostomy include stoma prolapse, stoma retraction, bleeding, necrosis, and hernia, with an incidence rate ranging from 21% to 70%[5]. However, spontaneous stoma closure is a rare complication after enterostomy. Here, we report a case of incisional hernia repair following spontaneous stoma closure with transverse loop colostomy, and present a literature review.

CASE PRESENTATION

Chief complaints

A 56-year-old male complained of recurrent abdominal pain, nausea, and vomiting, lasting for 1 month.

History of present illness

Symptoms started 1 month prior to presentation, including abdominal pain, nausea, and vomiting. There were no accompanying symptoms such as fever or diarrhea.

Personal and family history

The patient denied any family history of malignant tumors or other genetic diseases.

Physical examination upon admission

Body temperature: 36.6 °C; blood pressure: 117/77 mmHg; heart rate: 80 beats/minute; respiratory rate: 20 breaths/minute. Height: 160 cm; weight: 65 kg; body mass index: 25.4 kg/m². The upper abdominal scar healed well, with no leakage of intestinal contents. However, there was a peristomal bulge, measuring 4 cm × 5 cm, that was more pronounced in the standing position. Digital anal examination was not performed.

Laboratory examinations

Hemoglobin decreased to 103 g/L (normal range: 130-170 g/L). No other abnormality was found in routine blood and urine analyses.

Imaging examinations

Computed tomography revealed a 4 cm × 5 cm incisional hernia at the site of the initial surgical stoma (Figure 1). The transverse colon had been retracted from the skin to the subcutaneous tissue layer (Figure 1C). Evaluation via colonoscopy revealed no stricture and no obvious mucosal abnormality (Figure 1D). A detailed preoperative plan was made.

Figure 1 Computed tomography revealed a 4 cm × 5 cm incisional hernia at the site of the initial surgical stoma. A: Computed tomography (CT) of transverse loop colostomy; B: Site of the loop colostomy, which underwent spontaneous closure, and had completely epithelialized skin; C: Only a small amount of white scar tissue was found in the transverse colon area during colonoscopy; D: Preoperative CT of incisional hernia after spontaneous closure of the transverse loop colostomy (orange arrow); E: Postoperative CT showed no evidence of hernia recurrence (star symbol). The orange arrow showed the hernia mesh and metal nail.

FINAL DIAGNOSIS

Incisional hernia after spontaneous closure of transverse loop colostomy.

TREATMENT

There were no obvious signs intraoperatively of contamination in the abdominal cavity after exploration; therefore, we decided to perform stoma reversal and incisional hernia repair using the intraperitoneal onlay mesh method. A 10-mm trocar, serving as the observation port for laparoscopy, was placed at the left navel level and the lateral border of the rectus abdominis under direct vision through the initial incision. The stoma site incision was closed using nonabsorbable sutures, ensuring stability of the intraperitoneal pneumoperitoneum. Two additional 5-mm trocars were placed at the lateral edge of the rectus abdominis muscle, 6 cm above and below the left navel level, under direct laparoscopic vision after the pneumoperitoneum pressure reached 12 mmHg. A cropped 10 cm × 15 cm antiadhesion mesh (initial 10 cm × 20 cm, 5959480, BARD, United States) was placed and flattened beneath the incision, followed by fixation with hernia clips.

OUTCOME AND FOLLOW-UP

Postoperative recovery went smoothly. The patient was given a liquid diet on the first day after the operation and discharged on the fifth day. After 2 months follow-up, computed tomography showed no evidence of hernia recurrence (Figure 1E).

DISCUSSION

Enterostomy is an opening of the intestinal tract onto the anterior abdominal wall, to protect a distal gastrointestinal anastomosis, to relieve a benign or malignant obstruction, or to control sepsis related to perforation[6]. Stoma types or methods are diverse and can be classified according to time limit (temporary or permanent); intestinal segment (small intestine or colon); method (loop, end or double lumen); or location (right lower abdomen, right upper abdomen, left upper abdomen or left lower abdomen)[7,8].

The incidence of complications related to enterostomy is high, which seriously affects quality of life[9]. Early complications (< 1 month) include strangulation, ischemia, stenosis, obstruction, and mucocutaneous separation fistula. Late complications (> 1 month) include retraction, prolapse, parastomal hernia, and fistula[10]. In 2023, the China Stoma Management Collaborative Group reached a consensus on a new classification of enterostomy complications, which consists of classification and grading. The classification pertains to the categorization of enterostomy complications, reflecting the anatomical origin and cause of these complications. The grading is the modified Clavien-Dindo grading, a refinement of the existing grading system, reflecting the severity of complications, intervention level, and medical consumption[11].

Ge et al[12] compared the complications of ileostomy and colostomy. The stoma prolapse rate of ileostomy was lower than that of colostomy (1.27% vs 15.63%, P = 0.0002). The incidence of skin irritation and parastomal hernia was higher in ileostomy than in colostomy. Conversely, the incidence of parastomal fistula, enterocutaneous fistula, stenosis, and hemorrhage was higher in colostomy than in ileostomy[12].

The spontaneous closure of a stoma without surgical intervention is rare, and its underlying mechanism remains unclear. Stoma retraction (with synchronous restoration of rectal function without other complications) appears to be a crucial factor that facilitates spontaneous closure. Stoma retraction is a major complication of stomas, with an incidence rate as high as 25%. It refers to the highest point of the stoma intestinal mucosa retracting to the skin level or below it[13]. Often, it is preceded by disruption of the skin-mucosa suture line and is associated with stoma edema, cellulitis, and possible intraperitoneal leakage of effluent, which may require repeat laparotomy[14]. Stoma retraction depends on many factors, including intestinal hypoperistalsis; intestinal edema during emergency diversion surgery in the presence of mesenteric thickening and peritonitis; mucocutaneous separation; ischemic necrosis; and excessive weight gain. Albandar and Fatani[15] reported a case of self-manipulation in a patient who pushed the protruded stoma inside and eventually experienced regular stool passage. Figure 2 shows the probable process of spontaneous stoma closure with gradual stoma retraction.

Figure 2 Probable process of spontaneous stoma closure with gradual stoma retraction. A: Schematic diagram of colostomy; B: Suture fixation point gradually changing from bulging to concave; C: Suture fixation point further inwardly curve and more towards the center; D: After the skin scar hyperplasia healed, the spontaneous stoma closure formed.

Another potential mechanism for the spontaneous closure of the stoma is associated with healing of the enterocutaneous fistula. Enterostomy can be regarded as a postoperative, low-volume, and superficial intestinal cutaneous fistula, without infection or distal obstruction. All these factors are conducive to the spontaneous healing of the intestinal cutaneous fistula. The stoma, a type of iatrogenic end-to-end fistula, may gradually transform into a lateral fistula via stoma retraction. As long as the distal intestinal tract remains intact and healthy, the fistula may close spontaneously over time. However, its closure can be delayed by several factors, which are represented by the acronym FRIEND, standing for foreign body, radiation, infection, epithelialization, neoplasm, and distal obstruction[16]. With conservative management, 19%-92% of postoperative fistulae heal spontaneously, provided that there is no distal obstruction, the bowel is not diseased, and the patient is in an anabolic state[17,18].

Unfortunately, the risk of incisional hernia at the stomal site is inevitable after spontaneous closure, given the fascial defect at the closure site[19]. However, this situation may not be immediately apparent after closure but may manifest itself in a delayed manner. The reported incidence of incisional hernia following stoma closure is around 30%[20]. The risk is higher when the stoma closes spontaneously due to persistent muscle defects. Furthermore, daily activities, exertion, and long-term weight gain may gradually enlarge the muscle defect. In most cases, if the muscle defect exceeds 2 cm, patch hernia repair is required.

So far, only seven cases of spontaneous stoma closure have been reported in the English literature. Five of these cases involved ileal loop stomas, while two involved colonic loop stomas (Table 1)[10,15-17,21,22]. The time range for complete stoma closure was 3 weeks to 6 months. It is worth noting that some patients had received chemotherapy, radiotherapy, or antituberculosis treatment, which may affect stoma closure. Conservative management was used in all cases except the one reported by Thota et al[17]. In that case, anatomical repair was performed because diverticulectomy may turn the wound into a clean-contaminated one, increasing the risk of infection of the patch used for the hernia repair. To the best of our knowledge, this is the first report of mesh hernioplasty after spontaneous closure of a transverse loop colostomy.

Table 1 Summary of reported cases of spontaneous stoma closure.

Ref.	Year	Age (years)	Gender	Original pathology	Primary surgery	Type of stoma	Treatment plan after stoma surgery	Time to closure	Treatment plan after stoma closure
Saxena et al[21]	2015	26	F	Tubercular perforation of terminal ileum	Mesenteric lymph node biopsy and loop ileostomy	Loop ileostomy	Antitubercular treatment	6 months	Observe
Pandit et al[22]	2016	64	M	Perforation at the rectosigmoid junction	Perforation repair and proximal sigmoid loop colostomy	Sigmoid loop colostomy	N/A	3 weeks	Observe
Pandit et al[22]	2016	45	M	Rectal adenocarcinoma	Laparoscopic low anterior resection with covering loop ileostomy	Loop ileostomy	Chemoradiotherapy	6 weeks	Observe
Alyami et al[16]	2016	65	F	Colon adenocarcinoma	En bloc total colectomy, hysterectomy, and bilateral salpingoophorectomy, side-to-end stapled ileorectal anastomosis and loop ileostomy	Loop ileostomy	Chemotherapy	10 weeks, 18 weeks1	Observe
Saxena et al[10]	2022	18	F	Ileal perforation	Histopathological examination and loop ileostomy at the perforation site	Loop ileostomy	N/A	4 months	Observe
Thota et al[17]	2022	42	M	Hirschsprung’s disease	Duhamel procedure	Loop sigmoid colostomy	N/A	8 weeks	Diverticulum resection and anatomical repair
Albandar and Fatani[15]	2024	67	F	Adenocarcinoma of splenic flexure	Total colectomy with ileorectal anastomosis and a diverting loop ileostomy	Loop ileostomy	Chemoradiotherapy	6 months	Resection of the closed stoma and a side-to-side anastomosis
Present case	2025	56	M	Car accident injury	Partial small intestinal resection and transverse loop colostomy	Transverse loop colostomy	N/A	6 months	Mesh hernioplasty

¹This patient’s stoma reopened temporarily after 10 weeks and closed definitively at 18 weeks.

F: Female; M: Male; N/A: Not applicable.

CONCLUSION

Spontaneous stoma closure is rare and its mechanism remains unclear. The contributory factors include stoma retraction and the healing process of enterocutaneous fistula. Due to the limitations of the case report study and limited follow-up duration, it may be difficult to obtain generalized conclusions regarding optimal management. Long-term follow-up is recommended to detect the development of incisional hernia at an early stage.