Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_602_Библиотеки_им_академика_М_И_Перельмана.pdf
16
Closure of Temporary Colostomy
INDICATIONS
A temporary colostomy should be closed when it is
no longer needed. Anastomotic healing and absence
of a distal obstruction should be demonstrated by
contrast studies. Suitably prepared patients may
undergo colostomy closure as early as 2–3 weeks
after surgery.
PREOPERATIVE PREPARATION
Barium colon enema radiography to demonstrate
patency of distal colon
Nasogastric tube
Routine mechanical and antibiotic bowel preparation (saline enemas to cleanse the inactivated left
colon segment may be required as well)
Perioperative systemic antibiotics
PITFALLS AND DANGER POINTS
Suture-line leak
Intraabdominal abscess
Wound abscess
OPERATIVE STRATEGY
To avoid suture-line leakage, use only healthy, well
vascularized tissue for colostomy closure. Adequate
lysis of the adhesions between the transverse colon
and surrounding structures allows a suffi cient
segment of transverse colon to be mobilized, avoiding tension on the suture line. If necessary, the incision in the abdominal wall should be enlarged to
provide exposure. If the tissue in the vicinity of the
colostomy has been devascularized by operative
trauma, do not hesitate to resect a segment of bowel
and perform an end-to-end anastomosis instead of a
local reconstruction. Proper suturing or stapling of
healthy colon tissue and minimizing fecal contamination combined with perioperative antibiotics helps
prevent formation of abscesses.
Infection of the operative incision is rather
common following colostomy closure, owing in part
to failure to minimize the bacterial inoculum into the
wound. Another phenomenon that contributes to
wound infection is retraction of subcutaneous fat
that occurs around the colostomy. This can produce
a gap between the fascia and the epidermis when the
skin is sutured closed, creating deadspace. Avoid this
problem by leaving the skin open at the conclusion
of the operation.
OPERATIVE TECHNIQUE
Incision
Occlude the colostomy by inserting small gauze
packing moistened with povidone-iodine solution.
Make an incision in the skin around the colostomy
3–4 mm from the mucocutaneous junction (Fig.
16 –1). Continue this incision parallel to the mucocutaneous junction until the entire colostomy has
been encircled. Applying three Allis clamps to the
lips of the defect in the colon expedites this dissection and helps prevent contamination. Deepen the
incision by scalpel dissection until the seromuscular
coat of colon can be identifi ed. Then separate the
serosa and surrounding subcutaneous fat by Metzenbaum scissors dissection (Fig. 16 –2). Perform this
dissection with meticulous care to avoid trauma to
the colon wall. Continue down to the point where
the colon meets the anterior rectus fascia.
Fascial Dissection
Identify the fascial ring and use a scalpel to dissect
the subcutaneous fat off the anterior wall of the
fascia for a width of 1–2 cm until a clean rim of fascia
is visible all around the colostomy. Then dissect the
190
Op
19
eal
ssection
nger and gently
peritoneal attachments. Using the index fi
ng
-
fi
culty whatever is encountered while freeing
wall of the colon for injury. A few small superfi
cial
patches of serosal damage are of no signifi
-
.
Fig. 16–
1
2
3
erative Technique
1
colon away from the fascial ring until the peritoneal
cavity is entered.
Periton
dissect the transverse colon away from the adjoining
uide, separate the remainder of the colon from its
attachments to the anterior abdominal wall. This can
often be accomplished without appreciably enlarg
ng the defect in the abdominal wall. However, if any
if
e adhesions between the colon and peritoneum,
extend the incision laterally by dividing the remainder of the rectus muscle with electrocautery for a
distance adequate to accomplish the dissection
safely.
Di
ed, it is
er as a
Closure of Colon Defect by Suture
After the colostomy has been freed from all attachments for a distance of 5–6 cm (Fig. 16 –3), detach
the rim of skin from the colon. Carefully inspect the
cance so
long as they are not accompanied by devasculariza
tion. In most cases, merely freshening the edge of
the colostomy by excising a rim of 3–4 mm of scarred
colon reveals healthy tissue
The colon wall should now be of relatively normal
thickness. In these cases the colostomy defect, which
resulted from a longitudinal incision in the transverse
Fig. 16–
Fig. 16–
192
C
losure of Temporary Colostomy
m
midp
ate a
-
p
-
.
Fig
. 16–4
olon at the initial operation, should be closed in a
ransverse direction. Initiate an inverting stitch of
-0 PG on an atraumatic curved needle at the caudal
argin of the colonic defect and pursue it as a con-
inuous Connell or continuous Cushing suture to the
oint of the defect (Fig. 16 – 4)
Then initi
econd suture of the same material on the cephalad
margin of the defect and continue it also to the mid
oint; terminate the suture line here (Fig. 16–4).
Invert this layer with another layer of interrupted
4-0 silk atraumatic seromuscular Lembert sutures
(Fig. 16 –5). Because of the transverse direction of
e suture line, the lumen of the colon is quite com
modious at the conclusion of the closure. There
should be no tension whatever on this suture line.
eld and reduce the
olon into the abdominal cavity.
Closure of Colonic Defect by Staples
If the colon wall is not so thick that compressing it
o 2 mm produces necrosis, stapling is an excellent
method for closing the colon defect. Align the defect
so the closure can take place in a transverse direc-
ion. Place a single guy suture to mark the midpoint
f the transverse closure
lamps to approximate the colon staple line with the
bowel wall in eversion
Carry out stapling by triangulation with two appli-
ations of the 55 mm linear stapling device, rather
an attempting a single application of a 90 mm
Fig. 16 – 6)and apply Allis
ig. 16–5
Op
193
Fig. 16–
6
back
fl
ush with the stapler. Leave the guy suture at the
.
re the staples. Remove any redun-
u
with th
p
7
erative Technique
device. This minimizes the chance of catching the
wall of the colon in the staple line. First, apply
the stapler across the everted mucosa supported by
the Allis clamps on the caudal aspect of the defect
nd the guy suture. Fire the staples and use Mayo
scissors to excise the redundant everted mucosa
midpoint of the closure intact
Make the second application of the 55 mm linear
stapler with the device positioned deep to the Allis
clamps on the cephalad portion of the defect
Fig.
6 –7). It is important to position the guy suture to
include the previous staple line in this second line of
staples, ensuring that no gap exists between the two
sh
e stapler. Lightly electrocoagulate the everted
mucosa. Carefully inspect the integrity of the staple
line to ensure that proper B formation has taken
lace. It is important, especially with stapling, to
scertain that no tension is exerted on the closure.
Fig. 16–
19
4
C
R
y
Wh
l
fi
cient section of the right transverse colon,
ments of the colon have been suffi
ciently mobilized
p
q
4
4
-
n
wound. Then close the incision by the modifi
d
Management of Skin Wound
h
p
-
E
A
.
p
NS
W
n
Ab
stula
g
.
h
d
.
p
6
.
losure of Temporary Colostomy
esection and Anastomosis
f Colostom
enever the tissue is of inadequate quality for
imple transverse closure, enlarge the incision in the
dominal wall and resect a segment of colon. Mobi-
ize a suf
exure. Dissect
he omentum off the transverse colon proximal and
istal to the defect. After the proximal and distal seg-
nd the traumatized tissue excised, an end-to-end
nastomosis can be constructed by the usual twolayer
uture technique (see Figs. 4–18 through 4–26) or
losure of Abdominal Wall
Irrigate the area with a dilute antibiotic solution and
ly an Allis clamp to the midpoint of the abdomi
al wall on the caudal and cephalad aspects of the
e
mead-Jones technique.
nterrupted vertical mattress sutures of nylon may be
nserted, but do not tie them until the eighth or tent
ostoperative day. Keep the subcutaneous tissue
separated with moist gauze packing and approxi
mate the skin by previously placed sutures or tape
strips when healthy granulation tissue has formed.
POSTOPERATIVE CAR
pply nasogastric suction if necessary
ystemic antibiotics are not continued beyond the
erioperative period unless there was serious wound
ontamination during surgery.
COMPLICATIO
ound infectio
dominal abscess
REFERENCES
Frequently the colostomy can be closed without
nlarging the skin incision, which was no longer
han 5–6 cm. There is a high incidence of wound
infection following primary closure of the skin. In
uch cases we simply insert loosely packed gauze
into the subcutaneous space, which we allow to heal
by granulation and contraction. If desired, several
Doberneck RC. Revision and closure of the colostomy.
Sur
Clin North Am 1991;71:193
Renz BM, Feliciano DV, Sherman R. Same admission colos-
tomy closure (SACC): a new approac
a prospective stu
Sola JE, Buchman TG, Bender JS. Limited role of barium
enema examination
trauma patients. J Trauma 1994;3
y. Ann Surg 1993;218:279
receding colostomy closure in
to rectal wounds:
:245
17
Laparoscopic Stoma Construction
and Closure
Dan Enger Ruiz
Steven D. Wexner
INDICATIONS
Obstructing tumors
Colonic infl ammation (diverticulitis, infl ammatory
bowel disease, radiation)
Perineal sepsis (Crohn’s disease, complex fi stula,
Fournier’s disease)
Trauma (perineal injury, rectal perforation)
Dysfunction (fecal incontinence, dysmotility)
PREOPERATIVE PREPARATION
Enterostomal therapist consultation for marking
In elective setting, standard bowel preparation.
(selected cases)
Oral and/or intravenous antibiotic preparation.
(elective cases with bowel preparation)
Sequential compression stockings
Subcutaneous heparin
PITFALLS AND DANGER POINTS
Appropriate stoma location
Adequate abdominal opening to avoid outlet obstruction ischemia, parastomal hernia, prolapses
Injury to the spleen
Injury to the ureters
Injury to the bowel
Adequate orientation of the bowel (as mesentery
must not be torsed)
OPERATIVE STRATEGY
Deciding the best place for stoma placement is the
key issue in stoma formation. The stoma site should
be carefully preoperatively determined to avoid postoperative complications.
Another important issue is which stoma to use.
Loop stomas are often preferred over end stomas
because they vent the intestine and they are relatively easy to close. For protection of an anastomosis
or colonic diseases an end ileostomy is preferred. An
end ileostomy is the only choice after colectomy for
fulminant infl ammatory disease.
Loop ileostomies are selected over colostomies for
easier management and less major complications
after subsequent closure. Moreover, performing a
loop colostomy places the marginal artery at risk
during stoma closure, potentially devascularizing the
distal colon and therefore the proximal anastomosis.
The surgeon must keep in mind that the area of
manipulation has to form a semicircle or a triangle
with the laparoscope between the two operating
ports. For a loop ileostomy the most distal segment
that can be used without tension is chosen. For a left
colostomy a left paracolic dissection may be necessary and a gentle dissection is done to avoid splenic
injuries. Identifi cation of the ureter is required when
dissecting the mesentery from the retroperitonium.
Placement of ureteric catheters can be useful in cases
of major infl ammatory processes or tumors encroaching on the ureter(s).
OPERATIVE TECHNIQUE
Loop Ileostomy
Room Setup and Trocar Placement
The patient is placed in the supine position (Figure
17–1) and monitors are placed near the patient’s
right knee and left shoulder. The surgeon is operating
from the opposite side of the stoma site. Pneumoperitonium is raised in the standard fashion using a Hasson’s technique and a 10 mm laparoscope is introduced
at the supraumbilical port. This initial part is deliberately placed midway between the umbilicus and
xiphoid to allow adequate working space. Traditional
placement near the umbilicus will result insuffi cient
195
19
6
L
1
aparoscopic Stoma Construction and Closure
ig. 17–
Op
erative Technique
19
2
.
m
es an appropriate loop of bowel
b
E
After slowly grasping the ileum, desulfl
p
7
Fig. 17–
space between the instruments for triangulation. The
next 10 mm port is placed right in the ileostomy site
assuring avoidance of epigastric vessels that may be
damaged by transiluminating the chosen stoma site.
efore the trocar is placed, a 2 cm circular skin and
subcutaneous tissue disc is resected around the stoma
mark
Figure 17–2) An extra 10 mm cannula can be
placed contralateral to the stoma in the iliac fossa, if
needed, to facilitate the dissection
Choosing a Loop of Terminal Ileu
The patient is placed in the Trendelenburg position
o displace the small bowel out of the pelvis. Using
10 mm diameter laparoscopic Babcock-type clamp,
20–30 cm) proximal to the cecum and lifts it to the
stoma site, verifying it is tension-free
Figure 17–3)
Special care must be taken to avoid torsing of the
owel. Gently grasping the cecum and elevating it
nteriorly to expose the ileocecal junction and thus
the terminal ileum can facilitate this maneuver.
xposing the Ileum
ating the
neumoperitonium, and without rotating the bowel
the ileum is exteriorized through the stoma site
198
L
aparoscopic Stoma Construction and Closure
fl
ate the abdomen and
fi
rm orientation of the bowel and mesentery. The
L
ed lithotomy
p
knee. The surgeon and fi
rst assistant position is on
i-
6)
D
ttachment
ateral attachments
(
.
E
p
A
ig. 17–3
(Figure 17– 4). The loop of bowel occluding the
toma site is used to reinsul
n
stomy is then matured using standard techniques.
oop Sigmoid Colostomy
Room Setup and Trocar Placement
osition; monitors are placed lateral to each patient’s
he right side of the patient and the second assistant
between patient’s legs
onium is established in the standard fashion through
10 mm port introduced at the supraumbilical port.
This initial port is deliberated placed midway
between the umbilicus and xiphoid. A second 10 mm
rocar is placed at the stoma site after exploration of
e abdomen. If a third 10 mm cannula is needed for
Figure 17–5). Pneumoper
issection it is placed in between umbilicus and right
liac spina on the right side (Figure 17–
issecting the Left Parietocolic
A
In many cases the sigmoid colon must be mobilized
from its lateral peritoneal attachments to achieve the
stoma site without tension. In this case, a 5 mm port
s placed suprapubically from the right side and lap-
aroscopic scissors are used to dissect and mobilize
colon from its l
If the descending colon requires mobilization, the
surgeon should move from the right side to between
e patient’s legs
Figure 17–7)
xteriorizing the Sigmoid Loo
10 mm diameter Babcock is used to gently grasp
he loop of sigmoid colon that best reaches above
he stoma site at the skin level. The sigmoid is
withdrawn and trocar removed simultaneously
Op
erative Technique
199
4
Fig. 17–