Original Communication| Volume 155, ISSUE 4, P696-701, April 2014

Abdominal rectus muscle atrophy and midline shift after colostomy creation

Published:January 06, 2014DOI:


      Incisional hernia (IH) can be attributed to multiple factors. The presence of a parastomal hernia has shown to be a risk factor for IH after midline laparotomy. Our hypothesis is that this increased risk of IH may be caused by changes in biomechanical forces, such as midline shift to the contralateral side of the colostomy owing to decreased restraining forces at the site of the colostomy, and left abdominal rectus muscle (ARM) atrophy owing to intercostal nerve damage.


      Patients were selected if they underwent end-colostomy via open operation between 2004 and 2011. Patients were eligible if computed tomography (CT) had been performed postoperatively. If available, preoperative CTs were collected for case-control analyses. Midline shift was measured using V-scope application in the I-space, a CAVE-like virtual reality system. For the ARM atrophy hypothesis, measurements of ARM were performed at the level of colostomy, and 3 and 8 cm cranial and caudal of the colostomy.


      Postoperative CT were available for 77 patients; of these patients, 30 also had a preoperative CT. Median follow-up was 19 months. A mean shift to the right side was identified after preoperative and postoperative comparison; from −1.3 ± 4.6 to 2.1 ± 9.3 (P = .043). Furthermore, during rectus muscle measurements, a thinner left ARM was observed below the level of colostomy.


      Creation of a colostomy alters the abdominal wall. Atrophy of the left ARM was seen caudal to the level of the colostomy, and a midline shift to the right side was evident on CT. These changes may explain the increased rate of IH after colostomy creation
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hoer J.
        • Lawong G.
        • Klinge U.
        • Schumpelick V.
        [Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years] Einflussfaktoren der Narbenhernienentstehung. Retrospektive Untersuchung an 2.983 laparotomierten Patienten uber einen Zeitraum von 10 Jahren.
        Chirurgie. 2002; 73: 474-480
        • Mudge M.
        • Hughes L.E.
        Incisional hernia: a 10 year prospective study of incidence and attitudes.
        Br J Surg. 1985; 72: 70-71
        • Millbourn D.
        • Cengiz Y.
        • Israelsson L.A.
        Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial.
        Arch Surg. 2009; 144: 1056-1059
        • Sorensen L.T.
        • Hemmingsen U.B.
        • Kirkeby L.T.
        • Kallehave F.
        • Jorgensen L.N.
        Smoking is a risk factor for incisional hernia.
        Arch Surg. 2005; 140: 119-123
        • Franchi M.
        • Ghezzi F.
        • Buttarelli M.
        • Tateo S.
        • Balestreri D.
        • Bolis P.
        Incisional hernia in gynecologic oncology patients: a 10-year study.
        Obstet Gynecol. 2001; 97: 696-700
        • Togo S.
        • Nagano Y.
        • Masumoto C.
        • Takakura H.
        • Matsuo K.
        • Takeda K.
        • et al.
        Outcome of and risk factors for incisional hernia after partial hepatectomy.
        J Gastrointest Surg. 2008; 12: 1115-1120
        • Bevis P.M.
        • Windhaber R.A.
        • Lear P.A.
        • Poskitt K.R.
        • Earnshaw J.J.
        • Mitchell D.C.
        Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery.
        Br J Surg. 2010; 97: 1497-1502
        • Abo-Ryia M.H.
        • El-Khadrawy O.H.
        • Abd-Allah H.S.
        Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against incisional hernia development.
        Obes Surg. 2013; 23: 1571-1574
        • Murray B.W.
        • Cipher D.J.
        • Pham T.
        • Anthony T.
        The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery.
        Am J Surg. 2011; 202: 558-560
        • Cengiz Y.
        • Blomquist P.
        • Israelsson L.A.
        Small tissue bites and wound strength: an experimental study.
        Arch Surg. 2001; 136: 272-275
        • van Ramshorst G.H.
        • Eker H.H.
        • van der Voet J.A.
        • Jeekel J.
        • Lange J.F.
        Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia.
        J Gastrointest Surg. 2013; 17: 1477-1484
        • Timmermans L.
        • Deerenberg E.B.
        • Lamme B.
        • Jeekel J.
        • Lange J.F.
        Parastomal hernia is an independent risk factor for incisional hernia in patients with end colostomy.
        Surgery. 2013 Nov 12; ([Epub ahead of print])
        • Pollock A.V.
        • Evans M.
        Early prediction of late incisional hernias.
        Br J Surg. 1989; 76: 953-954
        • Burger J.W.
        • Lange J.F.
        • Halm J.A.
        • Kleinrensink G.J.
        • Jeekel H.
        Incisional hernia: early complication of abdominal surgery.
        World J Surg. 2005; 29: 1608-1613
        • Timmermans L.
        • Klitsie P.J.
        • Maat A.P.
        • de Goede B.
        • Kleinrensink G.J.
        • Lange J.F.
        Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication.
        Hernia. 2013; 17: 89-94
        • Rousian M.
        • Koning A.H.
        • van der Spek P.J.
        • Steegers E.A.
        • Exalto N.
        Virtual reality for embryonic measurements requiring depth perception.
        Fertil Steril. 2011; 95: 773-774
        • Verwoerd-Dikkeboom C.M.
        • Koning A.H.J.
        • Hop W.C.
        • Rosian M.
        • Van Der Spek P.J.
        • Exalto N.
        • et al.
        Reliability of three-dimensional sonographic measurements in early pregnancy using virtual reality.
        Ultrasound Obstet Gynecol. 2008; 32: 910-916
        • Meuffels D.E.
        • Potters J.W.
        • Koning A.H.J.
        • Brown C.H.
        • Verhaar J.A.N.
        • Reijman M.
        Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels: reliability of standard radiographs, CT scans, and 3D virtual reality images.
        Acta Orthop. 2011; 82: 699-703
        • van den Bosch A.E.
        • Koning A.H.
        • Meijboom F.J.
        • McGhie J.S.
        • Simoons M.L.
        • van der Spek P.J.
        • et al.
        Dynamic 3D echocardiography in virtual reality.
        Cardiovasc Ultrasound. 2005; 3: 37
        • Rankin G.
        • Stokes M.
        • Newham D.J.
        Abdominal muscle size and symmetry in normal subjects.
        Muscle Nerve. 2006; 34: 320-326
        • Ota M.
        • Ikezoe T.
        • Kaneoka K.
        • Ichihashi N.
        Age-related changes in the thickness of the deep and superficial abdominal muscles in women.
        Arch Gerontol Geriatr. 2012; 55: e26-e30
        • Ozel L.
        • Marur T.
        • Unal E.
        • Kara M.
        • Erdogdu E.
        • Demir T.
        • et al.
        Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation.
        Transplant Proc. 2012; 44: 1618-1622
        • Kunihara T.
        • Adachi A.
        • Akimaro Kudo F.
        • Shiiya N.
        • Yasuda K.
        The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge.
        J Cardiovasc Surg (Torino). 2005; 46: 527-531
        • van der Graaf T.
        • Verhagen P.C.M.S.
        • Kerver A.L.A.
        • Kleinrensink G.J.
        Surgical anatomy of the 10th and 11th intercostal, and subcostal nerves: prevention of damage during lumbotomy.
        J Urol. 2011; 186: 579-583
        • Fahim D.K.
        • Kim S.D.
        • Cho D.
        • Lee S.
        • Kim D.H.
        Avoiding abdominal flank bulge after anterolateral approaches to the thoracolumbar spine: cadaveric study and electrophysiological investigation.
        J Neurosurg-Spine. 2011; 15: 532-540
        • Wijeyekoon S.P.
        • Gurusamy K.
        • El-Gendy K.
        • Chan C.L.
        Prevention of parastomal herniation with biologic/composite prosthetic mesh: a systematic review and meta-analysis of randomized controlled trials.
        J Am Coll Surg. 2010; 211: 637-645

      Linked Article

      • Can we avoid rectus abdominis muscle atrophy and midline shift after colostomy creation?
        SurgeryVol. 157Issue 1
        • Preview
          We all understand that the creation of a colostomy alters the integrity, compliance, and durability of the anterior abdominal wall in more ways that can be fully appreciated. Furthermore and despite the careful construction of a stoma, which equates to an “iatrogenic” hernia, it is often difficult to comprehend why a number of patients later develop herniation. Indeed, we have all been surprised at the size of the defect when needing to repair a symptomatic hernia at a stoma that had earlier been constructed so carefully.
        • Full-Text
        • PDF