Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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STEP 1: SURGICAL ANATOMY

◆ Normal-appearing colon (usually sigmoid/descending colon) proximal to diseased bowel

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications:

◆ Relief of colonic obstruction

◆ Complete diversion of fecal stream

◆ Anesthesia: general

◆ Position: supine

CHAPTER

Diverting End Colostomy

with Mucous Fistula or

Hartmann’s Pouch

Dennis C. Gore

618 Section IX • Colon

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Midline laparotomy (Figure 54-1)

2. DISSECTION

◆ Mobilize the segment of colon chosen for colostomy, usually just proximal to the obstruc-

tion or other diseased lesion. For the transverse colon, this entails incising the attachments

to the omentum with either electrocautery or scissors.

◆ For sigmoid, descending, or ascending colon, incise the avascular lateral ligaments to the

peritoneum.

◆ With blunt forceps dissection, create an opening through the mesentery. Place a gastrointes-

tinal anastomosis (GIA) stapler through this aperture and engage the stapler (Figure 54-2).

Incision

FIGURE 54 –1

Place a GIA stapler through

opening and engage stapler

CHAPTER 54 • Diverting End Colostomy with Mucous Fistula or Hartmann’s Pouch 619

FIGURE 54 –2

Divide segment

of colon

620 Section IX • Colon

◆ Using forceps clamps and 3-0 silk ligatures, incise the colonic mesentery from the colos-

tomy site at a sufﬁ cient distance so that the two ends of the severed colon can be retracted

through the abdominal wall.

◆ Grasp the skin at the site chosen for colostomy, usually just lateral to the rectus abdominis

muscle in the right or left lower quadrants, retract the skin, and incise with scalpel or elec-

trocautery, creating a circular opening (Figure 54-3).

◆ Use electrocautery to make a cruciate incision through the abdominal wall and perito-

neum (Figure 54-4).

◆ Manually insert at least two ﬁ ngers through the colostomy site.

Incise skin with

electrocautery or scalpel

FIGURE 54 –3

Cruciate incision through fascia,

retraction of muscle

FIGURE 54 –4

CHAPTER 54 • Diverting End Colostomy with Mucous Fistula or Hartmann’s Pouch 621

622 Section IX • Colon

◆ Place two Babcock clamps through the colostomy site, grasp the end of the proximal colon,

and retract the colon end through the abdominal wall with at least 4 cm of colon exterior-

ized (Figure 54-5).

◆ Place several 3-0 Vicryl sutures in simple, interrupted fashion to secure the colon to the

anterior abdominal fascia.

◆ Use multiple 3-0 silk sutures in a Lembert fashion to buttress the staple line of the distal

colon end, thereby creating Hartmann’s pouch (Figure 54-6).

Pulling bowel segment

through abdominal wall

FIGURE 54 –5

CHAPTER 54 • Diverting End Colostomy with Mucous Fistula or Hartmann’s Pouch 623

Use Lembert sutures to buttress

the staple line of the distal colon,

thereby creating Hartmann’s pouch

FIGURE 54 –6

624 Section IX • Colon

◆ Complete any further procedures within the abdomen, irrigate copiously, and then close the

midline abdominal incision.

◆ Cover the midline wound with antiseptic-impregnated gauze.

◆ Use electrocautery to excise the stapled end of the colon, leaving 2 cm exteriorized from

the abdominal wall. Use 4-0 Vicryl sutures or judicious electrocautery to secure hemosta-

sis along the bowel end (Figure 54-7).

Excise stapled end

of colon

FIGURE 54 –7

CHAPTER 54 • Diverting End Colostomy with Mucous Fistula or Hartmann’s Pouch 625

◆ Use several 3-0 Vicryl sutures in simple, interrupted fashion to circumferentially secure

edges of the colostomy to skin (Figures 54-8 and 54-9).

◆ If you have a concern that the distal colonic segment is obstructed, creating a closed-loop

obstruction, exteriorize the distal colonic segment in the same manner as the end colos-

tomy, which creates a mucous ﬁ stula.

Sutures loop through skin,

bowel wall close to edge,

then out of edge to invert

colon wall only slightly

over skin surface

De la Flor/Cooley

FIGURE 54 –8

FIGURE 54 –9

626 Section IX • Colon

3. CLOSING

◆ Routine

STEP 4: POSTOPERATIVE CARE

◆ Routine ostomy care

STEP 5: PEARLS AND PITFALLS

◆ It is essential that the colon is straight and free of tension without any restriction on the

mesentery to ensure adequate blood supply to the very end of the colostomy.

◆ Before closure of the abdomen, use suture to close any rents in the mesentery that may be a

nidus for future internal herniation. Take care not to occlude the colonic blood supply.