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

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STEP 1: SURGICAL ANATOMY

◆ Normal-appearing small bowel just proximal to diseased

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications: complete diversion of enteric sulcus

◆ Anesthesia: general

◆ Position: supine

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Midline laparotomy (Figure 55-1)

2. DISSECTION

◆ Mobilize free the segment of small intestine chosen, usually as distally as feasible.

◆ With blunt forcep dissection, create an opening through the mesentery, place a gastrointesti-

nal anastomosis (GIA) stapler through this aperture, and engage the stapler (Figure 55- 2).

◆ Using forceps clamps and 3-0 silk ligatures, incise the small bowel mesentery from the

enterotomy site for a sufﬁ cient distance so that the enterotomy can be retracted through

the abdominal wall.

Brooke Ileostomy

Dennis C. Gore

CHAPTER

628 Section IX • Colon

Incision

FIGURE 55 –1

Place a GIA stapler through

opening and engage stapler

FIGURE 55 –2

CHAPTER 55 • Brooke Ileostomy 629

◆ Grasp the skin at the site chosen for the enterostomy (usually just lateral to the rectus ab-

dominis muscle in the right or left lower quadrant), retract the skin, and incise with scalpel

or electrocautery, thus creating a circular opening (Figure 55-3).

Incise skin with

electrocautery or scalpel

FIGURE 55 –3

630 Section IX • Colon

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

peritoneum (Figure 55-4).

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

Cruciate incision through fascia,

retraction of muscle

FIGURE 55 –4

CHAPTER 55 • Brooke Ileostomy 631

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

bowel, and retract the bowel segment through the abdominal wall with at least 6 cm of

bowel exteriorized (Figure 55-5).

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

anterior abdominal fascia.

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

abdominal wound.

◆ Cover the midline wound with antiseptic-impregnated gauze.

Pulling bowel segment

through abdominal wall

FIGURE 55 –5

632 Section IX • Colon

◆ Use electrocautery to excise the stapled end of bowel, leaving approximately 4 cm exterior-

ized (Figure 55-6).

◆ Use 4-0 Vicryl sutures or judicious electrocautery to secure hemostasis along bowel end.

◆ Place several 3-0 Vicryl sutures through ﬁ rst the skin edge, then through the bowel wall

just exterior to the abdominal opening, and then through the edge of the enterotomy. Use

multiple sutures circumferentially around the enterostomy. As these sutures are closed and

tied, the end of the bowel should invert (Figures 55-7 and 55-8).

Excise stapled end

of bowel

FIGURE 55 –6

CHAPTER 55 • Brooke Ileostomy 633

Sutures loop through skin,

bowel wall, then bowel end to

invert bowel over skin surface

FIGURE 55 –7

Brooke ileostomy

FIGURE 55 –8

634 Section IX • Colon

3. CLOSING

◆ Routine

STEP 4: POSTOPERATIVE CARE

◆ Provide routine ostomy care.

◆ Replace ﬂ uids lost from ileostomy intravenously with lactated Ringer solution or other

crystalloid solution until the patient’s oral intake is sufﬁ cient. An antimotility agent is

sometimes required to reduce ileostomy output.

STEP 5: PEARLS AND PITFALLS

◆ Adequate blood supply to the enterostomy is essential; supply is aided by maintaining a

tension-free placement and ensuring that the mesentery is free of restriction.

◆ The Brooke ileostomy should be of sufﬁ cient length from the abdominal wall so that enteric

sulcus will fall easily into the ostomy bag with minimal skin contact.

635

STEP 1: SURGICAL ANATOMY

◆ Normal-appearing colon (usually transverse colon) proximal to diseased bowel

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications:

◆ Relief of colonic obstruction

◆ Partial diversion of fecal stream

◆ Anesthesia: general

◆ Position: supine

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The most common colonic segments for placement of loop colostomy are the transverse

colon or sigmoid colon. For transverse colostomy, the incision is placed just lateral to the

rectus abdominis muscle, most often on the right upper abdomen. For a sigmoid colos-

tomy, the incision is placed in the left lower quadrant, just lateral to the rectus abdominis

muscle.

CHAPTER

Loop Colostomy

Dennis C. Gore

636 Section IX • Colon

2. DISSECTION

◆ Retract the loop of colon through the incision (Figure 56-1).

◆ Use forceps to bluntly dissect the opening through the mesentery at the loop apex (see

Figure 56-1).

◆ Place a plastic or glass rod through the aperture in the mesentery, position the rod trans-

verse to the incision, and thereby prevent retraction of the colon loop back into the abdo-

men (Figures 56-2 and 56-3).

Taenia coli

Colonic mesentery

FIGURE 56 –1