Patients with a colostomy or an ileal conduit may be considered for preoperative bowel preparation, although such preparation is not always necessary. They, along with patients with an ileostomy, can usually just be placed on a clear liquid diet for a few days before surgery.

The operation is performed under general anesthesia with endotracheal intubation. A single dose of an appropriate preoperative antibiotic is given. Sequential compression devices are placed and a Foley catheter is inserted unless the patient has an ileal conduit. An orogastric tube is inserted for gastric decompression. The patient is positioned supine with arms tucked and padded. Colostomies and ileostomies are over sewn with a 2-0 silk suture and covered with a clear, occlusive bandage. Urinary stomas have a 16 French Foley catheter inserted, the balloon is gently inflated, and it is draped off with a clear, occlusive bandage. The abdomen is prepped with Chloraprep or Betadine solution and an Ioban occlusive drape is placed over the whole abdomen.

Once the three ports are placed, careful adhesiolysis and reduction of the hernia begins. This maneuver is performed sharply with very judicious, if any, use of electrocautery or ultrasonic energy. This step can be the most tedious and time-consuming part of the operation as great care must be taken to avoid an enterotomy. Multiple reinspections of the operative field and intestine during and after adhesiolysis are mandatory. Loops of incarcerated bowel must be distinguished from the loop of bowel ending in the ostomy. The bowel mesentery must be preserved. An ostomy with a compromised blood supply will not serve the patient well. The stoma mesentery can also help serve as a guiding structure while trying to sort out multiple small intestinal loops incarcerated into a large hernia defect. The hernia contents must be reduced, but there is no need to excise the hernia sac itself. The afferent limb of the stoma is mobilized to allow for lateralization of the stoma limb as required for the Sugarbaker technique.

After the hernia contents are reduced, the facial defect is measured. There are a few techniques available. A spinal needle is placed through the abdominal wall perpendicular to the edge of the defect and marked on the abdominal wall. After all edges of the defect are marked, the size of the defect is measured after the abdomen is deflated so as not to overestimate its size. One can also cut a plastic ruler lengthwise and introduce it into the abdomen through the 10-mm trocar. This can be held up against the defect for measurement. This is handy when the defect is small, but is impractical if the defect is larger than the length of the ruler. Finally, a piece of cord tape or suture can be stretched across the defect intracorporally, withdrawn, and measured extracorporally. Regardless of the approach, an accurate measurement in the vertical and horizontial axes is essential to a good repair.

A dual-sided expanded polytetrafluoroethylene (ePTFE) mesh (Dual-Mesh, W.L. Gore, Flagstaff, AZ) is appropriately sized to cover the stoma as well as 5 cm beyond the facial defect. This dual-sided microporous mesh prevents erosion of the biomaterial into the afferent limb of the stoma as it tunnels laterally against the abdominal wall. The orientation is marked on the mesh to facilitate orientation intracorporally. Sutures are placed on the four sides of the mesh while keeping in mind the path the bowel will take as it exits the mesh laterally. Prior to inserting the mesh, two 5-mm trocars are placed ipsilateral to the stoma under direct visualization. These ports are used to view the mesh and as working ports for placing tacks along the medial edge of the mesh.