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182 Part II Abdominal Wall
A
D
B
C
E
F
Staple lines offset
G
H
FIGURE 9-11 Closure of a separated (divided end-loop) ileostomy. A. A circumferential incision is made and carried into the peritoneal cavity.
B, C. e stoma site and residual staples are excised. D. A linear-cutting stapler is applied to the antimesenteric side of the intestine. E, F. e
components of the staple line are oset. G, H. e functional end-to-end closure is completed with a linear stapling instrument.
pliable mobile tissue. is technique is especially useful in the
obese patient who requires construction of a urinary conduit
after cystectomy and radiation. e technique is especially
helpful because a supporting rod can be placed beneath the
stoma for 1 week to help avoid retraction through a thick
abdominal wall (Fig. 9-12).
Constructing a loop-end ileostomy involves transecting
the ileum as previously described, but the closed end will
remain closed (Fig. 9-12A). e staple line is inverted with
seromuscular sutures, or if it is to be used for a urinary conduit, only absorbable sutures are used to close the end of the
ileum, because stone formation has been reported around
staples (Fig. 9-12B). e orienting sutures are then placed as
described for construction of a loop ileostomy, and a tracheostomy tape is placed so that when the loop of ileum is pulled
through the abdominal wall, the closed recessive end will be
superior and just within the abdominal cavity (Fig. 9-12C).
e construction of the loop-end stoma then proceeds exactly
Chapter 9 Intestinal Stomas 183
Distal
B
Loop
Oversewn end
A
C
Mesentery sutured to
peritoneal surface
E
D
Two-point
sutures
Proximal
Three-point
sutures
F
FIGURE 9-12 Construction of a loop-end ileostomy. A. A tracheostomy tape is placed around the loop of intestine, with the mesentery mobilized
but completely preserved. B. e end of the ileum is inverted. C. e intestine is pulled through the abdominal wall so that the functional limb
will be in the inferior position, and the closed end is allowed to reside just within the abdominal cavity. D. e mesentery of the ileum is xed to
the abdominal wall because this is meant to be a permanent stoma. E. e tracheostomy tape is replaced with a small plastic rod. F. e stoma
construction is completed exactly the same as described for a loop ileostomy.
184 Part II Abdominal Wall
as that described for the loop ileostomy (Figs. 9-12D, 9-12E,
and 9-12F). However, in the case in which the stoma will be
permanent, the mesentery of the distal ileum is xed to the
abdominal wall (Fig. 9-12D). If the stoma will be used as a
urinary conduit, the loop of the conduit should be brought
through the abdominal wall before the ureteral anastomoses
have been carried out. It is a disconcerting problem to have
the ureters xed and then nd there is an inadequate length
of ileum to bring through the abdominal wall. It is also easier
to place the ureteral stents when the construction is done in
this fashion.
A special problem has been found in patients with a
loop-end ileostomy in that there continues to be mucus
secretion from the recessive limb, and after a period of several
months, this secretion may interfere with the perfect seal of
the ileostomy appliance. If interference does occur, it may be
necessary to resect the distal limb and convert the stoma to
a proper end ileostomy. is is a small price to pay, however,
because it is an easy operation to remove the recessive limb,
and it can be done without opening the abdominal cavity. Of
more importance is the fact that the loop conguration during the initial procedure has allowed maintenance of blood
supply and a protruding conguration under circumstances
in which this otherwise may have been impossible, and that
would have resulted in major complications.
POSTOPERATIVE CARE OF ILEOSTOMIES
e components of an ileostomy appliance are a skin barrier
with a faceplate, and a drainable pouch. Most ileostomy
appliances are now commercially available as one-piece or
semi-disposable two-piece units. e one in common use has
a skin barrier with a xed plastic ange (ring) so that the
stoma opening can be cut precisely, the skin barrier applied,
and the pouch snapped directly onto the plastic ange, thus
allowing easy drainage and disposal of the pouch part of the
appliance. e skin barrier component should need changing
only every 4–5 days in a patient with a properly protruding
and located stoma. A well-constructed ileostomy should allow
the patient to display normal physical vigor, to eat a wellbalanced palatable diet, and to engage in normal recreational
and sexual activity. ere should be no prolapse or retraction,
the skin should remain normal, and the appliance should not
leak. When rst constructed, ileostomy output typically averages 1500 mL per day of liquid euent, but after adaptation
occurs, between 500 mL and 800 mL of thick liquid content
should be passed per day.
ILEOSTOMY COMPLICATIONS
Before the concept of stoma eversion was conceived, in
approximately 1960, the majority of patients who underwent construction of an ileostomy had serious postoperative
complications, usually related to serositis, which caused a
partial obstruction at the stoma itself. ese patients suffered massive uid and electrolyte imbalance and often
death, which were related to the enormous sequestration of
uid secondary to the small bowel obstruction. is condition was called “ileostomy dysfunction” and was anticipated
after the construction of each stoma. is devastating problem essentially has been eliminated, since stomas have been
opened and everted immediately at the time of construction.
e output of an ileostomy should thus not be excessive,
even in the immediate postoperative period.
Patients with ileostomies do have problems, most often
related to maintenance of the seal of the appliance because
of poor location or defective conguration of the stoma. In
some cases, it is necessary either to revise the stoma locally
to bring it into a spigot conguration, or to relocate it so an
appliance can be securely applied. e most common problem
experienced by ileostomy patients is chemical dermatitis. is
can be prevented by proper stoma construction techniques,
and by obtaining a pouching system that is properly sized and
adherent. If the patient has a poorly constructed stoma, or a
poorly tting appliance, destruction of the peristomal skin can
be so severe as to require split-thickness skin graft for denitive management. In these cases and in others in which the
skin is injured around the stoma, a special ileostomy appliance
may be utilized. It is based on maintenance of the seal to the
mucosa of the ileum rather than to the peristomal skin. is
appliance is used infrequently, when it is the only solution to
complicated peristomal skin problems. Its use requires wearing supportive belts to maintain the appliance in place, but the
skin can be treated with medicated pads during this period.
Another potential complication of ileostomy is dehydration. In patients with newly constructed ileostomies, the
output of intestinal contents is frequently high enough that
patients will require intravenous uid administration until the
stoma output decreases and the patient can compensate with
adequate oral intake of uids and electrolytes. One of the
early symptoms associated with dehydration is nausea, which
further exacerbates the problem as patients are loath to drink
uids. is problem not infrequently results in readmission
to the hospital following major intestinal surgery accompanied by ileostomy formation. Patients should be counseled
prior to discharge regarding the signs and symptoms of dehydration, and to intervene early with increased oral intake of
uids. Patients with long-term ileostomies are also at risk
of becoming dehydrated, which occurs in hot weather and
during strenuous physical activity. e individuals should be
instructed to maintain adequate intake of uids and electrolytes. ey should routinely have medications on hand for
simple diarrhea so that control can be achieved before dehydration occurs.
Some patients with ileostomies will present with acute
blockage of the stoma, which is usually related to food indiscretion creating a “food bolus obstruction” just proximal to
the level where the intestine exits the abdominal wall. is
complication is most common in patients with newly constructed stomas, as there is some residual edema in the tissues
which creates a relative narrowing of the ileum as it crosses
the abdominal wall. Typically, patients will have ingested
some brous food with a high residual component and will
present with crampy abdominal pain, reduced stoma output,
Chapter 9 Intestinal Stomas 185
dehydration, and vomiting. ese patients should be admitted
to the hospital and started on intravenous uid replacement.
e stoma can then be irrigated in an attempt to release the
presumed food bolus blockage. A Foley or similar catheter is
placed into the stoma, and the stoma is then irrigated gently
with warm saline. If food particles are returned from the initial
irrigation, the irrigation can be continued until stoma function
returns and the blockage is eliminated. If the return is clear, it
suggests a more proximal obstruction or an adhesive obstruction, and a water-soluble contrast study should be done for
evaluation. If the problem is food blockage, the instillation of
the hyperosmolar contrast medium often will prove therapeutic. If there is no evidence of food blockage, it should be dealt
with as an adhesive small intestinal obstruction. Figure 9-13 is
an algorithm for the alleviation of ileostomy blockage.
Some patients develop a high ileostomy output because of
dietary indiscretion, infectious disease, short bowel syndrome,
or recurrence of inammatory bowel disease. e cause must
be determined and each problem dealt with individually. It is
important to maintain uid and electrolyte balance as these
problems are being resolved. Special care must be provided for
the patient with short bowel syndrome to maintain electrolyte
balance and to compensate for the vitamin B
, calcium, and
12
fat malabsorption that occurs with absence of the distal ileum.
Another special problem that may occur with an ileostomy
is the formation of a paraileostomy stula. is usually represents recurrence of Crohn’s disease and should be dealt with
based on the extent of the Crohn’s disease. While evaluation
and treatment are being carried out, the appliance should
be modied so that the stula is allowed to drain into the
appliance, and no attempt should be made to cover the stula
opening. is is usually achieved by modication of the conguration of the skin barrier component of the appliance.
Patients and those individuals aiding in the care of the
ileostomy should be in the habit of observing the ileostomy
Ileostomy blockage
No. 24 French Foley catheter
3 mL in balloon
Irrigate with 50 mL saline
Clean return Food particles
Suspect proximal
obstruction
Water-soluble
contrast study
FIGURE 9-13 Ileostomy blockage algorithm. (Reproduced, with
permission, from Kodner IJ. Stoma complications. In: Fazio VW, ed. Current
erapy in Colon and Rectal Surgery. Philadelphia, PA: BC Decker; 1990:420–425.)
Suspect food
blockage
Continue irrigation with
warm saline until stoma
function returns
for injury. ere are no pain bers in the ileum, and it is
not unusual for a patient to lacerate the stoma with a maltting appliance without noticing the injury, especially on the
inferior aspect of the stoma.
Review of the UOA data registry overall shows a low
incidence of complications from ileostomy and an even lower
incidence of need for corrective surgery. e vast majority
of patients with conventional ileostomies lead normal lives
and rarely have a restricted lifestyle because of the stoma.
Most patients spend less than 1 hour a day dealing with their
stomas.
CONTINENT ILEOSTOMY
e continent ileostomy, or Kock pouch, has been used as an
alternative to a conventional ileostomy for selected patients
with ulcerative colitis or familial polyposis. It involves construction of an internal pouch with a continent nipple valve.
e continent ileostomy allows placement of the stoma in
an inconspicuous location and avoids the need for wearing
an appliance permanently. It does require multiple intubations of the pouch daily to allow emptying. e complication
rate for construction of this continent ileostomy has been
high because of the diculty in maintaining continence of
the nipple valve and position of the pouch so that intubation
can be easily accomplished. is operation should probably
be done only in centers where it is performed frequently
and where the complications are managed by an experienced team. e continent ileostomy can be constructed as a
primary procedure for patients with ulcerative colitis. It may
also be considered for patients who have an existing ileostomy
that malfunctions, is poorly located, or causes severe injury
to the peristomal skin because of allergic reaction to the
ostomy equipment. However, the Kock pouch has been used
infrequently as primary treatment for patients with familial
polyposis and ulcerative colitis since the advent of the restorative proctocolectomy with ileal pouch-anal anastomosis.
Most surgeons agree that the continent ileostomy is contraindicated for patients with Crohn’s disease because of the
signicant risk of recurrent disease and the potential for loss
of substantial length of intestine should the patient require
pouch excision. It is also not to be recommended for patients
who have a well-functioning end ileostomy.
e advantages of continent ileostomy are that a patient
need not wear an appliance, the patient is continent
between intubations, and she or he may experience a better
quality of life than if they had a conventional ileostomy.
e disadvantages are that not all patients are continent,
it does require multiple intubations during the day, there
can be diculty in intubation, and the surgery is prolonged and carries a substantial risk of complications. If
the procedure fails, the individual will lose a signicant
amount of small intestine. Also, psychological factors may
have been involved in the original motivation for choosing
the internal ileostomy that are not alleviated by the more
complicated surgical procedure.
186 Part II Abdominal Wall
Construction of Continent Ileostomy
e construction of an intestinal reservoir for feces was rst
described in 1967 by Nils Kock. His original description of
a U-shaped pouch was based on the theory that interruption
of coordinated peristalsis would enhance capacity. Since then,
J- and S-shaped pouches have been used with similar results.
An S-shaped pouch is described here.
e construction of a continent ileostomy, or Kock pouch,
can be broken into four components: (1) the creation of a
pouch, (2) the creation of a nipple valve, which provides continence, (3) the suspension of the pouch from the abdominal
wall in such a way as to prevent slippage of the nipple valve,
and (4) the creation of a stoma.
e terminal ileum should be transected as close to the
cecum as possible (Fig. 9-14A). e S-shaped reservoir is fashioned from a 30 to 45 cm segment of distal ileum, starting
15cm from the cut end (Fig. 9-14B). e last 15 cm is used
for the outlet (5 cm) and nipple valve (10 cm). e intestine
is tacked in place in the shape of an S, using interrupted seromuscular sutures of 2-0 polyglycolic acid placed at the edge of
the mesentery. Each limb of the S should be 10–15 cm long.
eintestine is opened along the entire portion of the S, with
the surgeon taking care to incise close to the mesenteric border
on the outer limbs of the S and exactly at the antimesenteric surface of the central limb. A single-layer continuous suture line of
2-0 synthetic absorbable suture is rst placed between the two
walls of the central limb and the inner walls of thetwo outer
limbs (Fig. 9-14C). e sutures that begin on the posterior wall
continue onto the anterior wall as the suture line reaches the
outer wall of each of the two outer limbs of the S. e anterior
wall is completed by continuing the suture from each direction,
using an inverting full-thickness technique (either “baseball”
or Connell) until the sutures meet in the middle. Before the
pouch is closed, the nipple valve must be constructed.
e 15 cm of ileum distal to the pouch will become the
nipple valve and stoma. Prior to the completion of the anterior
wall suture, with the pouch mostly open, the nipple valve is
made by intussuscepting the ileum into the pouch (Figs.9-14D
and 9-14E). A Babcock clamp is passed into the distal ileum
from within the pouch and is closed onto the full thickness of
the bowel at a point 5 cm from the pouch. e clamp is drawn
into the pouch, intussuscepting the bowel on itself to form the
nipple valve. e valve is maintained in this position by placing
a line of staples on either side of the mesentery and a third row
of staples on the antimesenteric aspect (Fig. 9-14F). Occasionally it is possible to place four staple lines equidistant around
the circumference of the nipple valve(Fig. 9-14G). A linearcutting stapling instrument with the cutting blade removed is
used to place the staple lines. One arm of the instrument is
inserted into the lumen of the nipple from within the pouch
before closing and ring the instrument. ese staple lines
make a serosa-to-serosa xation of the nipple valve and prevent
its unfolding. e anterior wall of the pouch is then completed
as previously described (Fig. 9-15A). A 5 cm outlet of distal
ileum remains that will pass through the abdominal wall and
allow construction of a ush stoma.
e right lower quadrant stoma site is created as described
earlier in this chapter, with the opening placed below the belt
line and within the rectus muscle. Before the outlet is passed
through the abdominal wall opening, a sling of soft synthetic
mesh (1 × 10 cm) is passed through a window made in the mesentery of both the pouch and nipple valve under the major vessels as they fold into the nipple valve mesentery (Figs. 9-15B and
9-15C). e strip of mesh maintains the nipple conguration
and helps secure the pouch to the abdominal wall. Seromuscular
absorbable sutures are used to x the mesh to the base of the
outlet (Fig. 9-15D). e two ends of the sling are left long
because they are sutured together at the antimesenteric surface
of the outlet. is facilitates delivery of the outlet through the
stoma site and allows a securing suture of nonabsorbable material to be placed through the sling into the anterior fascia. As the
outlet is readied to be drawn through the abdominal wall, a row
of three untied seromuscular sutures is placed on the shoulders
ofthe pouch medial and lateral to the outlet (Fig.9-15E). ese
sutures, incorporating the posterior fascia and peritoneum, are
used to x the pouch to the anterior abdominal wall. e outlet is delivered through the stoma site and the pouch is drawn
toward the abdominal wall. e sutures are then tied, rst laterally and then medially (Fig. 9-15F). A permanent securing
suture is placed through the tails of the sling and the anterior
fascia, and the ends of the mesh are trimmed.
If possible, the cut edge of the small intestine’s mesentery
is sutured to the anterior abdominal wall (Fig. 9-15F). A continuous suture is placed from the outlet of the pouch to the
falciform ligament. e pouch in its nal position should
rest at the right pelvic brim, with the antimesenteric surface
(anterior wall) of the pouch directed inferiorly.
e terminal ileum at the outlet should be excised at skin
level (Fig. 9-15G). e stoma is nally completed by absorbable sutures between the subcuticular layer of the skin and the
full thickness of the intestinal wall (Fig. 9-15H). A Medina
catheter is passed through the stoma into the pouch and is
secured to the skin to prevent slippage of the tube into or out
of the pouch (Fig. 9-15I). ere should be minimal resistance
and no deviation from a straight passage. e pouch should
be drained in this manner for 2 weeks before intermittent
clamping is begun during the third week. Finally, the pouch
should be extubated and reintubated every 4 hours until the
intervals gradually increase to 6 or 8 hours.
e nipple valve provides increasing continence as pressure rises in the pouch. Should the nipple valve lose its
conguration and prolapse or should it slip through the
mesenteric aspect of the pouch (the weakest point), either
incontinence or obstruction will result. ese two problems,
along with “pouchitis,” are the most common complications
following the continent ileostomy procedure. As a result,
many variations of pouch construction have been used in
attempts to prevent or correct these problems.
If a stula should form from the nipple valve or if the
nipple valve should slip, it may be possible to preserve the
pouch and construct a new nipple valve (Fig. 9-16). e
technique involves resecting the pouch outlet, including
the nipple valve, after fully mobilizing the pouch from the
Chapter 9 Intestinal Stomas 187
bb
b-b
Line of
incison
cc
a-a
A
Division of ileum and mesentery
B
Closure of
posterior wall
c c
aa
Intussusception
5 cm
C
Construction
of nipple
valve
D
E
F
Staple
G
Mucosa
Mesentery
FIGURE 9-14 Construction of a continent ileostomy. A. e colectomy should be completed with as much distal ileum preserved as possible.
B. Alignment of the components of the S-shaped pouch and nipple valve and the line of incision to open the pouch. C. e pouch construction
is begun with continuous 2-0 synthetic absorbable suture material. D. e anterior wall of the pouch is formed by continuous suture from each
corner, and the nipple valve is constructed before complete closure of the pouch. E. e ileum is intussuscepted to form the 5 cm long nipple valve.
F, G. e intussusception is maintained by placement of multiple lines of staples adjacent to the mesentery and on the antimesenteric borders.
188 Part II Abdominal Wall
Catheter
Medial Lateral
Suture lines
Mersilene collar
B
A
Collar in place
C
Anterior wall
closure
Mesenteric ‘window’
Mersilene
Medial
suture line
F
E
Mesenteric
closure
G
Collar tucked
inside shoulder
of pouch
D
H
I
FIGURE 9-15 Completion of the continent ileostomy. A. e anterior wall of the pouch is completed. B. A band of soft synthetic mesh
(1 × 10 cm). C. e mesh collar is placed through the mesentery of the pouch and nipple valve around the valve. D. e mesh collar is sutured
to the nipple valve and to the shoulders of the pouch. E. Fixation sutures are placed between the shoulders of the pouch and the abdominal wall.
F. e pouch is secured to the abdominal wall. G. e terminal ileum of the outlet is excised at skin level. H. e stoma is completed by placing
sutures between full thickness of intestine and dermis. I. e Medina catheter is replaced in the completed pouch and is secured to the skin.
Fistula
tated pouch
Chapter 9 Intestinal Stomas 189
Outlet removed
Unfolded
nipple valve
B
15 cm
A
Ileal
transection
C
Intussusception
on new nipple valve
Ileum sutured
Old outlet site
D
180 degrees pouch rotation
to ro
E
Nipple valve
F
Staple fixation on nipple valve
FIGURE 9-16 Preservation of the continent ileostomy after stula formation or loss of the nipple conguration. A. Fistula between skin and
nipple value (left) and slipped nipple value (right). B. e faulty nipple valve and outlet are excised. C. e distal ileum is transected 15 cm proximal to pouch, leaving enough intestine to reconstruct the valve and stoma. D. e pouch is rotated 180 degrees, and the intestine is anastomosed
to the pouch through a second enterostomy. E, F, G. e nipple valve is reconstructed as before, through the enterotomy made by resecting the
old valve.
190 Part II Abdominal Wall
above, and the stoma is constructed (Figs. 9-16H and 9-16I).
e pouch should be protected by constant drainage through
an indwelling Medina catheter for at least 1 week. Because
the pouch will not require expansion and the patient will not
need education, the prolonged period of progressive clamping should not be necessary.
G
Mersilene collar
affixed and stoma
completed
H
Completed pouch
I
and stoma
FIGURE 9-16 Continued—H, I. e pouch is xed to the abdominal
wall, and the stoma is completed.
abdominal wall and pelvis (Fig. 9-16B). e terminal ileum
is transected 15 cm proximal to the pouch (Fig. 9-16C). e
pouch is then rotated 180 degrees on its mesentery (Fig.
9-16D). A new nipple valve is created as previously described
by intussuscepting the new outlet on itself and placing staple
lines along the valve to secure the fold (Figs. 9-16E, 9-16F,
and 9-16G). e opening in the pouch wall created when
the old outlet was resected serves as the entry to the pouch
to perform this maneuver. e proximal ileum’s cut edge is
then anastomosed to the pouch through a second enterotomy
in a position that allows the pouch to lie comfortably in the
right lower quadrant as before (Fig. 9-16D). If at all possible,
the existing stoma site should be preserved and reused. e
pouch then is resuspended by using a mesh sling as described
URINARY CONDUIT
e urinary conduit is constructed of a segment of intestine
with well-maintained vascularity so that it can be connected
to the urinary tract to allow egress of urine through the
abdominal wall via a stoma constructed exactly like an ileostomy. It is not intended to have any type of reservoir capacity
but merely to provide an open conduit. is urinary conduit
is constructed most often after removal of the urinary bladder
for invasive cancer. It is also used for management of severe
obstructive uropathy, the congenital abnormalities of spina
bida, meningomyelocele, or bladder exstrophy, and for
trauma to the spinal cord resulting in a severely neurogenic
bladder. e incidence of this surgery for congenital and
traumatic disorders is decreasing as other means of emptying
the bladder are devised. e cystectomy, construction of the
urinary conduit, and ureterointestinal anastomosis are most
often carried out by urologists, but the construction of the
stoma, as well as restoration of intestinal continuity, may be
done by a surgeon more experienced in intestinal and stoma
surgery.
e basic principles of construction of the conduit and
stoma involve isolation of a segment of intestine, with maintenance of the mesenteric blood supply and enough mobility
to allow the distal end to be used as a stoma and the proximal end to serve as the site for ureteral implantation. It is
most important to maintain the isoperistaltic direction of the
intestine, especially if the conduit is constructed of sigmoid
colon. e conduit must not be made of irradiated bowel,
even if this requires using either colonic or proximal small
intestinal conduits. If the stoma is improperly constructed,
there may be a stasis of urine, resulting in reux and damage
to the proximal tract.
e surgical technique consists of choosing a long enough
segment of small intestine to allow the stoma to be constructed at the level of the abdominal wall and still allow the
proximal end to reach close enough to the retroperitoneum
to preclude tension on the ureterointestinal anastomoses
(Fig. 9-17). Usually, 18–20 cm of intestine is enough, but
this must be modied if there is a shortened mesentery or
a massively obese abdominal wall. It is in these latter situations that the loop-end stoma, supported over a small rod,
can be advantageous. After the segment of intestine is chosen,
the mesentery at the distal point is incised to allow enough
mobility for reaching the abdominal wall. e mesentery at
the proximal site of transection is incised only in a limited
fashion, and care must be taken to preserve a generous blood
supply (Fig. 9-17A). Intestinal continuity is restored, with the
intended conduit positioned posterior to the restored intestine
Chapter 9 Intestinal Stomas 191
Mesenteric-peritoneal
closure
Ureteral implant
sites
A
Ileal anastomosis
18 to 20 cm
C
D
Three-point sutures
Ureters
Completed ileal
anastomosis
Stents
Ureters Suture closure
B
of ileal segment
Stoma
E
Ureteral implantation
FIGURE 9-17 Construction of a urinary conduit. A. An 18 to 20 cm segment of distal ileum is taken out of continuity, and the blood supply
is carefully preserved. B. Intestinal continuity is restored, and the intended conduit located posterior to the restored intestine. C. e ureteral
conduit anastomoses are completed. D. e stoma is constructed with a spigot conguration. E. Stents are placed through the completed ureteral
anastomoses.
(Fig. 9-17B). e ileoileal anastomosis may be completed in
any fashion that uses sutures or staples. e conduit is then
cleaned of intestinal content, and the proximal end is closed.
Closure must be done with absorbable sutures, because staples
can lead to stone formation. Itis then preferable to make the
opening in the abdominal wall to construct the stoma as previously described for an ileostomy (Figs. 9-17C and 9-17D).
is procedure ensures that the ureteral anastomosis will be
completed with the conduit in its nal position and without
the need for applying tension to bring the intestine through