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

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CHAPTER 56 • Loop Colostomy 637

Glass or plastic rod

FIGURE 56 –2

FIGURE 56 –3

638 Section IX • Colon

◆ Secure the rod in place by attaching tube catheter to each end of the rod circling over the

colon (Figure 59-4).

◆ The colotomy is performed with electrocautery along the taenia coli (Figure 56-5).

◆ Edges of the colotomy are secured to the edges of the incision with multiple 3-0 Vicryl

sutures (Figure 56-6).

Tube catheter

FIGURE 56 –4

CHAPTER 56 • Loop Colostomy 639

FIGURE 56 –6

FIGURE 56 –5

640 Section IX • Colon

3. CLOSING

◆ Routine

STEP 4: POSTOPERATIVE CARE

◆ Provide routine ostomy care.

◆ The plastic rod can be removed once the surgical site has healed, which is usually approxi-

mately 2 weeks.

STEP 5: PEARLS AND PITFALLS

◆ Omentum and pericolic fat precludes solid healing of the colostomy to the incision. It is

best to trim fat. However, use caution and vigilance in ensuring hemostasis on retracted

omentum and mesenteric fat.

641

STEP 1: SURGICAL ANATOMY

◆ The surgeon should be familiar with the anatomy of the double-barrel or looped stoma.

◆ Fascial closure of the abdominal wall after stoma takedown requires knowledge of the anat-

omy of the fascial relationship to the rectus abdominis muscle. Below the arcuate line, the

posterior wall of the rectus sheath is absent, and the rectus muscle lies on thin transversalis

fascia. Thus recognition and closure of the anterior rectus fascia is signiﬁ cantly important in

preventing postoperative incisional hernia in patients with stomas below the umbilicus.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Reestablishment of intestinal continuity should take into consideration the original condi-

tion for which the diversion was created. Appropriate preoperative imaging and diagnostic

studies should be obtained to establish the safety of reversal.

◆ Wrapping the stoma with Sepraﬁ lm, a sodium hyaluronate–based bioresorbable membrane

that prevents adhesions during the initial surgery, allows for easier takedown later, and a

midline incision should be avoided.

◆ Informed consent should include potential complications, such as anastomotic stricture or

leak, bowel obstruction, wound infection at the former stoma site, intra-abdominal wound

infection, hematoma, injury to adjacent bowel or mesentery, incisional hernia, and the need

for re-creation of the ostomy.

CHAPTER

Stoma Takedown: Takedown

of Loop Colostomy

or Ileostomy

Valerie P. Bauer

642 Section IX • Colon

◆ The type of bowel preparation is determined by the location of the stoma and the surgeon’s

preference.

◆ Loop ileostomy requires clear liquid the day before and a bottle of magnesium citrate the

night before surgery.

◆ Loop colostomy requires clear liquid the day before and Fleet enema before surgery.

Mechanical bowel preparation is no longer favored for this procedure.

◆ Appropriate preoperative parenteral antibiotics are administered within 1 hour before cut

time, according to the Physician Quality Reporting Initiative (PQRI) measures deﬁ ned for

elective colorectal operations. We use ertapenem (Invanz) 1 g intravenously (IV) without re-

dosing, because it has 24-hour duration of action.

◆ Patients who have been taking steroids preoperatively should receive a stress dose of hydro-

cortisone 100 mg IV before the operation. This should be continued postoperatively and ta-

pered accordingly.

STEP 3: OPERATIVE STEPS

◆ The patient is placed supine on the operating table with arms outstretched on armboards.

◆ After general endotracheal anesthesia is administered, a Foley catheter is placed along with

sequential compression devices on the lower extremities.

◆ The ostomy appliance is removed and the abdomen is shaved as needed with clippers.

◆ The abdomen is prepped and draped, and a 2-0 Vicryl suture is used to close the proximal

loop of the stoma (Figure 57-1).

FIGURE 57 –1

CHAPTER 57 • Stoma Takedown: Takedown of Loop Colostomy or Ileostomy 643

◆ A no. 15 blade knife is used to make an elliptical incision parallel to the skin lines but staying close

to the edge of the ostomy. The incision is carried vertically down to the anterior abdominal fascia

(Figure 57-2). Figure 57-2 shows an elliptical incision through the skin.

◆ Once the white line of fascia is identiﬁ ed, it is retracted away from the plane of dissection. The

knife is drawn gently toward the bowel circumferentially and the peritoneum is cut (Figure 57-3).

Figure 57-3 shows a circumferential dissection around the stoma.

Soft tissue/

subcutaneous fat

Richardson

retractor

Barrel loop

FIGURE 57 –3

Proximal bowel

Distal bowel

FIGURE 57 –2

644 Section IX • Colon

◆ As the stoma is lifted up, care is taken to ensure that the mesentery is not cut or ripped.

Excess traction can cause tears leading to unrecognized intra-abdominal bleeding

(Figure 57-4). A Richardson retractor is used for circumferential exposure to free the

stoma.

◆ A ﬁ nger is placed beneath the incision and passed against the abdominal wall. Small adhe-

sions are freed (Figure 57-5).

◆ The mesentery is fanned out, scored, and divided using hemostats clamps and 2-0 Vicryl

suture (Figure 57-6).

Proximal bowel

Distal bowel

Mesentery intact

FIGURE 57–4

CHAPTER 57 • Stoma Takedown: Takedown of Loop Colostomy or Ileostomy 645

Adhesions

FIGURE 57 –5

Bowel

Mesentary

FIGURE 57 –6

646 Section IX • Colon

◆ The serosal edge of the bowel is cleaned and Ochsner clamps are placed from the antimes-

entric border to the mesentery in oblique fashion (Figure 57-7).

◆ The ﬁ eld is prepared for opening the bowel. Every measure should be taken to prevent fecal

or enteral spillage into the abdominal cavity. A blue towel is folded and placed on the ﬁ eld,

which will contain contaminated instruments: a metal pool sucker, Allys bowel clamps, and

sponge stick. Moist laparotomy pads are packed around the stoma.

◆ A no. 10 blade knife is used to divide the bowel (Figure 57-8). Allys clamps are placed on

the antimesenteric and mesenteric side of each lumen (Figure 57-9). The proximal limb is

held open with the Allys clamps and the pool sucker is placed into the lumen triangulating

the bowel. A bulb syringe with saline is used to irrigate the lumen, taking care not to touch

open colon with the tip of the syringe or spill saline over the edge of the lumen.

FIGURE 57 –7