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

Ileal pouch

Anvil

Circular intraluminal stapler

Main rod

Rectal pouch

A

B

Main rod and anvil are connected

FIGURE 63–16

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Brooke Ileostomy

A protecting Brooke loop ileostomy may be created in the right lower quadrant through the rectus abdominis muscle to protect the pouch while it heals.

Umbilical tape is passed between the mesentery and distal ileum. A Vicryl stitch may be used to mark the proximal limb of the ileostomy to avoid confusion about which side to mature.

Two Ochsner clamps are placed on the anterior fascia of the rectus muscle, and an Allys clamp is placed on the skin between the two. The assistant maintains even traction so that all layers are parallel and aligned.

An Ochsner clamp is placed on the skin over the ileostomy site and pulled up. A no. 10 blade knife is used to cut a circular disc.

Electrocautery is used to cut through subcutaneous tissue down to the anterior rectus fascia, which is sharply divided. Muscle fibers are spread perpendicularly, and the peritoneum is cut longitudinally enough to snugly fit two fingers. Injury to the inferior epigastric vessels should be avoided.

The ileostomy is wrapped in Seprafilm and brought out of the abdominal cavity through the ostomy site on traction using the umbilical tape for a length of at least 4 cm, taking care not to twist the mesentery. This will minimize adhesions and facilitate ease of takedown at a later time.

The proximal limb is confirmed by visualizing the suture, and a transverse incision is made across the ileum using Bovie electrocautery.

Vicryl sutures are placed through the mucosa at points equidistant from each other on the proximal limb, then through the seromuscular layer proximally at the skin level, and then to skin. The proximal limb is everted to form a spigot-like protuberance that falls into the ileostomy bag, diverting the sulcus away from the level of the skin. The distal limb is sutured to the inferior portion of the skin edge without eversion.

The appliance is cut to fit circumferentially so that there are no gaps exposing the skin at the end of the procedure after skin is closed.

3. CLOSING

A #10 closed suction Jackson-Pratt drain is placed in the pelvis.

The omentum is moved to the side and placed in either paracolic gutter. Two Ochsner clamps are placed at the umbilicus opposite each other. One sheet of Seprafilm is cut in half and placed over the bowel under the incision. This minimizes adhesion formation and makes reentry easier for future operations.

The abdomen is closed using no. 1 polydioxanone (PDS) running suture.

The subcutaneous tissue is irrigated with bacitracin irrigation, and the skin closed with staples.

The umbilicus is reapproximated. A bacitracin-soaked cotton ball wrapped in Adaptic is packed into the umbilicus as a bolster.

A well-fitting ileostomy appliance is cut to size and placed so that skin is not visible around the wafer. This prevents early production of sulcus from draining into the healing mucocutaneous wound.

STEP 4: POSTOPERATIVE CARE

Adherence to a postoperative colorectal clinical pathway ensures standardization of care.

Adequate pain control is achieved using patient-controlled analgesia or epidural catheter.

Consideration for stress ulcer prophylaxis should be given to patients with symptoms or history of peptic ulcer disease.

All patients should receive prophylaxis for deep venous thrombosis, using sequential compression devices while in bed, and heparin 5000 U subcutaneously every 8 hours or enoxaparin 40 mg subcutaneously every morning, starting within 24 hours from surgery. Dosing schedules should start on postoperative day 1, after results of morning laboratory tests are back to ensure there is no significant drop in hemoglobin to suggest postoperative bleeding.

Adequate intravenous fluid should be administered with monitoring of urine output via urimeter on the Foley bag. Adequate fluid resuscitation should be given based on the clinical assessment of intravascular volume status.

The diet may be limited to ice chips and sips of water in the postanesthesia care unit and on postoperative day 1. Return of bowel function is measured by the frequency and pitch of bowel sounds, lack of abdominal distention, and the patient’s subjective will to eat. A clear liquid diet may be offered as sips of clear fluids without carbonation and without a straw to minimize accumulation of air in the intestine. This may be advanced ad lib as bowel function returns.

Early ambulation is crucial for return of bowel function. Patients should be instructed to walk multiple times a day beginning on postoperative day 1 and should be encouraged to do so frequently.

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The umbilical bolster should be removed before the patient leaves the hospital. Skin staples are removed in the office during the postoperative visit.

The ostomy care nurse should be consulted, and adequate postoperative education and support should be given to the patient before discharge from the hospital.

The closed-suction drain may be removed on postoperative day 3 or when the drainage has decreased to less than 50 mL/day.

STEP 5: PEARLS AND PITFALLS

Damage to the superior hypogastric plexus during high ligation of the IMA or to the hypogastric nerves at the sacral promontory during mobilization of the upper mesorectum results in retrograde ejaculation.

Damage to the inferior hypogastric pelvic plexus may also result in urinary dysfunction due to denervation and paralysis of the detrusor muscle.

Damage to the nervi erigentes during lateral and anterior dissection in the pelvis results in erectile dysfunction.

Shortened ileocolic mesentery may preclude pouch placement in the pelvis. The patient should be prepared to accept permanent ileostomy should this happen.

Shortened small bowel mesentery or large body habitus may preclude formation of protecting loop ileostomy. The right colon may be mobilized to provide additional distance.

Care should be taken not to twist the small bowel mesentery when bringing out an ileostomy or creating an ileoanal anastomosis. This can be done by identifying the SMA at the root and “shaking hands” with the mesentery to feel for twists.

Strong consideration should be made in using a loop ileostomy to protect the pouch. Most patients with ulcerative colitis who are undergoing this procedure are malnourished, taking high-dose steroids, and at increased risk for impaired wound healing and anastomotic leak. The ileostomy may be reversed in 6 weeks after contrast study through the distal limb of the loop confirms anastomotic integrity.

Patients taking high-dose steroids should follow an appropriate tapering of dosage after discharge from the hospital and should be cautioned on problems with wound healing.

SELECTED REFERENCES

1. Beck DE, Opelka FG: Perioperative steroid use in colorectal patients. Dis Colon Rectum 1996;39: 995-999.

2. FDA safety alert (12/11/2008): http://www.fda.gov/cder/drug/infopage/OSP_solution/default.htm

3. Zeng Q, Yu Z, You J, Zhang Q: Efficacy and safety of Seprafilm for preventing postoperative abdominal adhesion: Systematic review and meta-analysis. World J Surg 2007;31:2125-31;2132 [discussion].

4. Guidelines from the Joint Commission on Surgical Care Improvement Project Core Measurement Set. Available on the Internet: www.jointcommission.org/PerformanceMeasurement.

STEP 3: OPERATIVE STEPS

1.INCISION

A midline abdominal incision is made from the pubic symphysis to approximately 5 cm cranial to the umbilicus.

The midline fascia is divided with electrocautery. The peritoneum is elevated with tissue forceps, and after ensuring that no bowel is entrapped by the graspers, the peritoneum is incised sharply with a scalpel.

2.DISSECTION

Once the peritoneum has been entered, a systematic exploration is performed to search for metastatic diseases in the peritoneal cavity and the liver.

A fixed retractor is placed to retract small bowel superiorly and laterally out of the operative field. Retraction of small bowel is aided by placing the patient in a Trendelenburg position.

Mobilization of the sigmoid colon is achieved by using electrocautery to incise the lateral visceral fascia covering the mesosigmoid along the white line of Toldt, which can be easily visualized by retracting the sigmoid colon medially. Working through this avascular plane allows for easy identification of gonadal vessels and the left ureter as they course over the left iliac vessels into the pelvis (Figure 64-1).

The medial visceral fascia is incised with electrocautery, and the right ureter is visualized as it courses over the right iliac vessels (Figure 64-2).

The presacral space is entered by dividing the loose areolar tissue at the level of the sacral promontory. The presacral space is developed sharply with electrocautery caudally toward the levator ani muscle, under direct vision. A fiber-optic pelvic retractor is used for retraction of the bladder and the rectum to facilitate visualization in the pelvis. After the sharp posterior pelvic dissection is completed, the distal margin can be manually evaluated

(Figure 64-3).

The mesorectum is mobilized laterally toward both the right and left pelvic side wall, preserving the hypogastric nerves on the sacrum. The mesorectum is divided laterally either with clamps and sutures or with a vessel sealer device, such as LigaSure.

The rectum is mobilized ventrally by dividing the rectovaginal septum or the rectovesicle space. In males, the dissection plane is ventral to Denonvillier fascia, preserving the seminal vesicles.

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Tumor

Gonadal vessels

Iliac vessels

Ureter

FIGURE 64–1