Two Wound Closure Techniques After Stoma Reversal: What a Cochrane Review Found

For many people living with a temporary stoma, reversal surgery sits on the horizon as a meaningful goal. The idea of closing the stoma and reconnecting the bowel brings a sense of completion to what is often a difficult chapter. But reversal surgery is still surgery, and like all operations it carries a risk of complications. Among the most common complications after stoma reversal is a surgical site infection at the wound where the stoma once was. A 2024 Cochrane systematic review and meta-analysis examined whether the technique used to close that wound influences how often infections occur.

What a Stoma Reversal Involves

A stoma is an opening on the abdomen through which waste leaves the body, created when surgery on the bowel or rectum makes normal digestion temporarily or permanently impossible. The NHS notes that stomas can be temporary or permanent. A temporary stoma is usually created to protect a join further along the bowel while it heals after an operation; once healing is confirmed, a second planned operation called a stoma reversal or closure reconnects the bowel and closes the stoma opening.

Reversal surgery is generally considered less complex than the original operation that created the stoma, but it is still an abdominal procedure with its own recovery period and its own complication profile. One of the most frequent complications is a surgical site infection (SSI) at the site of the former stoma, where the skin wound is closed as part of the reversal operation.

The Wound at the Stoma Site

When a stoma is reversed, the surgeon closes the opening in the abdomen, reconnects the bowel, and then closes the circular skin wound that remains where the stoma protruded. This circular wound poses a particular challenge because the stoma site is not a sterile environment. Faecal bacteria can contaminate the wound edges during the reversal procedure, increasing the risk of infection even when precautions are taken.

Two main techniques have been used to close this wound.

Linear Closure

In linear or primary closure, the surgeon closes the circular wound by bringing the wound edges together in a straight line, using sutures, staples, or a combination. The wound is closed entirely at the time of surgery. This is the more traditional approach and the one most familiar to patients recovering from other types of surgery. A fully closed wound can feel reassuring, but it also means that if bacteria are trapped inside, there is little opportunity for them to drain out, and an infection may develop under the closed skin surface.

Purse-String Closure

In purse-string closure, the surgeon uses a suture placed around the rim of the circular wound and draws it inward like the drawstring of a bag, reducing the wound to a small central opening rather than closing it completely. The remaining small hole is left open to heal on its own from the inside out, a process called healing by secondary intention. The wound is packed with dressing material and gradually closes over several weeks.

The rationale for the purse-string approach is that the small open channel allows any contaminated fluid or bacteria to drain from the wound rather than becoming trapped, which reduces the environment in which an SSI can develop. The trade-off is that the wound takes longer to close, and patients require wound dressing changes during the healing period.

What the Cochrane Review Examined

The 2024 Cochrane review and meta-analysis (pubmed:38470607) pooled data from randomised controlled trials that assigned participants undergoing stoma reversal to either purse-string or linear skin closure and then compared outcomes. Surgical site infection was the primary outcome of interest, given its clinical significance: an SSI after stoma reversal can extend a hospital stay, require antibiotic treatment, delay return to normal activity, and cause considerable discomfort at a stage when patients are hoping for straightforward recovery.

Secondary outcomes assessed across the included trials included wound dehiscence (the wound breaking open), overall wound healing time, and in some studies cosmetic satisfaction and patient-reported experience.

What the Evidence Found

The Cochrane review found that purse-string skin closure was associated with a lower rate of surgical site infection compared with linear closure. This finding is consistent with a body of randomised trial evidence that has accumulated over more than two decades of research into this specific question, and the Cochrane analysis brought that evidence together to provide a pooled estimate. The direction of effect favoured purse-string closure for infection risk.

The review authors assessed the certainty of the evidence in accordance with Cochrane methodology, which examines factors including the risk of bias in individual trials, the consistency of results across studies, and the precision of the pooled estimate.

On the question of healing time, the evidence picture is more nuanced. Because purse-string wounds heal by secondary intention, they take longer to close fully than linear wounds, which are sealed at the time of surgery. This means people who undergo purse-string closure can expect a period of weeks during which the wound is still healing and requires regular dressing changes. For many patients this is manageable in the community with nurse or self-care support, but it represents a difference in the recovery experience that patients should be aware of when discussing options with their surgical team.

What This Means for Patients Approaching Reversal

For anyone with a temporary stoma planning ahead for reversal surgery, the Cochrane evidence adds useful context to what can otherwise be an unfamiliar topic. Most patients focus on the mechanics of the reversal itself -- whether the bowel will reconnect successfully, how long recovery will take, when they will feel normal again -- and the detail of how the skin wound will be closed can go unasked.

This review suggests the question is worth raising. The choice of wound closure technique has a measurable influence on a clinically meaningful outcome: the likelihood of getting an infection at the wound site. The purse-string approach appears to reduce that risk, though it carries the practical consequence of a longer open healing period.

Importantly, the decision is not one-size-fits-all. The surgeon will consider the size of the stoma opening, the degree of contamination during the procedure, local surgical practice, and individual patient factors before deciding which closure is most appropriate. In some situations, linear closure remains a reasonable choice. In others, the purse-string technique offers a meaningful advantage.

The value of this Cochrane review for patients is that it makes the conversation possible. Knowing that two techniques exist and that they differ in their infection risk profile gives patients a framework to ask their surgeon which approach is planned and why.

Living Through Recovery After Reversal

Whether the wound is closed by purse-string or linear technique, reversal surgery is followed by a recovery period during which the bowel adapts to having its usual pathway reconnected. Bowel habits may be unpredictable for weeks or months as the system adjusts. Some people experience diarrhoea, urgency, or frequency before settling into a more regular pattern. People who had a loop ileostomy protecting a low rectal join may experience more pronounced adjustment than those who had a simpler reversal. A stoma care nurse can offer guidance on what to expect and how to manage symptoms during this period.

Regular contact with the surgical team during the postoperative period allows any wound complications to be identified and managed promptly. If a wound shows signs of increasing redness, warmth, swelling, or discharge that does not look like normal healing, patients should contact their surgical team rather than waiting for a scheduled appointment.