Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

Place a GIA stapler through opening and engage stapler

A

Divide segment of colon

B

FIGURE 54–2

6 2 0 S E C T I O N I X • C O L O N

Using forceps clamps and 3-0 silk ligatures, incise the colonic mesentery from the colostomy site at a sufficient 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 electrocautery, creating a circular opening (Figure 54-3).

Use electrocautery to make a cruciate incision through the abdominal wall and peritoneum (Figure 54-4).

Manually insert at least two fingers through the colostomy site.

Incise skin with electrocautery or scalpel

FIGURE 54–3

Cruciate incision through fascia, retraction of muscle

FIGURE 54–4

6 2 2 S E C T I O N I X • C O L O N

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 exteriorized (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

Use Lembert sutures to buttress the staple line of the distal colon, thereby creating Hartmann’s pouch

FIGURE 54–6

6 2 4 S E C T I O N I X • C O L O N

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

Excise stapled end of colon

FIGURE 54–7

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 colostomy, which creates a mucous fistula.

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