6 4 0 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.
The plastic rod can be removed once the surgical site has healed, which is usually approximately 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.
C H A P T E R
57
STOMA TAKEDOWN: TAKEDOWN
OF LOOP COLOSTOMY
OR ILEOSTOMY
Valerie P. Bauer
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 anatomy 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 significantly 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 condition 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 Seprafilm, 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.
641
6 4 2 S E C T I O N I X • C O L O N
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 defined for elective colorectal operations. We use ertapenem (Invanz) 1 g intravenously (IV) without redosing, because it has 24-hour duration of action.
Patients who have been taking steroids preoperatively should receive a stress dose of hydrocortisone 100 mg IV before the operation. This should be continued postoperatively and tapered 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).
C H A P T E R 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 identified, 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.
Proximal bowel
Distal bowel
FIGURE 57–2
Barrel loop
Soft tissue/ subcutaneous fat
Richardson retractor
6 4 4 S E C T I O N I X • C O L O N
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 finger is placed beneath the incision and passed against the abdominal wall. Small adhesions 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
6 4 6 S E C T I O N I X • C O L O N
The serosal edge of the bowel is cleaned and Ochsner clamps are placed from the antimesentric border to the mesentery in oblique fashion (Figure 57-7).
The field 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 field, 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.
6 4 8 S E C T I O N I X • C O L O N
The antimesenteric and mesenteric borders of each lumen are lined up.
A double-armed 4-0 Maxon monofilament suture is used to create a single-layered running anastomosis (Figure 57-10). The serosal edge is grasped and the mucosa and submucosal edges are reapproximated. This is done by placing the knot on the outer portion of the bowel at the antimesenteric border. One arm of suture is passed under the knot and used to complete half of the anastomosis, as is the other arm on the other side. The suture line is inspected for integrity.
The completed anastomosis is dropped back into the abdominal cavity (Figure 57-11).
Surgical gloves are changed and the anterior rectus fascia is reapproximated using 0 polydioxanone (PDS) in figure-of-eight interrupted sutures.
The subcutaneous skin is irrigated with bacitracin antibiotic.
A nylon vertical mattress suture is used to loosely close the skin, followed by placement of Telfa wicks between each suture (Figure 57-12). A dry dressing is placed over the wicks and changed as needed. The wicks, however, are not removed until the patient leaves the hospital.
