Restoration of the gastrointestinal tract in patients with temporary stomas represents a surgical challenge [1], as more than 22% of these patients present with a concomitant incisional hernia at the site of a previous laparotomy, which may coexist with a parastomal hernia, thereby increasing the complexity of the surgical approach [2, 3].

Abdominal wall surgery and restoration of gastrointestinal continuity during the same hospitalization remain a subject of debate, with conflicting clinical evidence [2, 4–6]. This comprehensive approach allows both conditions to be addressed simultaneously—either in a single operative session and/or within the same hospital stay—which may translate into greater efficiency, reduced costs, and improved patient satisfaction by avoiding separate hospitalizations. However, many of these patients require multiple interventions, and the second surgery is frequently not performed, potentially resulting in a disabling hernia or the need for an emergency procedure [7].

Several studies advocate for a staged approach, supported by reported increases in surgical site infection, hernia recurrence, the need for extensive adhesiolysis, and higher rates of anastomotic leakage [7, 8]. In addition, concomitant management has been associated with an increased risk of mesh infection, high technical complexity, and postoperative complications—particularly anastomotic leakage—as well as a possible increase in mortality in complex repairs or high-complexity colorectal procedures [9–11].

In this study, we propose that a simultaneous approach to stoma reversal and incisional hernia repair, performed in patients who undergo preoperative optimization and with the participation of both colorectal surgery and abdominal wall surgery teams, may represent a safe and effective strategy to address both conditions during the same hospitalization, thereby reducing the morbidity associated with sequential procedures.

The objective of this study was to evaluate the clinical outcomes of incisional hernia repair performed concomitantly with stoma closure during a single hospitalization. Complications associated with the combined approach were analyzed as the primary outcome, while length of hospital stay, surgical success rate, and the incidence of reinterventions due to anastomotic leakage were assessed as secondary outcomes.

The study was conducted at Clínica Universitaria Colombia, a university hospital in Bogotá, Colombia. Adult patients who underwent elective gastrointestinal tract restoration and abdominal wall reconstruction performed in sequential two-stage approach during the same hospitalization between July 2018 and December 2023 were included.

Patients who underwent localized stoma-closure approaches requiring postoperative prophylactic mesh placement at the resulting abdominal wall defect were excluded. Patients with complex hernias were included, defined as those associated with lipodystrophy, sequelae of open abdomen, loss of domain, multiple recurrences, parastomal hernias, abdominal wall tumors, or giant hernia defects.

During the study period, 30 patients underwent simultaneous repair of complex incisional hernia and intestinal tract reconstruction. The majority of patients were male, accounting for 70% (n = 21) of the cohort, with a mean age of 51.5 years (range: 18–79 years). The sociodemographic characteristics and underlying pathology of the study population are detailed in Table 1.

Regarding the type of ostomy, Hartmann’s reversal was performed in 9 patients (30%), followed by ileostomy closure in 9 patients (30%), cecostomy closure in 1 patient (3.3%), and loop colostomy closure in 1 patient (3.3%). The remaining cases were not related to ostomies but to other conditions, most notably enterocutaneous fistula, which was present in 20% of cases (n = 6).

Table 2 describes the characteristics of the hernias. The mean transverse hernia diameter was 12.8 cm, with a range from 5 cm to 20 cm. In 8 cases, abdominal wall prehabilitation strategies were required, with botulinum toxin being the most frequently used, followed by progressive preoperative pneumoperitoneum in 1 case, and combined strategies of progressive preoperative pneumoperitoneum and botulinum toxin in 1 patient.

Anterior component separation was required and represented the most prevalent technique in this study, being used in 56.6% of the cases in which both surgical stages were completed.

When patients were classified according to the European Hernia Society (EHS) ventral hernia classification, the most prevalent category in our cohort was M1M5W3, corresponding to incisional hernias involving the majority of the midline of the abdominal wall (Figure 1).

In this study, both surgical procedures were completed in 73.33% (n = 22) of cases. The time interval between procedures was 6.3 days. Surgical and follow-up characteristics are summarized in Table 2.

In 26.6% of cases (n = 8), abdominal wall reconstruction could not be completed. The most frequent causes were anastomotic dehiscence and surgical site infection, each present in 10% of cases. Other causes included bacteremia and the presence of retracted fascia or poor tissue quality.

In the majority of cases (46.6%), no complications occurred, allowing successful completion of both procedures. According to the Clavien–Dindo classification, 30% of patients experienced grade IIIB complications. The most common complication was postoperative ileus (16%), followed by anastomotic dehiscence and deep surgical site infection, each occurring in 6% of cases. In addition, a mortality rate of 3% (one patient) was reported, secondary to anastomotic dehiscence with subsequent multiple organ dysfunction. Figure 2.

Simultaneous repair of complex incisional hernias and restoration of intestinal continuity remains a subject of debate due to technical complexity and the potential risk of postoperative complications. In this case series, 30 patients with heterogeneous clinical and surgical characteristics were included. The success rate for completing both procedures during the same hospitalization was 73%, a figure comparable to that reported in other similar case series, ranging from 65% to 80% [12, 14–16]. The risk of wound-related complications must be weighed against the risk of hernia recurrence when determining whether definitive abdominal wall reconstruction is appropriate at the time of gastrointestinal reconstruction [13].

The absence of unified protocols for managing patients with incisional hernia and ostomy, together with persistent concerns regarding the risk of infection associated with mesh use in contaminated or potentially contaminated fields, has led many surgeons to favor a staged approach. This strategy aims to reduce infectious complications and optimize local conditions prior to definitive abdominal wall reconstruction. In our cohort, the mean interval between intestinal restoration and abdominal wall reconstruction was 6.3 days, allowing verification of anastomotic integrity and exclusion of leakage prior to the second intervention, while also permitting physiological recovery and thereby reducing the risk of complications during abdominal wall reconstruction. This two-stage strategy within a single hospitalization seeks to balance the benefits of a simultaneous approach—such as reduced costs, fewer hospitalizations, and lower anesthetic risk—with improved control of infectious risk, particularly in contaminated or potentially septic scenarios. Importantly, contamination and surgical site infection may occur in up to 40% of cases, significantly increasing the complexity of both surgical and postoperative management [2].

In our cohort, the main reasons for failure to perform the second procedure were anastomotic dehiscence and surgical site infection, each occurring in up to 10% of cases. These findings are consistent with the literature, where such complications represent major causes of failure of thecombined approach [4, 5]. In line with our results, Rudnicki et al. analyzed a cohort of 62 patients who underwent Hartmann’s reversal with concomitant hernia repair, performed simultaneously in 32 cases and in a second operation in 30 cases. The authors reported a significantly higher rate of perioperative complications in the combined surgery group (57% vs. 20%, p < 0.01). Notably, 25% of these patients developed surgical site infection, wound dehiscence, or repair failure; consequently, two-thirds underwent repair using suture alone without prosthetic mesh [17].

Within the overall complication rate, the most frequent event was postoperative ileus (13.3%), followed by anastomotic dehiscence, deep surgical site infection, and intestinal perforation (each 6.6%). Less common complications included hemoperitoneum, soft tissue necrosis, intestinal obstruction, ureteral injury, and one case of mortality (3.3%; n = 1). When compared with the results reported by Curran et al., who described complication rates of up to 39%–43% in combined procedures, our outcomes suggest a favorable morbidity profile. This difference likely reflects rigorous patient selection, adequate preoperative optimization, and a coordinated approach between colorectal and abdominal wall surgery teams, which enabled anticipation and mitigation of intraoperative risks [3].

In our series, the mean transverse diameter of hernia defects was 12.8 cm, underscoring the complexity of the cases included. Given these dimensions, anterior component separation was performed in 68% of patients and posterior component separation in 6.6%, with the aim of facilitating tension-free fascial closure and optimizing reconstruction of the muscular plane.

In addition, prehabilitation strategies were implemented in 26% of patients, including botulinum toxin injection and, to a lesser extent, progressive preoperative pneumoperitoneum.

In most cases (20%), botulinum toxin was used alone, while 3.3% received combined therapy and another 3.3% underwent pneumoperitoneum alone. These interventions proved particularly useful in patients with large defects, enabling complete fascial closure in 100% of cases.

Our findings are consistent with those reported by Carles Olona et al., who applied botulinum toxin in patients with hernias with transverse diameters greater than 12 cm and similarly achieved complete fascial closure in all treated cases. According to the authors, toxin-induced muscle relaxation facilitates aponeurotic approximation and reduces intra-abdominal pressure, thereby improving repair quality and decreasing tension along the midline [18].

Appropriate patient selection remains the key determinant of success for this approach. We propose a protocol for simultaneous procedures during the same hospitalization that emphasizes preoperative optimization, including enrollment in the ERAS protocol, preoperative weight reduction, and glycemic control to reduce obesity-related morbidity. Smoking cessation was also strongly encouraged. All cases were discussed in a multidisciplinary surgical board to individualize surgical strategies, involving collaboration between surgeons with expertise in colorectal and abdominal wall pathology, thereby minimizing factors associated with morbidity in this patient population [19, 20].

Overall, our results support the feasibility of a sequential approach during the same hospitalization in selected patients, particularly those undergoing ostomy reversal. The implementation of prehabilitation protocols and shared decision-making between colorectal and abdominal wall surgery teams is essential to optimize outcomes and reduce complications.

Regarding study limitations, first, this is a relatively small case series from a single center.

While this limits generalizability, it allowed for control of procedural conditions and ensured participation of a consistent surgical team with expertise in each specialty. Another limitation is the retrospective design, although the study is based on a prospectively maintained database.

The complexity of the cases hindered standardization of surgical techniques and precluded a randomized prospective study; thus, we believe these patients require collaborative management among different surgical teams. Finally, the diversity of techniques employed led us to conduct a descriptive analysis, as meaningful statistical comparisons could not be established.

Finally, a potential selection bias must be acknowledged. The improved outcomes observed in the group undergoing a deferred single-stage approach may, at least in part, reflect an a priori selection of patients with a favorable clinical course after the first procedure, who did no develop complications and were therefore eligible for the second intervention. This potential bias limits the generalizability of the results and underscores the need for prospective comparative studies.

This study demonstrates that it is feasible to plan a two-stage surgical approach for intestinal restoration and abdominal wall reconstruction during the same hospital admission. This strategy allows the distribution of surgical complexity and may reduce postoperative morbidity by separating the interventions. However, a substantial proportion of patients may ultimately not undergo the second surgical stage.

Therefore, future comparative studies between single-stage and two-stage approaches are required to more precisely define the most appropriate indications for each strategy. In addition, further evidence is needed to assess the safety, costs, and clinical implications of performing these interventions either simultaneously or sequentially. This work represents a meaningful step toward generating key evidence to support the development and refinement of this surgical approach.