Special article
Abdominal Wall Closure After a Stomal Reversal Procedure
Cierre de la pared abdominal después del cierre de un estoma temporal
Manuel López-Canoa,b,
, José Antonio Pereirac, Borja Villanuevaa, Francesc Vallriberad, Eloy Espind, Manuel Armengol Carrascoa,b, María Antonia Arbós Víab, Xavier Feliue, Salvador Morales-Condef
Corresponding author
a Cirugía de la Pared Abdominal, Servicio de Cirugía General y Digestiva, Hospital Universitario Vall d’Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
b Grupo de Investigación de Cirugía General y Digestiva, Pared Abdominal, Biomateriales, Institut de Recerca Vall d’Hebrón (IRVH), Edificio Collserola; Lab 211A, Barcelona, Spain
c Departament de Ciéncies Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
d Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Vall d’Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
e Servicio de Cirugía General, Hospital General d’Igualada, Igualada, Barcelona, Spain
f Unidad de Innovación en Cirugía Mínimamente Invasiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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General y Digestiva, Pared Abdominal, Biomateriales, Institut de Recerca Vall d’Hebrón (IRVH), Edificio Collserola; Lab 211A, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departament de Ciéncies Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Vall d’Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital General d’Igualada, Igualada, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Innovación en Cirugía Mínimamente Invasiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cierre de la pared abdominal después del cierre de un estoma temporal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1594 "Ancho" => 2281 "Tamanyo" => 226472 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">General overview of the different factors involved in abdominal wall closure of a temporary ostomy site.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The creation of a temporary ostomy is a surgical tool used to redirect intestinal contents away from a more distal problematic area or to avoid an anastomosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Temporary ostomies can be considered both our “friend” as well as our “enemy”.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The former is because of the advantages its use provides in certain situations,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> while the latter is due to the morbidities that can arise from its presence<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and the negative impact on patient quality of life<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> (in 20%–40%, the ostomy will never be reversed).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5–7</span></a> A temporary ostomy is probably only truly beneficial if the morbidity and mortality involved in its closure are minimal.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of this paper is to exclusively analyze the problems related with the closure of the abdominal wall through which the ostomy is constructed during closure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Points for Analysis</span><p id="par0015" class="elsevierStylePara elsevierViewall">The abdominal wall is made up of the skin, aponeurosis, muscle and peritoneum.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> For this reason, when closing a stoma it is necessary to treat a skin wound and a musculoaponeurotic wound. The musculoaponeurotic wound can present a concomitant parastomal hernia or be the origin of a later incisional hernia. Thus, prosthetic material may be used during the closure of the wound (either to treat or prevent a hernia). In addition, closure of the abdominal wall of a temporary ostomy is associated with bacterial contamination because the intestine is open and there is therefore a greater risk of surgical site infection (SSI) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In this context and in our opinion, 5 points should be considered:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0025" class="elsevierStylePara elsevierViewall">SSI in the closure of a temporary stoma</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0030" class="elsevierStylePara elsevierViewall">The presence of a hernia at the time of stoma closure: how to close the musculoaponeurotic wound?</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0035" class="elsevierStylePara elsevierViewall">The absence of a hernia at the time of stoma closure: should we prevent the appearance of a later incisional hernia?</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0040" class="elsevierStylePara elsevierViewall">The advantages of laparoscopic closure of the stoma</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Closure of the skin at the stoma site</p></li></ul></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical Site Infection in the Closure of a Temporary Stoma</span><p id="par0050" class="elsevierStylePara elsevierViewall">SSI is reported as being the most frequent complication after the closure of a temporary stoma<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> with an incidence that ranges between 2% and 40%.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–12</span></a> This variability in incidence may be related with under-reported percentages, the analysis of different types of temporary ostomies (different wound management protocols) or the use of data collection designs that are not homogenous enough to detect such events. One of the largest and most recent patient series published<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> shows an SSI incidence after temporary stoma reversal of 20%–30%, with the following associated risk factors: (1) morbid obesity (thickness of subcutaneous fat greater than 25<span class="elsevierStyleHsp" style=""></span>mm in the region of the navel); (2) the temporary stoma is a colostomy (SSI 5 times more frequent than in the case of ileostomy); or (3) the temporary stoma was created as an emergency procedure (persistence of “sleeping” bacteria at the surgical site). In addition, this same study<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> shows that the gram-positive microorganisms (basically enterococci and methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>) can play a determinant role in SSI after the closure of a temporary stoma, representing 70% of the bacteria isolated on culture. According to these authors, abdominal wall closure after temporary stoma reversal can be an inherently different procedure from colon and rectal surgery since the colonization of the skin and intestine can be completely different.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Presence of a Hernia at the Time of a Stoma Closure: How to Close the Musculofascial Wound?</span><p id="par0055" class="elsevierStylePara elsevierViewall">Incisional hernias are more frequently reported in association with colostomies (63%)<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> than with ileostomies (20%–30%).<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> It is interesting to observe how, in one of the largest published series about SSI and temporary stoma closure, the presence of a concomitant hernia was indicated as a risk factor for SSI.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Basically, this was seen in patients who were treated with the placement of synthetic mesh. The authors explained that it is a procedure that has additional dissection and entails longer surgical times. This increased risk of SSI related with the use of prosthetic material has also been reported by other authors.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Thus, these groups<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,16</span></a> recommend not reinforcing the hernia repair with synthetic material when closing a temporary stoma.</p><p id="par0060" class="elsevierStylePara elsevierViewall">On the other hand, the use of synthetic prostheses for the treatment of a hernia in contaminated and potentially contaminated areas is currently under debate.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> Some studies justify their use in these situations.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–24</span></a> These studies defend and argue in favor of hernia repair with synthetic mesh during the closure of a temporary ostomy. An alternative for avoiding the uncertainty of using synthetic material could be the use of biological prostheses; however, more evidence of the functional and long-term results are needed to determine in which situations and patients these expensive materials could be justified.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a> In our opinion, more data are required about repairing associated hernias with mesh during temporary ostomy reversal. In this context of limited available evidence, the surgical technique to be used for the abdominal wall closure will depend on individual clinical experience<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and factors such as surgeon preference or the clinical scenario in particular (type of patient, associated risk factors for SSI, etc.).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Absence of a Hernia at the Time of the Stoma Closure: Should Measures be Taken to Prevent the Appearance of an Incisional Hernia?</span><p id="par0065" class="elsevierStylePara elsevierViewall">The literature suggests that the incidence of incisional hernias at the closure site of a temporary stoma can be high.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,28–32</span></a> In a recent systematic review and meta-analysis on this subject,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> a percentage of 35% was observed when clinical and radiological evaluations were combined. For this reason, it has been suggested<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,28–33</span></a> that the closure of the musculoaponeurotic defect after the closure of a temporary ostomy should be reinforced by adding a prosthetic material. Nonetheless, the utility of reinforcement in these situations has not been sufficiently studied (probably due to the risk of associated SSI), which poses problems similar to those mentioned in the previous section. It could be argued in these cases that absorbable synthetic prosthetic material could be used,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> but unfortunately there are no supporting clinical data. At the writing of this paper, we have found only two related studies. The first, which is currently in the development stage and whose final objective is a randomized study (Reinforcement of Closure of Stoma Site [ROCSS]),<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a> will evaluate a biological prosthetic material (dermis porcina) in the prevention of incisional hernias at the closure site of temporary ostomies. The second is a retrospective study which concludes that the placement of synthetic prosthetic material reduces the later appearance of incisional hernias at the stoma site.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Once again, and until more evidence appears, the implementation of preventive prosthetic material will depend on the surgeon's better judgment and the characteristics of the clinical scenario.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Advantages of Laparoscopic Stoma Closure</span><p id="par0070" class="elsevierStylePara elsevierViewall">In the era of minimally invasive surgery, some authors have associated advantages with the use of the laparoscopic approach for closure of temporary stomas<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>: faster postoperative recovery, shorter hospital stay, vision of the entire abdominal cavity, avoiding the re-opening of previous laparotomies, lower rate of reoperations due to intestinal obstruction or a reduction in SSI rate.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mentioned advantages have been confirmed both for the closure of temporary ileostomies<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39–41</span></a> as well as the closure of temporary colostomies (i.e. Hartmann's procedure).<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42–45</span></a> Unfortunately, the majority of these published studies are characterized by two factors: (a) they mostly analyze the aspects related with the surgical technique for re-establishing intestinal continuity; and (b) practically no consideration is given to the aspects of abdominal wall closure and the problems that may arise. Only one author<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> makes an anecdotal mention that the laparoscopic approach is able to: (a) allow for exact dissection along the line joining the abdominal wall and intestinal loop; (b) avoid excessive dissection and resection of musculoaponeurotic tissue; and (c) minimize the damage caused by the use of electrocautery. The result of all these advantages would be the existence of less tension in the wall closure, with no vascular compromise along the edges of the musculoaponeurotic wound.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> In this previous context, it is tempting to speculate that some general beneficial aspects, especially the reduction in SSI rate, may favor different wall closure strategies (placement of synthetic prosthetic material). However, it seems evident that more studies are needed to clarify the actual impact of the laparoscopic approach in the closure of the abdominal wall at the stoma site.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Closure of the Skin at the Stoma Site</span><p id="par0080" class="elsevierStylePara elsevierViewall">Several options have been described for skin closure in these circumstances. Some authors propose leaving it open, allowing the skin wound to heal by secondary intention (granulation) and thus diminishing the risk for SSI.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47,48</span></a> On the other hand, primary closure has also been proposed, describing different variations (“air-tight” primary closure, “loose” primary closure or “delayed” primary closure), which provides for rapid healing but can be associated at the same time with a greater incidence of SSI.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Last of all, a hybrid closure combining the two previously mentioned options can be carried out by closing the skin with a “purse-string” suture.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Comparisons have been made among the different options (especially the last 2),<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and the purse-string suture has been shown to be a good alternative to primary closure in terms of lower rate of SSI. In a recent systematic review and meta-analysis,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> the authors conclude that the approximation technique with a purse-string suture was associated with a reduction of 80% in SSI, with no negative impact on hospital stay or long-term cosmetic results.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Summary</span><p id="par0090" class="elsevierStylePara elsevierViewall">The closure of a temporary stoma is sometimes perceived as minor surgery.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> In our opinion, it is not a minor procedure at all. The surgical technique for the closure of a temporary stoma raises 2 concerns that are different although closely related. On the one hand is the reconstruction of the intestinal transit with its potential problems.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the other is the closure of the abdominal wall with certain particularities that may give rise to complex therapeutic situations (both for decision-making as well as in the immediate and long-term results of those decisions).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Minimizing the risk of SSI is a key aspect in the closure of the abdominal wall at the site of a temporary ostomy. It is therefore important to analyze the previous surgical characteristics (type of temporary stoma, emergency or not). In addition, it may be of interest to implement a weight loss program prior to stoma reversal and to even consider avoiding closure in morbidly obese patients. As closing the wall can be a procedure that is inherently different from colon and rectal surgery, using antibiotics that cover gram-positive bacteria in the preoperative prophylaxis can be beneficial.</p><p id="par0100" class="elsevierStylePara elsevierViewall">When an associated hernia appears at the site of the temporary stoma, it may be logical to think that the best solution is standard hernia treatment (application of prosthetic material). However, the evidence in this regard is not solid and more data are needed. The incidence rates of associated hernias (63% for colostomies and 20%–30% for ileostomies) merit urgent attention in clinical research to determine the best possible treatment.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Furthermore, the incidence of incisional hernias at the site of a previous temporary stoma can reach 35%. Likewise, one-third of patients who undergo stoma reversal could require later abdominal wall surgery. Currently, there is an important lack of data and attention given to the complexity of potential “future” hernias and what they may mean in terms of morbidity and mortality. Studies are necessary (preferably randomized) to define the efficacy of prophylactic prosthetic materials and to determine which type of material is best. The same reasoning could be applied to the influence of the laparoscopic approach in wall closures at temporary stoma sites. The closure of the skin in these patients seems better when using an approximation with a “purse-string” suture.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Finally, answering the many specific questions regarding abdominal wall closure at a temporary stoma site combines aspects from different highly specialized areas. We therefore believe that cooperation is essential amongst the surgeons involved in the creation and reconstruction of the stoma (mostly surgeons specialized in colon and rectal surgery) and surgeons specialized in abdominal wall surgery.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres346832" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec328495" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres346833" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec328494" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Points for Analysis" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical Site Infection in the Closure of a Temporary Stoma" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Presence of a Hernia at the Time of a Stoma Closure: How to Close the Musculofascial Wound?" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Absence of a Hernia at the Time of the Stoma Closure: Should Measures be Taken to Prevent the Appearance of an Incisional Hernia?" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Advantages of Laparoscopic Stoma Closure" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Closure of the Skin at the Stoma Site" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Summary" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-01" "fechaAceptado" => "2014-01-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec328495" "palabras" => array:8 [ 0 => "Abdominal wall" 1 => "Hernia" 2 => "Incisional hernia" 3 => "Mesh" 4 => "Stoma" 5 => "Temporary stoma" 6 => "Surgical site infection" 7 => "Laparoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec328494" "palabras" => array:8 [ 0 => "Pared abdominal" 1 => "Hernia" 2 => "Hernia incisional" 3 => "Malla" 4 => "Ostomía" 5 => "Ostomía temporal" 6 => "Infección del sitio quirúrgico" 7 => "Laparoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Revertir un estoma temporal implica 2 procedimientos quirúrgicos diferentes: la reconstrucción del tránsito intestinal y el cierre de la pared abdominal en el sitio del estoma. Este último presenta diferentes aspectos que deben ser analizados: a) la infección del sitio quirúrgico (ISQ), b) el manejo de una hernia coincidente en el sitio del estoma en el momento de su cierre, c) la prevención del desarrollo de una hernia incisional posterior, d) el cierre del estoma en el caso de que se realice la reconstrucción del tránsito por vía laparoscópica, o e) el cierre de la piel del sitio del estoma. El objetivo de este trabajo es analizar estos aspectos en relación con la reconstrucción de la pared abdominal por la que emerge un estoma temporal cuando se procede al cierre de este.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López-Cano M, Pereira JA, Villanueva B, Vallribera F, Espin E, Armengol Carrasco M, et al. Cierre de la pared abdominal después del cierre de un estoma temporal. Cir Esp. 2014;92(6):387–392.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1594 "Ancho" => 2281 "Tamanyo" => 226472 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">General overview of the different factors involved in abdominal wall closure of a temporary ostomy site.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:51 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morbidity of ostomy takedown" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.M. Kaiser" 1 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 0 | 12 |
| 2024 October | 52 | 4 | 56 |
| 2024 September | 105 | 24 | 129 |
| 2024 August | 76 | 8 | 84 |
| 2024 July | 107 | 7 | 114 |
| 2024 June | 76 | 8 | 84 |
| 2024 May | 108 | 6 | 114 |
| 2024 April | 133 | 16 | 149 |
| 2024 March | 142 | 5 | 147 |
| 2024 February | 123 | 5 | 128 |
| 2024 January | 185 | 6 | 191 |
| 2023 December | 160 | 16 | 176 |
| 2023 November | 170 | 5 | 175 |
| 2023 October | 182 | 10 | 192 |
| 2023 September | 115 | 6 | 121 |
| 2023 August | 110 | 4 | 114 |
| 2023 July | 178 | 18 | 196 |
| 2023 June | 123 | 5 | 128 |
| 2023 May | 146 | 8 | 154 |
| 2023 April | 88 | 1 | 89 |
| 2023 March | 148 | 2 | 150 |
| 2023 February | 104 | 7 | 111 |
| 2023 January | 93 | 5 | 98 |
| 2022 December | 81 | 10 | 91 |
| 2022 November | 141 | 12 | 153 |
| 2022 October | 104 | 13 | 117 |
| 2022 September | 145 | 11 | 156 |
| 2022 August | 120 | 15 | 135 |
| 2022 July | 87 | 9 | 96 |
| 2022 June | 136 | 11 | 147 |
| 2022 May | 97 | 13 | 110 |
| 2022 April | 79 | 12 | 91 |
| 2022 March | 142 | 14 | 156 |
| 2022 February | 118 | 5 | 123 |
| 2022 January | 169 | 9 | 178 |
| 2021 December | 130 | 22 | 152 |
| 2021 November | 127 | 17 | 144 |
| 2021 October | 117 | 22 | 139 |
| 2021 September | 95 | 25 | 120 |
| 2021 August | 93 | 5 | 98 |
| 2021 July | 121 | 13 | 134 |
| 2021 June | 103 | 21 | 124 |
| 2021 May | 109 | 10 | 119 |
| 2021 April | 302 | 29 | 331 |
| 2021 March | 154 | 16 | 170 |
| 2021 February | 121 | 16 | 137 |
| 2021 January | 108 | 20 | 128 |
| 2020 December | 110 | 10 | 120 |
| 2020 November | 113 | 20 | 133 |
| 2020 October | 85 | 16 | 101 |
| 2020 September | 158 | 16 | 174 |
| 2020 August | 138 | 12 | 150 |
| 2020 July | 124 | 38 | 162 |
| 2020 June | 114 | 9 | 123 |
| 2020 May | 114 | 13 | 127 |
| 2020 April | 78 | 4 | 82 |
| 2020 March | 102 | 18 | 120 |
| 2020 February | 151 | 8 | 159 |
| 2020 January | 160 | 7 | 167 |
| 2019 December | 155 | 6 | 161 |
| 2019 November | 124 | 13 | 137 |
| 2019 October | 151 | 8 | 159 |
| 2019 September | 152 | 15 | 167 |
| 2019 August | 97 | 7 | 104 |
| 2019 July | 167 | 20 | 187 |
| 2019 June | 201 | 28 | 229 |
| 2019 May | 343 | 67 | 410 |
| 2019 April | 230 | 24 | 254 |
| 2019 March | 82 | 12 | 94 |
| 2019 February | 116 | 21 | 137 |
| 2019 January | 84 | 4 | 88 |
| 2018 December | 84 | 16 | 100 |
| 2018 November | 109 | 23 | 132 |
| 2018 October | 122 | 7 | 129 |
| 2018 September | 153 | 8 | 161 |
| 2018 August | 102 | 4 | 106 |
| 2018 July | 49 | 4 | 53 |
| 2018 June | 39 | 2 | 41 |
| 2018 May | 49 | 2 | 51 |
| 2018 April | 73 | 10 | 83 |
| 2018 March | 43 | 2 | 45 |
| 2018 February | 52 | 2 | 54 |
| 2018 January | 59 | 0 | 59 |
| 2017 December | 45 | 1 | 46 |
| 2017 November | 63 | 4 | 67 |
| 2017 October | 75 | 4 | 79 |
| 2017 September | 51 | 8 | 59 |
| 2017 August | 61 | 6 | 67 |
| 2017 July | 60 | 3 | 63 |
| 2017 June | 88 | 7 | 95 |
| 2017 May | 130 | 4 | 134 |
| 2017 April | 93 | 3 | 96 |
| 2017 March | 94 | 36 | 130 |
| 2017 February | 153 | 6 | 159 |
| 2017 January | 122 | 4 | 126 |
| 2016 December | 98 | 10 | 108 |
| 2016 November | 122 | 10 | 132 |
| 2016 October | 136 | 11 | 147 |
| 2016 September | 216 | 8 | 224 |
| 2016 August | 187 | 1 | 188 |
| 2016 July | 92 | 6 | 98 |
| 2016 June | 64 | 13 | 77 |
| 2016 May | 68 | 30 | 98 |
| 2016 April | 60 | 11 | 71 |
| 2016 March | 68 | 22 | 90 |
| 2016 February | 63 | 15 | 78 |
| 2016 January | 49 | 12 | 61 |
| 2015 December | 43 | 9 | 52 |
| 2015 November | 45 | 5 | 50 |
| 2015 October | 42 | 20 | 62 |
| 2015 September | 54 | 9 | 63 |
| 2015 August | 68 | 11 | 79 |
| 2015 July | 71 | 18 | 89 |
| 2015 June | 42 | 8 | 50 |
| 2015 May | 42 | 13 | 55 |
| 2015 April | 52 | 9 | 61 |
| 2015 March | 58 | 13 | 71 |
| 2015 February | 19 | 10 | 29 |
| 2015 January | 25 | 4 | 29 |
| 2014 December | 35 | 20 | 55 |
| 2014 November | 48 | 14 | 62 |
| 2014 October | 59 | 22 | 81 |
| 2014 September | 29 | 7 | 36 |
| 2014 August | 1 | 0 | 1 |
| 2014 July | 1 | 1 | 2 |
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