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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_639_Библиотеки_им_академика_М_И_Перельмана.pdf
172 Part II Abdominal Wall
Fascia
A
Rectus muscle
Peritoneum
ALC
MC
LC
DLC
B
C
E
Colon delivered through abdominal
wound (perviously marked site)
“Maturation” of colostomy
Mesenteric
peritoneal closure
D
Colon opened
FIGURE 9-5 Construction of an end (diverting) colostomy. A. Selection of stoma location and technique of incision of the abdominal wall at the
colostomy site. B. Technique of colonic mobilization and provision of adequate blood supply for the colostomy. C, D, E. Final stages of constructing
a “mature” end colostomy. (LC, left colic artery; MC, middle colic artery; ALC, ascending left colic artery; DLC, descending left colic artery.)
Chapter 9 Intestinal Stomas 173
more distant postoperative course if she or he wishes to
irrigate the stoma or not.
Long-Term Colostomy Management
e patient with a properly constructed, well-functioning
colostomy may elect to irrigate once a day or every other day
and to wear only minimal appliance over the stoma or simply
cover it with a gauze in the intervening period, although the
patient should be instructed to always carry an appliance
should episodes of diarrhea occur. Simple appliances exist
to allow absorption of mucus and deodorized passage of gas
during the period between irrigations, if the patient elects to
irrigate.
IRRIGATION
e advantages of irrigating the colostomy include the absence
of need for wearing an appliance at all times, the provision
of a more regulated lifestyle, the reduced passage of uncontrolled gas, less leakage of stool between irrigations, and the
general feeling of comfort that some people experience after
irrigating the colostomy. e disadvantages are that it is a
time-consuming ritual and that some people feel discomfort
when the bowel is distended during irrigation. Irrigation carries a minimal risk of perforation. Absorption of water during
the irrigation process can be signicant, and the patient with
an irritable bowel syndrome will usually not achieve adequate
control by irrigation and may be frustrated by attempting to
do so. e principle of irrigation is based on the fact that the
distal colon displays a few mass peristaltic motions each day
and that these can be stimulated by distention of the intestine. It has been shown that 80% of people who irrigate daily
can depend on the discharge from the colostomy being one
or two movements per day. Poor results from irrigation can
be anticipated if the patient has irritable bowel syndrome,
a peristomal hernia, irradiated bowel, inammatory bowel
disease, poor eyesight, reduced manual dexterity, or simply
fear of dealing with the intestine at the abdominal wall. A
preoperative history of irritable bowel syndrome is most
important because these patients must never be promised
regular function of their colostomies.
e technique of irrigation, usually performed in the
morning, uses a cone tip that ts into the stoma only enough
to provide a seal and to allow the instillation of 500–1000 mL
of water. It is not necessary to dilate the stoma, and a nger
is inserted only periodically to determine the direction for
placement of the cone tip. Once the water has been instilled,
a drainage bag is applied, and the individual can proceed with
morning chores while the colostomy empties in response to
the stimulation. Between irrigations the patient usually wears
a security pouch, which permits passage of gas through a
charcoal lter and provides a small pad to absorb any mucus
normally secreted by the colonic mucosa.
Ischemia or infection causing partial loss of the intestinal
wall or separation of the stoma from the skin can result in
stricture of the colostomy. A tight stricture makes irrigation
impossible and frequently causes the patient signicant
discomfort because of the resulting partial obstruction.
Because the stricture is always at skin level, its correction is
simple and no patient should suer because of a colostomy
stricture.
Colostomy Complications
GENERAL CONSIDERATIONS
A common problem experienced by the patient with a colostomy is irregularity of function, which most often is related
to irritable bowel syndrome or irradiation of the intestine.
Many problems are related to improper location of the stoma,
which allows seepage of mucus and maceration of the skin
because an appliance seal cannot be adequately maintained.
Parastomal hernia formation is common, and prolapse less
so. Patients experience episodes of diarrhea and constipation depending on their underlying disease, dietary habits,
and episodic infections. Patients with colostomies can be
troubled with gas and odor problems because there is no
sphincter around the stoma and gas can be passed uncontrollably. However, most appliances today are odor-proof,
making odor only an issue during changing or emptying the
appliance. is problem is usually regulated by diet, and in
some cases by administering mild antidiarrheal agents when
social activity dictates. Minimal bleeding around a stoma is
common because the mucosa is exposed to environmental
trauma. Of course, prolonged bleeding should be evaluated
to be sure that there is not a recurrence of the primary disease
process. e same is true of cramps and diarrhea. ese can
be acceptable occasionally, but anything of a prolonged or
severe nature must be evaluated.
Evaluation of the UOA data registry shows that hernia
formation is the most common complication of end colostomy, with obstruction, abscess, and stula presenting less
frequently. Of all the complications that occur, few require
surgical correction. Fecal impaction can occur with a colostomy and can be managed by irrigation and laxatives. Digital
disimpaction is rarely required.
STOMA STRICTURE
In the past, it was believed unsafe to open the colon and
suture the edges to the skin at the time of initial operation
and stomas were thus opened in a delayed fashion. Serositis
developed because the serosal surface of the exposed colon
was irritated by exposure to air. After the exposed end of
the colon was opened, it would take some time for the
mucosa to eventually anneal to the epidermis. is process
was called “maturation” of the colostomy. Strictures were
common because the inammation associated with serositis often led to brosis. Surgeons eventually learned to open
stomas immediately at the time of initial operation and
suture the intestinal wall to the skin. For historical reasons,
174 Part II Abdominal Wall
this maneuver is still referred to as immediate “maturation”
of the stoma.
Another cause of colostomy stricture is ischemia, usually
as a result of resection of too much mesentery during construction of the stoma, or from inadequate mobilization and
tension. Repair may require a simple local procedure if the
stricture is focal at the skin level, or revision of the stoma via
a transabdominal approach if the stricture involves a longer
segment.
COLOSTOMY NECROSIS
Ischemia or necrosis of the colostomy results from excessive
resection of colonic mesentery, excessive tension on the mesentery leading to the stoma, creation of a fascial opening too
small to accommodate the bowel and its mesentery, or poor
perfusion due to low-ow states. e blood supply to an end
colostomy is unidirectional, without collaterals; therefore, it
will be most sensitive to changes in visceral perfusion. If the
necrosis is limited to the area of the stoma anterior to the
fascia, it may be observed carefully, and stoma revision performed electively at a later date, if necessary. If the necrosis
extends into the peritoneal cavity, the abdomen should be
explored and the stoma recreated. In some cases it is dicult
to ascertain the extent of necrosis. Gentle exible endoscopy
via the stoma is an accurate method to determine the level of
necrosis. Occasionally it may be possible to use a glass test
tube and light to make this determination, but endoscopy is
more reliable.
PARACOLOSTOMY HERNIA
Paracolostomy hernia is a frequent complication of colostomy
creation, even when all is done according to acceptable surgical principles. e creation of an abnormal opening in the
abdominal wall that is then subjected on a daily basis to the
pressures of Valsalva maneuvers may predispose the patient
to suer a gradual enlargement of the fascial opening. e
relative weakness of the posterior rectus sheath in the inferior
abdominal wall, with the potential space that exists alongside the rectus muscle, may also predispose the patient to
develop a peritonealized sac in the rectus sheath without a
large fascial defect. Although it is surgical dogma to create
stomas in the rectus sheath to lessen the development of
parastomal hernias, there are no denitive data to support
this contention.
Asymptomatic parastomal hernias should be observed
because the rate of recurrence after repair or relocation of the
stoma is high. Patients should be counseled to seek immediate medical attention if they develop symptoms or signs of
intestinal incarceration in the hernia. Symptomatic hernias
may be relocated or repaired, although no technique has
proven to be reliably successful. Local suture repair often fails,
and although broad fascial mesh repair appears to be a more
rigorous method of repair, there is still a substantial risk of
recurrence and the added concern of mesh infection. Laparoscopic repair with intraperitoneal mesh is being used more
frequently, although it would appear to oer no advantage
over open mesh repair other than a potential reduction in
wound complications and short-term postoperative recovery.
Some surgeons are placing mesh in the abdominal wall at
the time of permanent stoma creation as prophylaxis against
hernia formation, but the experience is too preliminary to
make denitive assessments of the safety and ecacy of this
technique.
COLOSTOMY PROLAPSE
Prolapse of the colostomy is seen most often with the transverse
loop colostomy. is is probably the result of several factors,
most prominent being the lack of xation of the transverse
mesocolon to the retroperitoneum, and the size of the fascial
opening necessary to bring both limbs of the colon and the
mesocolon to the skin level. If the transverse loop colostomy
is constructed to decompress a dilated colon, the fascial opening may need to be large initially, and then be excessive once
the colon decompresses and thus predispose the colostomy
to prolapse later. e surgical treatment of transverse loop
colostomy prolapse is dicult, and the best treatment is to
rid the patient of the primary disease and restore intestinal
continuity. If this is not possible, the loop colostomy should
be converted to an end colostomy with mucous stula, or a
divided end-loop colostomy, with concurrent tightening of
the fascial defect.
Prolapse of an end colostomy can be managed by a local
procedure in which the mucocutaneous junction is disconnected, the redundant colon resected, and the mucocutaneous
junction recreated. Concurrent hernia repair can be performed
as indicated.
COLOSTOMY PERFORATION
Perforation of the colon just proximal to the stoma most often
occurs during careless irrigation with a catheter or during
contrast x-ray studies when a catheter is placed in the colostomy and a balloon is inated. is occurrence represents a
surgical emergency and must be dealt with by laparotomy
and reconstruction of the colostomy with adequate drainage,
if there is signicant fecal or barium contamination. Cases
of mild inammation with extravasation of air can only be
managed with antibiotics and localized drainage, and surgery
can be avoided.
ILEOSTOMY
An ileostomy is an opening constructed between the small
intestine and the abdominal wall, usually by using distal ileum,
but sometimes more proximal small intestine. e stoma is
constructed on a permanent basis for patients who require
removal of the entire colon, and usually the rectum, for inammatory bowel disease, either Crohn’s disease or ulcerative colitis. e use of a loop ileostomy is becoming more frequent
because of the complex sphincter-preserving operations being
Chapter 9 Intestinal Stomas 175
performed for ulcerative colitis, familial polyposis, and rectal
cancer. For these operations, it is necessary to have complete
diversion of intestinal ow while the distal anastomosis and
neorectum are allowed to heal and adapt. e loop ileostomy
is also useful in cases where multiple or complex anastomoses must be performed distally, usually for Crohn’s disease or
diverticulitis. As sphincter- preserving operations are used more
often, diminishing numbers of permanent ileostomies will be
constructed, but similar principles and techniques will be utilized in constructing the temporary loop ileostomies. e same
principles used in constructing an ileostomy can be applied to
the construction of a urinary conduit.
e surgical construction of an ileostomy must be more
precise than that for a colostomy because the content is liquid, high volume, and corrosive to the peristomal skin. erefore, the stoma must be accurately located preoperatively, and
it must have a spigot conguration to allow an appliance to
seal eectively and precisely around the stoma.
Various types of ileostomies can be constructed. e most
common has been the end ileostomy, using a technique
popularized by Brooke and Turnbull. e loop ileostomy is
used, as described, to divert stool away from diseased areas
or surgical anastomoses distally. e loop-end ileostomy is
a stoma that uses the principles of a loop ileostomy but is
constructed as a permanent stoma when the mesentery and
its blood supply need special protection. e continent
ileostomy, a technique devised by the Swedish surgeon, Nils
Kock, is an internal pouch that does not require the wearing
of an external appliance. e urinary conduit is a stoma constructed of small intestine to provide a conduit to the outside
for the urinary tract.
Determination of Ileostomy Location
e location of the ileostomy must be carefully chosen before
surgery (Fig. 9-6). It should avoid any deep folds of fat, scars,
bony prominences of the abdominal wall, the inguinal folds,
and the waistline crease. e site is chosen by drawing a vertical line through the umbilicus and a transverse line through
the inferior margin of the umbilicus and applying a disk the
size of a stoma faceplate (approximately 8 cm in diameter) to
determine the location. e disk is allowed to abut on both
of the lines in the right lower quadrant, and the site is marked
with ink. e patient is then brought to an exaggerated sitting
position and allowed to turn in various directions to be sure the
site is adequate in all positions, and there are no creases or skin
folds created by changes of position. If so, the location should
be adjusted to bring the stoma to the summit of the infraumbilical fat fold to be sure that there is clearance for tting of
an appliance. When the patient is in the operating room and
anesthesia has been administered, the chosen site is scratched
with a ne needle before preparation of the abdominal skin is
carried out. e majority of complications arising from ileostomies can be avoided by taking these precautions in marking
the site for the stoma preoperatively. Even in cases in which the
use of a stoma seems remote, the precaution of marking the site
preoperatively should be taken. In addition, whenever possible,
patients should be seen by a CWOCN and an ostomy visitor so
that they can be given information about the stoma and its care.
e visit from an ostomate (someone who has done well with
a similar stoma) is helpful because it allows the patient to know
that the surgery can be survived and that life can be continued
productively and normally with the presence of a stoma. e
discussion should avoid excessive details about types of equipment and types of stoma problems during the postoperative
period, as this information can be overwhelming to a patient
facing complex surgery, often life-threatening disease processes,
and the concept of having a stoma.
When an ileostomy is anticipated, the choice of abdominal
incision is a left paramedian skin incision, slanting the incision
to the midline fascia (Fig. 9-6A). is gives the advantage of
opening the fascia through the midline to provide a simple,
eective closure and at the same time preserve all the right
lower quadrant peristomal skin for maintenance of the
appliance seal.
End Ileostomy
e construction of the ileostomy begins early in the operative procedure. When the colon is mobilized for colectomy,
as is the usual case when an ileostomy is to be constructed,
full mobilization of the mesentery of the distal ileum should
be carried out (Fig. 9-6D). is is an important and often
neglected part of the procedure. ere is an embryonic fusion
plane of the mesentery of the small intestine to the right posterior abdominal wall. e ileum can be elevated on this mesentery up to the duodenum, allowing extreme mobility of the
terminal ileum. e ileocolic artery is then transected as part
of the colectomy, and the remaining blood supply to the small
intestine is preserved (Fig. 9-6C). It is important to preserve
the most distal arcade of vessels and mesenteric tissue on the
ileum at the segment of the intended ileostomy. is blood
supply is prepared early in the operative procedure so that if
there is any question about the vascularity of the distal ileum,
it will be known long before the abdomen is closed. e preservation of this distal bit of mesentery and fat on the ileum
sometimes appears to cause excess bulk around the ileostomy,
but this fat soon atrophies, allowing a well-vascularized stoma
of appropriate size. e intestine is transected with a linearcutting type of stapling instrument so that the end of the
ileum can be easily pulled through the abdominal wall without increased risk of contamination. is can, of course, also
be accomplished by suturing the end of the ileum.
When the intestinal resection has been completed, an opening is prepared in the right lower quadrant of the abdominal
wall at the previously marked site (Fig. 9-6B). It is important
to return the abdominal fascia to its natural position prior to
making the stoma opening so that the fascia does not impinge
upon the stoma when closed. is is of signicant concern
during situations when a Pfannensteil incision is used to
accomplish the colectomy, as is common with hand-assisted
laparoscopic colectomy. e round conguration of the stoma
176 Part II Abdominal Wall
RLQ site
A
MC
Fascia
Line of separation
Rectus muscle
Abdominal
incision
Peritoneum
B
RC
ICA
SMA
D
TC
C
Embryonic
fusion
plane
I
D
D
TC
I
Plane of dissection
FIGURE 9-6 General considerations in construction of an ileostomy. A. Locating the ileostomy site and the use of a paramedian skin incision that
slants to the midline fascia, allowing preservation of the peristomal skin. B. Technique for making the abdominal wall opening. C. Vascular supply
of the distal ileum, which must be used to maintain viability of the ileostomy. (MC, middle colic artery; RC, right colic artery; ICA, ileocolic artery;
SMA, superior mesenteric artery.) D. Plane of mobilization of the distal ileum to allow construction of an ileostomy without tension. (P, pancreas;
D, duodenum; TC, transverse colon; I, ileum.)
is maintained by placing traction clamps on the dermis, fascia,
and peritoneum. A 3 cm disk of skin is excised, and a longitudinal incision approximately 3–4 cm long is made through
all layers, with each layer being retracted with small retractors
as the incision is deepened. Ifthe patient is obese, some fat
can be excised, although this is not mandatory. e fascia is
incised longitudinally as well, and frequently a small lateral
notch is placed on each side. e muscle is separated, and any
vessels are coagulated. e posterior fascia and peritoneum are
then incised.
Chapter 9 Intestinal Stomas 177
A
Mesentery sutured to
peritoneal surface of abdomen
C
B
Ileum opened
D
Three-point sutures
(Full thickess ileumileal serosa - dermis)
E
FIGURE 9-7 Construction of an end ileostomy. A. e distal arcade of vessels and some mesentery are preserved on the segment to be used for
ileostomy construction. B. e closed ileum is pulled through the abdominal wall to a length of 6 cm. C. e mesentery of the ileum is xed to the
abdominal wall. D. e adequacy of the blood supply is veried. E. e spigot conguration is achieved by placing sutures to include full thickness
of intestine, the seromuscular layer at the base of the stoma, and the dermis.
178 Part II Abdominal Wall
e size of the stoma opening should be approximated
based on estimates of the diameter of the intestine and
mesentery to be brought through, and the thickness of the
abdominal wall. e geometric shape of the stoma opening
should also be determined by these factors. If the abdominal
wall is thin, the opening in the abdominal wall can be cylindrical. If the abdominal wall is thick, the shape of the incision
should be pyramidal, with the fascial opening larger than the
skin opening to accommodate the amount of mesentery that
will be brought through at the fascial level. e oft-used “two
nger” rule to gauge the size of the stoma opening is usually
not adequate to account for all of the above considerations.
e ileum is brought through the abdominal wall to the
intended length, usually about 6 cm (Fig. 9-7B). If the abdominal wall is thick, this maneuver may be dicult to accomplish. It
may be helpful to use a small plastic wound protector/retractor
through the stoma to facilitate passage of the intestine through
the abdominal wall. Alternatively, the fat and skin can be raised
o of the fascia as a ap, the intestine brought through the
muscle and fascia rst, and then subsequently brought through
the fat to skin level. e mesentery of the distal ileum may be
sutured to the right lateral abdominal wall, although there are
no data to prove that this maneuver reduces the incidence of
intestinal obstruction, stoma prolapse, or stoma retraction.
e abdomen is then closed. e incision is protected, and
attention is directed to the ileostomy where the staple line or
suture line is excised, verifying the adequacy of blood supply.
If the blood supply of the stoma is questioned, more of the
ileum should be resected.
e next objective is to make a protruding, everting stoma.
is is accomplished by placing 3-0 chromic catgut sutures
through the full thickness of intestine, the seromuscular area of
the ileum at the base of the stoma, and the dermis (Fig. 9-7E).
Sutures through the skin should be avoided, because any stellate scarring will prevent the maintenance of the required seal
of the appliance. Eight of these sutures should be placed, one
in and one between each quadrant; and as traction is applied
after they are all placed, the stoma should evert nicely.
After the stoma is completed, an ileostomy appliance is
applied. A simple appliance in which the skin barrier can be
cut to the size of the stoma is best. In the immediate postoperative period, if there is any question about leakage around
the appliance or maltting of the appliance, it should be
changed and the skin cleaned immediately. It is important
to preserve the integrity of the peristomal skin, and all the
nursing sta should be aware of the importance of this. e
leaking appliance should not be left for changing by the next
shift or for the CWOCN the next morning, because the skin
can be damaged during this waiting period.
then follow one of two techniques. e technique popularized
by Turnbull at the Cleveland Clinic involves choosing the
site in the intestine for the intended loop ileostomy and then
placing orienting sutures proximally and distally (Fig. 9-8A).
A loose suture with one knot can be placed proximally and
A
Two-point
sutures
Three-point
sutures
Loop Ileostomy
e loop ileostomy stoma is constructed when both diversion
of the intestinal ow and decompression of the distal intestine are required. e location is chosen exactly as one would
choose the site for an end ileostomy. e construction can
B
FIGURE 9-8 Construction of a loop ileostomy. A. A tracheostomy
tape is placed at the segment for the intended ileostomy with sutures
to identify proximal and distal limbs. B. e loop is pulled through the
abdominal wall while its proper orientation is maintained. e tape is
replaced by a plastic rod, and the spigot conguration is completed.
Chapter 9 Intestinal Stomas 179
one with two groups of knots distally. It is important to maintain this orientation as the stoma is constructed.
e opening in the abdominal wall is made the same as
for an end ileostomy (Fig. 9-6B), but the loop of intestine
is drawn through this abdominal opening by a tape placed
through the mesentery and around the intestine (Fig. 9-8A).
Some surgeons recommend orienting the proximal functioning loop in the inferior position, placing a partial twist on
the loop of intestine. Although this may help congure the
spout of the ileostomy so that ileal euent is less likely to
undermine the appliance, this maneuver may be associated
with a higher rate of intestinal obstruction. In massively obese
patients with a shortened mesentery, it is necessary to make
a pyramidal conguration of the opening in the abdominal
wall, with the internal opening being much larger than the
external opening at the skin. If this maneuver is used, it is
best to place a row of tacking sutures between the peritoneum and the loop of intestine to maintain position and
orientation. Once the loop is drawn through the abdominal
wall, the abdomen is closed, maintaining the orientation of
the loop. It is usually not necessary to x the mesentery of
the ileum to the abdominal wall when constructing a loop
ileostomy. e wound is then protected, and attention is
directed to the stoma.
e tape is replaced by a small plastic rod, which is
commercially available (Fig. 9-8B). It is not sutured to
the peristomal skin, but it often has a heavy suture tied
around each side so that should the rod dislodge, it can
be drawn back through the mesentery rather than being
pushed through, with risk of injuring the mesentery. e
loop of intestine is opened by making a four-fths circumferential incision at the distal aspect of the loop, allowing
1 cm of ileum above the skin level in the superior aspect
(Fig. 9-8B). e recessive limb thus is formed distally, and
sutures are placed between the full thickness of ileum and
dermis at this level. As the proximal aspect of the stoma
is constructed, sutures are placed as previously described
between the full thickness of ileum, the seromuscular
area at the base of the stoma, and the dermis. As these
sutures are tied, the stoma should assume a spigot conguration supported by the rod. e ileostomy appliance
may be placed beneath the rod or over the rod, depending
on the tension of the mesentery. e rod is left in place
for 1 week, and the same ileostomy care is provided as
previously described.
Another technique for constructing a completely diverting
ileostomy is to use the divided end-loop method popularized
by Abcarian and Prasad (Fig. 9-9). is technique involves
transecting the ileum with a linear-cutting stapling instrument. No compromise of the mesentery is involved. e
opening in the abdominal wall is made in identical fashion
to that previously described, but when the intestine is pulled
through, the proximal component is excised, and the stoma
is constructed as previously described for an end ileostomy.
e recessive limb at the base of the stoma has one corner
of the staple line excised, and the full thickness of ileum is
sutured to the dermis at the superior aspect of the stoma.
is allows a small recessive limb that serves to decompress
the distal intestine.
If a loop ileostomy cannot be brought to skin level because
of obesity and/or tension on the mesentery (a situation most
often encountered following restorative proctocolectomy), it
may be helpful to create a divided end ileostomy to achieve
more length. e ileum at the site chosen for ileostomy is
divided and the proximal end brought out as an end stoma.
e distal end is left closed in the peritoneal cavity or abdominal wall. is maneuver will sometimes result in formal
laparotomy being required to close the stoma, but is a better
alternative than a ush ileostomy.
CLOSURE OF LOOP ILEOSTOMY
When endoscopic procedures and contrast studies have
shown that the pouch is intact or that the distal anastomoses
have healed securely, consideration can be given to closing
the loop ileostomy. If the primary procedure has involved the
anal sphincter mechanism, careful physical examination and
manometric studies should verify the adequacy of sphincter
function before intestinal continuity is restored.
For closure of the loop ileostomy (Fig. 9-10), a circumferential dissection is carried out, with a minimal rim of skin included,
until the peritoneal cavity is entered and clean peritoneal surface
of abdominal wall can be palpated circumferentially. Once this
is accomplished, the loop of intestine can usually be brought
easily through the circular incision in the abdominal wall. Closure is completed by excising the rim of brous tissue, with care
being taken to preserve as much of the viable intestinal wall as
possible (Figs. 9-10B and 9-10C). e choice of closure then
varies between hand-sutured transverse closure (Figs. 9-10D
and 9-10E), stapled transverse closure (Figs. 9-10F and 9-10G),
or formal construction of an anastomosis.
For closure of the separated (divided end-loop) ileostomy
(Fig. 9-11), the mobilization is carried out in similar fashion,
and a functional end-to-end closure is performed. A linearcutting stapler is applied and removed, and the enterotomy
is closed transversely. e intestine should be rotated so that
antimesenteric surfaces are used for the staple line.
After intestinal continuity is restored, the abdominal wall
is closed. Because of the risk of skin infection, many surgeons
are reluctant to close the skin primarily. Rather, the skin defect
can be handled by a number of alternative methods: closure
over a drain; partial closure in linear fashion; or partial pursestring closure.
LOOP-END ILEOSTOMY
A loop-end ileostomy should be constructed in the rare circumstances in which it is unsafe to resect the mesentery of the
distal ileum or when there is tension created on the mesentery
as the ileum is brought to the abdominal wall for construction
of the ileostomy. is occurs in the patient with a thickened
mesentery or a very obese abdominal wall, or in a patient
who has had multiple surgical procedures that altered the
mesentery. ese conditions preclude dealing with the usually
180 Part II Abdominal Wall
A
Distal
Proximal
B
D
C
Two-point
sutures
Three-point
sutures
E
FIGURE 9-9 Construction of a separated (divided end-loop) ileostomy. A. e distal ileum, but very little of the mesentery, is transected, using
a linear-cutting staple device, in preparation for constructing the ileostomy. B, C. e proximal, functioning component is brought through for
spigot construction, whereas only the corner of the distal component is brought through. D. e entire staple line of the proximal component and
a corner of the distal component are excised. E. e functioning spigot and nonfunctioning recessive opening are completed.
Chapter 9 Intestinal Stomas 181
B C
A
E
Suture closure
D
Staple closure
F
G
FIGURE 9-10 Closure of a loop ileostomy. A. A circumferential incision is made and carried into the peritoneal cavity. B. e loop of intestine
is completely mobilized. C. e brofatty tissue is completely excised, preserving all the intestine. D, E. A suture closure can be performed, or a
transverse stapled closure (F, G ) can be performed.