Introduction

Stoma reversal is a common procedure in general surgery, with postoperative complications as surgical site infection associated with patients’ perception of a poor cosmetic outcome. Gunsight skin incision and closure technique has lower incidence of surgical site infection and better drainage of fluid; in addition, patients feel satisfied, and the cosmetic result is better compared with other techniques proposed in the international literature. Primary wound closure with conventional technique is associated with high rates of surgical site infection¹. The gunsight skin incision and closure technique is a modified wound management approach. The wound edges are approximated, leaving a small residual hole in the center of the wound to facilitate adequate drainage and decrease the rate of surgical site infection. In addition, the cosmetic result is more satisfactory for patients than that of other techniques described². The aim of the present study is to describe the technique and the experience with 15 cases.

Material and methods

Data from 15 patients with colostomy and ileostomy admitted to the institution for stoma reversal between November 2020 and May 2021 were included and recorded. Patients with stoma leakage or conventional skin incision and closing technique for stoma reversal were excluded.

Surgical technique

All the procedures were performed by different surgeons. The first step was marking the triangles of the surgical site determined by the mobility of the peristomal skin (Fig. 1). For stoma reversal, the skin was incised with a scalpel and then an electric scalpel was used while observing adequate exposure of the structures. The stoma was taken down, reconstructed, and the fascial defect was repaired. A circumferential subcuticular suture (3-0 nylon) was placed in the wound edge, creating the gunsight with a small central residual hole (Fig. 2). Then, simple interrupted sutures were placed to connect the limbs of the gunsight (Fig. 3). After the wounds were covered with sterile gauze and polyurethane transparent film dressings, the surgical procedure ended. Fifteen days after the stitches were removed (Fig. 4)

Figure 1 A: Marking the triangles determined by the mobility of the peristomal skin. B: Skin incision. 

Figure 2 A and B: adequate tissue exposure for fascial closure after stoma takedown. C and D: subcutical suture in the wound edges to create the gunsite. Gunsight skin closure with a central hole. 

Figure 3 A and B: simple interrupted sutures placed to connect the limbs of the gunsight. C: surgical wound on postoperative day 7. 

Figure 4 Surgical wound on postoperative day 15. 

The level of postoperative cosmetic satisfaction with this technique was evaluated using a Likert scale, and a database was generated with the scores and their frequencies.

Results

Between November 2020 and May 2021, the gunsight skin incision and closure technique were performed on 15 patients. Most patients were men (65%); mean age was 38 ± 2.5 years, body mass index was 28 ± 1.5 kg/m², and length of hospital stay was 4 ± 2 days. There were no postoperative complications, and all the patients were discharged on postoperative day 5. The patients were contacted by telephone call 15 and 30 days after discharge; all of them reported high satisfaction with a positive cosmetic result as evidenced by the 3-point Likert scale, and 100% of the patients fully agreed with the technique.

Discussion

Surgical site infection after stoma reversal significantly increases postoperative morbidity, causing discomfort in patients and affecting their quality of life. For this reason, efforts have been made to reduce this complication. The surgical technique for skin closure after stoma reversal plays an important role; therefore, we decided to document our experience with the gunsight skin incision and closure technique^1,2.

The ideal technique for wound closure after stoma reversal to reduce surgical site infection rates and postoperative morbidity is still debated. Surgical site infection rates range from 0% to 40%³. In a recent study, Marquez et al. compared 61 patients (78%) treated with primary skin closure versus 17 patients (22%) treated with purse-string suture closure. Overall surgical site infection rate was 18%, with 0 of 17 patients in the purse-string suture closure group compared with 14 of 61 patients in the primary closure group (p < 0.03).⁴ These results suggested lower risk of surgical site infection in patients who were not treated with primary skin closure. We did not consider the type of anastomosis (hand-sewn vs. stapled closure or one vs. two layers of sutures) in our study. However, in several studies the type of anastomosis (hand-sewn vs. stappled suture), had no significant influence on the rate of surgical site infection⁵.

In a retrospective cohort study by Klink et al., surgical site infection was significantly higher in patients treated with primary linear closure (17%) compared with the group treated with purse-string suture closure (5%). In addition, prolonged operative time, high ASA score, obesity, diabetes and kidney dysfunction had no significant influence on the rate of surgical site infection⁶.

Poskus et al. evaluated the complications after closure of loop ileostomy in 132 patients and reported complications in 24 patients (18.2%): bowel obstruction in 9 (6.8%), surgical site infection in 4 (3.0%), peritonitis due to anastomotic leak in 3 (2.3%), intra-abdominal abscess in 2 (1.5%), anastomotic leak with enterocutaneous fistula in 1 (0.76%), and deep vein thrombosis in 1 (0.76%)⁷. These findings were not consistent with ours since we had no postoperative complications. In our study, we explored the possibility of surgical site infection after discharge: all the patients were followed up at days 7, 15 and 30 after discharge and no complications were documented.

Patients’ satisfaction with the cosmetic outcome was also evaluated with the Likert scale, a bipolar scaling method used to assess a person’s opinion on a subject through a questionnaire. The scale measures either positive or negative response to a statement and the level of agreement or disagreement with a statement consisting of five levels: 1) completely dissatisfied, 2) dissatisfied, 3) neither satisfied nor dissatisfied, 4) satisfied, 5) completely satisfied. The questionnaire is easy to answer and is simple and economical to implement. Some studies show lower incidence of surgical site infection in stoma reversal when closure is performed with subcuticular suture compared with skin closure with transdermal suture and skin stapler^8,9.

The cohort size and the determination of infection based on direct observation of the surgical site are limitations of the study presented. However, according to the review of the medical literature, surgical site infection in our environment is detected by direct observation. A randomized controlled clinical trial is needed to confirm the reduction of these complications with the gunsight skin incision and closure technique. The gunsight skin incision and closure technique for stoma reversal offers the following advantages: a) low surgical site infection rate, b) good surgical exposure, c) adequate wound drainage, d) good cosmetic result, e) use of the same skin area in case a future stoma is required, and f) high patient satisfaction. For these reasons we consider this technique as the first-choice approach. We are currently conducting a randomized clinical trial at our tertiary-care hospital comparing the gunsight skin incision and closure technique versus purse-string suture closure to reduce the rate of complications after stoma reversal.