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Retrorectus Mesh Reinforcement of Ileostomy Closure Is Feasible, Safe and Effective: Results from the Stoma Closure and Reinforcement (SCAR) Trial
Robert D. Shaw, Jenaya L. Goldwag, Mark Eid, Lauren Wilson, Srinivas Ivatury, matthew Wilson
General Surgery, Dartmouth Hitchcock Medical Center, Hanover, New Hampshire, United States

Objective:
To evaluate the safety and efficacy of permanent mesh placement in the retro-rectus position during ileostomy reversal to prevent incisional hernias.
Design:
Prospective, single-center, cohort study. Patients were followed 30 days post-operatively with planned every 6-month routine colorectal cancer surveillance with CT imagining.
Setting:
Dartmouth-Hitchcock Medical center, a quaternary care academic medical center in Lebanon, NH.
Patients:
20 adult patients with left-sided colon and rectal cancer treated with resection and diverting loop ileostomy. Participants were excluded from the pilot study if they had a pre-existing systemic infection at the time of their scheduled ileostomy closure, had severe medical comorbidities or were taking medications that affect tissue healing.
Intervention:
Following ileostomy reversal, the posterior rectus sheath was closed and a circumferential myocutaneous flap was raised. BardTM soft mesh was placed in the retro-rectus plane and secured in place with fibrin sealant.
Main Outcome Measure:
Surgical site occurrences including seroma, hematoma, dehiscence/disruption, and cellulitis, as well as unplanned return to the operating room at 30 days post-operatively.
Results (Table 1):
A total of 20 patients were enrolled with a mean defect size of 11.2cm2 (SD, 5.1). Average operative time for mesh implantation was 16.4 minutes (SD, 7). On average patients presented for their first outpatient follow-up at 37 days and at this time there were no wound occurrences, complications requiring intervention, or clinical evidence of hernia formation.
Conclusion:
Permanent mesh implantation during ileostomy reversal is safe and feasible as marked by zero wound occurrences and the modest amount of additional time for the intervention. While there have been zero incidences of clinical hernia formation, the long-term radiographic evaluations are needed to confirm a reduction in stoma site hernias compared to historical controls of primary fascial closure.

Table 1. Descriptive characteristics of patients, operative information, and 30-day follow-up
Male12
Female8
BMI (Mean, SD)29.19 (7.9)
ASA 
II8
III11
IV1
DM5
Steroid Therapy2
Tobacco Use7
Neoadjuvant ChemoXRT4
Adjuvant Therapy7
Total Neoadjuvant Therapy9
Operative Approach 
Minimally Invasive16
Open4
Duration of Diversion (days, mean, SD) 
No Adjuvant Therapy92 (41)
Adjuvant Therapy272 (90)
Defect Size, cm2 (Mean, SD)11.2 (5.1)
Mesh Size, cm2 (Mean, SD)64.2 (20.3)
Total Operative Time, Min (Mean, SD)84 (26.5)
Mesh Implant Time, Min (Mean, SD)16.4 (7)
LOS, Days (Mean)2.3
Time to Outpatient Follow-up (days, mean)37
Readmission2
Complications requiring intervention0
Wound Occurence0


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