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

Grasp the skin at the site chosen for the enterostomy (usually just lateral to the rectus abdominis 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

6 3 2 S E C T I O N I X • C O L O N

Use electrocautery to excise the stapled end of bowel, leaving approximately 4 cm exteriorized (Figure 55-6).

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

Place several 3-0 Vicryl sutures through first 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

Sutures loop through skin, bowel wall, then bowel end to invert bowel over skin surface

FIGURE 55–7

Brooke ileostomy

FIGURE 55–8

6 3 4 S E C T I O N I X • C O L O N

3. CLOSING

Routine

STEP 4: POSTOPERATIVE CARE

Provide routine ostomy care.

Replace fluids lost from ileostomy intravenously with lactated Ringer solution or other crystalloid solution until the patient’s oral intake is sufficient. 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 sufficient length from the abdominal wall so that enteric sulcus will fall easily into the ostomy bag with minimal skin contact.

CH A P T E R56

LOOP COLOSTOMY

Dennis C. Gore

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 colostomy, the incision is placed in the left lower quadrant, just lateral to the rectus abdominis muscle.

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