Radiological incidence of donor-site incisional hernia and parastomal hernia after vertical rectus abdominus myocutaneous flap-based reconstruction following colorectal surgery.

AIM: A vertical rectus abdominis myocutaneous (VRAM) flap is commonly used to reconstruct perineal defects for low rectal and anal cancer. The incidence of midline incisional hernias after VRAM reconstruction varies from 3.6% when detected clinically to 50% when detected radiologically. The aim of this study is to accurately determine the radiological incidence of donor-site incisional and parastomal hernia following VRAM reconstruction. METHOD: This was a retrospective cohort study of patients undergoing colorectal surgery requiring VRAM reconstruction over 10 years. Data were collected on patient demographics, indication for surgery and surgical procedure, including details of any hernia repair. Images from surveillance CTs were reviewed for the presence and size of midline incisional and/or parastomal hernias. Parastomal hernias were classified based on the European Hernia Society (EHS) classification. RESULTS: One hundred and seventy three patients were included in the analysis. The median age was 67 years (range 29-88 years) and the median length of follow-up was 49 months (interquartile range 24.3-71.0 months). The cumulative incidence of donor-site incisional hernia after VRAM at 1, 2 and 5 years was 15.1%, 25.4% and 29.1%, respectively. The cumulative incidence for PSH at 1, 2 and 5 years was 33.1%, 46.6% and 53.3%, respectively (95% CI 45.4%-60.5%). CONCLUSION: Most patients who develop donor-site incisional hernia and parastomal herniation following VRAM tend to do so within the first 2 years. Although the use of CT imaging improves the diagnosis of donor-site incisional and parastomal hernias, the clinical significance of this is unknown.

Hughes abdominal closure versus standard mass closure to reduce incisional hernias following surgery for colorectal cancer: the HART RCT.

BACKGROUND: Incisional hernias can cause chronic pain and complications and affect quality of life. Surgical repair requires health-care resources and has a significant associated failure rate. A prospective, multicentre, single-blinded randomised controlled trial was conducted to investigate the clinical effectiveness and cost-effectiveness of the Hughes abdominal closure method compared with standard mass closure following surgery for colorectal cancer. The study randomised, in a 1 : 1 ratio, 802 adult patients (aged ≥ 18 years) undergoing surgical resection for colorectal cancer from 28 surgical departments in UK centres. INTERVENTION: Hughes abdominal closure or standard mass closure. MAIN OUTCOME MEASURES: The primary outcome was the incidence of incisional hernias at 1 year, as assessed by clinical examination. Within-trial cost-effectiveness and cost-utility analyses over 1 year were conducted from an NHS and a social care perspective. A key secondary outcome was quality of life, and other outcomes included the incidence of incisional hernias as detected by computed tomography scanning. RESULTS: The incidence of incisional hernia at 1-year clinical examination was 50 (14.8%) in the Hughes abdominal closure arm compared with 57 (17.1%) in the standard mass closure arm (odds ratio 0.84, 95% confidence interval 0.55 to 1.27; p = 0.4). In year 2, the incidence of incisional hernia was 78 (28.7%) in the Hughes abdominal closure arm compared with 84 (31.8%) in the standard mass closure arm (odds ratio 0.86, 95% confidence interval 0.59 to 1.25; p = 0.43). Computed tomography scanning identified a total of 301 incisional hernias across both arms, compared with 100 identified by clinical examination at the 1-year follow-up. Computed tomography scanning missed 16 incisional hernias that were picked up by clinical examination. Hughes abdominal closure was found to be less cost-effective than standard mass closure. The mean incremental cost for patients undergoing Hughes abdominal closure was £616.45 (95% confidence interval -£699.56 to £1932.47; p = 0.3580). Quality of life did not differ significantly between the study arms at any time point. LIMITATIONS: As this was a pragmatic trial, the control arm allowed surgeon discretion in the approach to standard mass closure, introducing variability in the techniques and equipment used. Intraoperative randomisation may result in a loss of equipoise for some surgeons. Follow-up was limited to 2 years, which may not have been enough time to see a difference in the primary outcome. CONCLUSIONS: Hughes abdominal closure did not significantly reduce the incidence of incisional hernias detected by clinical examination and was less cost-effective at 1 year than standard mass closure in colorectal cancer patients. Computed tomography scanning may be more effective at identifying incisional hernias than clinical examination, but the clinical benefit of this needs further research. FUTURE WORK: An extended follow-up using routinely collected NHS data sets aims to report on incisional hernia rates at 2-5 years post surgery to investigate any potential mortality benefit of the closure methods. Furthermore, the proportion of incisional hernias identified by a computed tomography scan (at 1 and 2 years post surgery), but not during clinical examination (occult hernias), proceeding to surgical repair within 3-5 years after the initial operation will be explored. TRIAL REGISTRATION: This trial is registered as ISRCTN25616490. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 34. See the NIHR Journals Library website for further project information.

Bowel cancer treatment involves surgery for the majority of patients. A complication of this surgery is the formation of a hernia at the site of the incision in the abdominal wall, known as an incisional hernia. The lining of the abdomen, fat or the intestine can squeeze through the gap and form a lump under the skin. An incisional hernia can form any time after surgery and can cause serious complications and pain, and can also affect the patient's quality of life. Surgery to correct incisional hernias is not always successful, so finding a way of preventing them is important. This research compares the traditional way of sewing up the abdomen, where the two sides are brought together in one layer with a continuous thread, with an alternative method called the Hughes abdominal closure method/Hughes repair. In the Hughes repair, a series of horizontal and vertical stitches are arranged to spread the load and ease the tension across the wound. A total of 802 patients from 28 sites in the UK were recruited to the trial. Half of the patients were randomly allocated to have traditional abdominal closure and half were randomised to have Hughes abdominal closure. All were followed up for 1 year after surgery to assess whether or not an incisional hernia had occurred. We also assessed quality of life during follow-up, and we compared the costs and benefits of each procedure to see which option was the better value for money. By comparing the results from the two methods, it was hoped that the best method of abdominal closure to reduce the risk of an incisional hernia occurring would be found. The analysis of the data suggested that the risk of an incisional hernia was no different with either closure method. Furthermore, Hughes abdominal closure was more expensive and provided less value for money than standard abdominal closure.

The impact of virtual reality simulation training on operative performance in laparoscopic cholecystectomy: meta-analysis of randomized clinical trials.

BACKGROUND: Simulation training can improve the learning curve of surgical trainees. This research aimed to systematically review randomized clinical trials (RCT) evaluating the performance of junior surgical trainees following virtual reality training (VRT) and other training methods in laparoscopic cholecystectomy. METHODS: MEDLINE (PubMed), Embase (Ovid SP), Web of Science, Scopus and LILACS were searched for trials randomizing participants to VRT or no additional training (NAT) or simulation training (ST). Outcomes of interest were the reported performance using global rating scores (GRS), the Objective Structured Assessment of Technical Skill (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS), error counts and time to completion of task during laparoscopic cholecystectomy on either porcine models or humans. Study quality was assessed using the Cochrane Risk of Bias Tool. PROSPERO ID: CRD42020208499. RESULTS: A total of 351 titles/abstracts were screened and 96 full texts were reviewed. Eighteen RCT were included and 15 manuscripts had data available for meta-analysis. Thirteen studies compared VRT and NAT, and 4 studies compared VRT and ST. One study compared VRT with NAT and ST and reported GRS only. Meta-analysis showed OSATS score (mean difference (MD) 6.22, 95%CI 3.81 to 8.36, P < 0.001) and time to completion of task (MD -8.35 min, 95%CI 13.10 to 3.60, P = <0.001) significantly improved after VRT compared with NAT. No significant difference was found in GOALS score. No significant differences were found between VRT and ST groups. Intraoperative errors were reported as reduced in VRT groups compared with NAT but were not suitable for meta-analysis. CONCLUSION: Meta-analysis suggests that performance measured by OSATS and time to completion of task is improved with VRT compared with NAT for junior trainee in laparoscopic cholecystectomy. However, conclusions are limited by methodological heterogeneity and more research is needed to quantify the potential benefit to surgical training.

Tuneable synthetic reduced graphene oxide scaffolds elicit high levels of three-dimensional glioblastoma interconnectivity in vitro.

Three-dimensional tissue scaffolds have utilised nanomaterials to great effect over the last decade. In particular, scaffold design has evolved to consider mechanical structure, morphology, chemistry, electrical properties, and of course biocompatibility - all vital to the performance of the scaffold and how successful they are in developing cell cultures. We have developed an entirely synthetic and tuneable three-dimensional scaffold of reduced graphene oxide (rGO) that shows good biocompatibility, and favourable mechanical properties as well as reasonable electrical conductivity. Importantly, the synthesis is scaleable and suitable for producing scaffolds of any desired geometry and size, and we observe a high level of biocompatibility and cell proliferation for multiple cell lines. In particular, one of the most devastating forms of malignant brain cancer, glioblastoma (GBM), grows especially well on our rGO scaffold in vitro, and without the addition of response-specific growth factors. We have observed that our scaffold elicits spontaneous formation of a high degree of intercellular connections across the GBM culture. This phenomenon is not well documented in vitro and nothing similar has been observed in synthetic scaffolds without the use of response-specific growth factors - which risk obscuring any potential phenotypic behaviour of the cells. The use of scaffolds like ours, which are not subject to the limitations of existing two-dimensional substrate technologies, provide an excellent system for further investigation into the mechanisms behind the rapid proliferation and success of cancers like GBM. These synthetic scaffolds can advance our understanding of these malignancies in the pursuit of improved theranostics against them.

Trainee perspective of the causes of stress and burnout in surgical training: a qualitative study from Wales.

OBJECTIVES: Stress and burn-out among surgical trainees has been reported most prevalent in core surgical trainees (CST) and female trainees in particular. This study aimed to identify factors perceived by CSTs to be associated with stress and burnout in those at risk. DESIGN: An open-ended questionnaire was distributed to 79 CSTs and two researchers categorised responses independently, according to Michie's model of workplace stress. SETTING: A UK regional postgraduate medical region (Wales). PARTICIPANTS: Sixty-three responses were received; 42 males, 21 females. The response rate was 79.7%. RESULTS: Inter-rater reliability was good (k=0.792 (79.2%), p<0.001). The most common theme of Michie's model related to CST stress and burnout was career development, with most statements associated with curriculum, examination and academic demands required to attain a CST certificate of completion of training, and higher surgical national training number appointment. This was closely followed by those intrinsic to the job with recurrent discussion around the difficulties balancing work perceived to be service provision (ward work and on-calls), outpatient clinic and operative experience. Conversely, the most common themes relevant to stress and burnout among female trainees were associated with relationships at work (primarily the male-dominated nature of surgery), extraorganisational factors (family-work life balance) and individual characteristics (personality and physiological differences). CONCLUSION: CSTs' perceptions regarding the causes of National Health Service related stress and burnout are numerous, and these findings provide a basis for the development of targeted stressor counter-measures to improve training and well-being.

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm.

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.

Outcomes Following Immediate Vertical Rectus Abdominis Myocutaneous (VRAM) Flap-Based Perineal Reconstruction Following Resectional Surgery For Pelvic Malignancies.

BACKGROUND: Increasingly radical surgery combined with neo-adjuvant radiotherapy present a challenge for the reconstructive surgeon. The study objective was to review outcomes of Vertical Rectus Abdominis Myocutaneous (VRAM) flap-based perineal reconstruction following resectional surgery for pelvic malignancies. METHODS: Single-centre retrospective analysis of patients undergoing immediate VRAM flap reconstruction of a perineal/pelvic defect for pelvic malignancy between July 2009 and November 2017. Primary outcome was perineal morbidity (surgical site infection (SSI), flap loss or dehiscence and perineal hernia). Secondary outcomes were length of stay and donor site morbidity (SSI, full-thickness dehiscence and incisional hernia). RESULTS: A total of 178 patients (96 females) were included. Median age was 67 years (range 28-88). The majority were performed for locally advanced rectal adenocarcinoma (n = 122; 68.5%) and 136 (76.4%) patients had received neoadjuvant radiotherapy. Four patients had complete flap loss (2.3%), and 40 had perineal dehiscence (22.5%); however, only, 18 patients required a return to theatre during the admission for perineal-related complications (10.1%). Abdominal dehiscence occurred in six patients (3.4%). Median length of post-operative stay was 15 days (6-131). Sixty-day mortality rate was 1.1%. SSI at the midline and perineum occurred in 34 (19.1%) and 38 patients (21.3%), respectively. At 90-day post-operatively, 75.6% of perineal wounds were healed. During a median follow-up of 44.5 months, twelve, eleven and 39 patients were diagnosed with perineal, midline and parastomal hernias, respectively (6.9%, 6.2% and 21.9%). CONCLUSIONS: It is important to have accurate knowledge of perineal and donor-site morbidity rates to allow an informed consent process.

Diagnosis of colorectal and emergency surgical site infections in the era of enhanced recovery: an all-Wales prospective study.

AIM: Surgical site infections (SSIs) are associated with increased morbidity, hospital stay and cost. The literature reports that 25% of patients who undergo colorectal surgical procedures develop a SSI. Due to the enhanced recovery programme, patients are being discharged earlier with some SSIs presenting in primary care, making accurate recording of SSIs difficult. The aim of this study was to accurately record the 30-day SSI rate after surgery performed by colorectal surgeons nationally within Wales. METHOD: During March 2019, a national prospective snapshot study of all patients undergoing elective or emergency colorectal and general surgical procedures under the care of a colorectal consultant at 12 Welsh hospitals was completed. There was a multimodal 30-day follow-up using electronic records, clinic visits and/or telephone calls. Diagnosis of SSI was based on Centers for Disease Control and Prevention diagnostic criteria. RESULTS: Within Wales, of the 545 patients included, 13% developed a SSI within 30 days, with SSI rates of 14.3% for elective surgery and 11.7% for emergency surgery. Of these SSIs, 49.3% were diagnosed in primary care, with 28.2% of patients being managed exclusively in the community. There were two peaks of diagnosis at days 5-7 and days 22-28. SSI rates between laparoscopic (8.6%) and open (16.2%) surgeries were significantly different (p = 0.028), and there was also a significantly different rate of SSI between procedure groups (p = 0.001), with high SSI rates for colon (22%) and rectal (18.9%) surgery compared with general surgical procedures. CONCLUSION: This first all-Wales prospective study demonstrated an overall SSI rate of 13%. By incorporating accurate primary care follow-up it was found that 49.3% of these SSIs were diagnosed in primary care.

Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: A systematic review.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) flap is an established technique employed to reconstruct pelvic and perineal defects not amenable to primary closure. The aim of this study was to systematically review the morbidity of VRAM flap reconstruction following exenterative pelvic surgery. MATERIALS AND METHODS: A systematic literature search was conducted by using Medline, EMBASE, and Cochrane databases. Abstracts of all studies published from inception to November 2019 were identified. Search terms used included 'vertical rectus abdominis myocutaneous', 'vertical rectus abdominis musculocutaneous' and 'VRAM'. Only studies that described outcomes when a VRAM flap was used during exenterative pelvic surgery were included; case reports were excluded. The primary outcome measure was VRAM flap morbidity. Secondary outcome measures included donor site morbidity and hospital length of stay. RESULTS: Sixty-five studies with a total of 1827 patients were identified and included. Perineal reconstruction was most commonly performed following abdominal perineal excision of the rectum (APER) (n = 636 and 34.8%). Median patient age at surgery ranged from 38 to 78 years. Mean perineal flap morbidity was 27%, with a complete flap loss rate of 1.8% and a perineal hernia rate of 0.2%. Mean donor site morbidity was 15%, with an abdominal dehiscence rate of 5.5% and an incisional hernia rate of 3.3%. CONCLUSIONS: While overall morbidity after VRAM flap reconstruction in pelvic visceral surgery is high; the risk of major complications remains low. These data are important when counselling patients for surgery.

Real-world use of workplace based assessments in surgical training: A UK nationwide cross-sectional exploration of trainee perspectives and consensus recommendations from the Association of Surgeons in Training.

BACKGROUND: Despite widespread uptake, the utility of Workplace Based Assessments (WBAs) is disputed and evidence underpinning their use is largely based upon their completion in ideal conditions, rather than the real-world setting. AIM: To ascertain the real-world usage of WBAs, as perceived by UK surgical trainees. MATERIALS AND METHODS: An anonymous online questionnaire conducted nationally via the Association of Surgeons in Training (ASiT). Evaluation of 906 completed trainee responses, across all surgical specialties and training levels, employed mixed methods to interpret quantitative and qualitative data. RESULTS: The sample permitted a 3.0% confidence level with acceptable internal consistency (Cronbach's alpha 0.755). Formative use was supported by 72.5% and summative use was rejected by almost as many (66.3%). WBA use was perceived to deviate markedly from that recommended by the Joint Committee on Surgical Training (JCST). Significant misuse was identified and elements perceived as inaccurate appear commonplace across the breadth of surgical specialties. Inaccurate completion was acknowledged by 89.6% of respondents and some trainers appear complicit, 147 individuals (16.2%) having reported this to trainers, 40.9% aware of 'unobserved sign-off', and 33.6% aware of 'password disclosure' by trainers. Furthermore, a majority of trainees felt the Annual Review of Competency Progression (ARCP) respected WBA quantity above quality (55.4%), and a third felt pressure to overstate the number completed (32.0%). Reasons for misuse appeared largely centred upon time restraints, lack of engagement and a will to achieve the required targets for career progression. 1.5 CONCLUSIONS: This study demonstrates that UK surgical trainees perceive that most trainees deviate from guidance in their use of WBAs. This is worrying in both the apparent frequency and nature of misuse and somewhat undermines existing evidence for their role in surgical training. Trainees perceive that required numbers of WBAs are too high, that training programmes fail to encourage their use as formative assessments, and that there is a lack of engagement by many trainees and trainers. We present consensus recommendations from ASiT for the improvement of WBA use in UK surgical training.

Langmuir Films of Layered Nanomaterials: Edge Interactions and Cell Culture Applications.

The application of nanomaterials in technology is limited by challenges in their processing into macroscopic structures with reliable and scalable methods. Herein, it is demonstrated that using scalable fabrication methods such as liquid-phase exfoliation, it is possible to produce dispersions of a wide variety of layered nanomaterials, including the first demonstration of boron nitride, with controllable and standardized size and thickness scaling. These can be used, as-produced, for Langmuir deposition, to create single layer films with tuneable density. Of particular importance, we show that the difference in edge chemistry of these materials dictates the film formation process, and therefore can be used to provide a generic fabrication methodology that is demonstrated for various layered nanomaterials, including graphene, boron nitride, and transition metal dichalcogenides. We show that this leads to controllable cancer cell growth on graphene substrates with different edge densities but comparable surface coverage, which can be produced on a statistically relevant cell study amount. This opens pathways for the generic fabrication of a range of layered nanomaterial films for various applications toward a commercially viable film fabrication technology.

Surgical trainees' experience of pregnancy, maternity and paternity leave: a cross-sectional study.

BACKGROUND: Internationally, supporting surgical trainees during pregnancy, maternity and paternity leave is essential for trainee well-being and for retention of high-calibre surgeons, regardless of their parental status. This study sought to determine the current experience of surgical trainees regarding pregnancy, maternity and paternity leave. METHODS: A cross-sectional anonymised electronic voluntary survey of all surgical trainees working in the UK and Ireland was distributed via the Association of Surgeons in Training and the British Orthopaedic Trainees' Association. RESULTS: There were 876 complete responses, of whom 61.4% (n=555) were female. 46.5% (258/555) had been pregnant during surgical training. The majority (51.9%, n=134/258) stopped night on-call shifts by 30 weeks' gestation. The most common reason for this was concerns related to tiredness and maternal health. 41% did not have rest facilities available on night shifts. 27.1% (n=70/258) of trainees did not feel supported by their department during pregnancy, and 17.1% (n=50/258) found the process of arranging maternity leave difficult or very difficult. 61% (n=118/193) of trainees felt they had returned to their normal level of working within 6 months of returning to work after maternity leave, while a significant minority took longer. 25% (n=33/135) of trainees found arranging paternity leave difficult or very difficult, and the most common source of information regarding paternity leave was other trainees. CONCLUSION: Over a quarter of surgical trainees felt unsupported by their department during pregnancy, while a quarter of male trainees experience difficulty in arranging paternity leave. Efforts must be made to ensure support is available in pregnancy and maternity/paternity leave.

Management of sacrococcygeal pilonidal sinus disease.

The ideal treatment for patients who suffer from pilonidal sinus disease should lead to a cure with a rapid recovery period allowing a return to normal daily activities, with a low level of associated morbidity. A variety of different surgical techniques have been described for the primary treatment of pilonidal sinus disease and current practice remains variable and contentious. Whilst some management options have improved outcomes for some patients, the complications of surgery, particularly related to wound healing, often remain worse than the primary disease. This clinical review aims to provide an update on the management options to guide clinicians involved in the care of patients who suffer from sacrococcygeal pilonidal sinus disease.

Surgical gender gap: a curriculum concordance and career vector perspective.

INTRODUCTION: Women's participation in medicine has increased dramatically during the last 50 years, yet Office for National Statistics data (2016) regarding annual pay continue to show an unequivocal 34% deficit in female doctors' remuneration compared with their male counterparts. This study aimed to identify whether there are measurable differences in the training, career vectors and profiles of higher general surgical trainees (HSTs), related to gender. METHOD: The Deanery roster supplemented with Intercollegiate Surgical Curriculum Programme and Scopus data was used to identify the profiles of 101 consecutive HSTs (38 women, 63 men, single UK deanery). Primary outcome measures were training programme attrition rate, time to completion of training and achievement of third level 4 competence (3L4C) in indicative operations. Secondary outcomes were publication number, citations and Hirsch Indices (HIs). RESULTS: Attrition rates were similar irrespective of gender (female n=3 (7.9%) vs male n=6 (9.5%), p=0.871). Training duration was on average 16 months longer in women (94 (72-134) months) than men (78 (72-112), p=0.002). Operative learning curve trajectories were similar; median operations required to achieve 3L4C was 380 (f) versus 410 (m, p=1.00). Academic profiles of men were stronger than women, specifically higher degrees; men (n=31, 83.8%), women (n=6, 16.2%, p=0.001); median (range) publication number 8 (0-57) versus 3 (0-38, p=0.003), citations 43 (0-1600) versus 9 (0-774, p=0.001), and HI 3 (0-26) versus 2 (0-12, p=0.002). CONCLUSION: A complex variable gender gap was apparent related to time in training and academic profile, but not training attrition or operative learning curve trajectory.

Impact of pigment epithelium-derived factor on colorectal cancer in vitro and in vivo.

Pigment epithelial derived factor (PEDF) is a secreted glycoprotein that is a non-inhibitory member of the serine protease inhibitor (serpin) family. PEDF exhibits multiple biological properties including neuroprotective, anti-angiogenic, and immune-modulating. Interestingly, PEDF exerts the inhibitory effects in cancers derived from certain tissues, including prostatic, ovarian, and pancreatic carcinomas. The current study aimed to elucidate its role in colorectal cancer development. PEDF expression in human colorectal cancer tissue was assessed using quantitative polymerase chain reaction (qPCR) and immunohistochemical staining (IHC). The effect of treatment with recombinant PEDF on cellular function was examined using in vitro functional assays. PEDF expression was downregulated in colorectal cancer cell tissue. Treatment with recombinant PEDF resulted in significant decreases in the rate of colorectal cancer cell migration and invasion and an increase in cellular adhesion in colorectal cancer cell lines examined. These results indicate that upregulation of PEDF expression may serve as a new strategy for further investigation of therapeutic relevance to the prevention of the metastatic spread of colorectal cancer.

Stomal Closure: Strategies to Prevent Incisional Hernia.

Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or "purse-string" closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.