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Chapter 28 • End Ileostomy and Loop Ileostomy 355
Figure 28-1
Figure 28-2
Figure 28-3 Figure 28-4
356 Chapter 28 • End Ileostomy and Loop Ileostomy
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The first suture is placed on the mesenteric edge of the bowel (full thickness) and then to
the subcuticular layer at the cephalad apex of the stoma opening (Figure 28-5).
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Placement of 3-0 absorbable sutures is done to create a Brooke stoma (spigot) using a full-
thickness suture through the cut edge of the terminal ileum (Figure 28-6), followed by a
seromuscular bite of the ileum a distance of 5 cm from the edge (Figure 28-7), followed by
a subcuticular bite (Figures 28-8 and 28-9). Hemostats are used to hold the sutures until
sutures have been placed in all four quadrants and the intervening spaces (Figure 28-10).
Figure 28-5 Figure 28-6
Figure 28-7 Figure 28-8
Chapter 28 • End Ileostomy and Loop Ileostomy 357
Figure 28-9
Figure 28-10
358 Chapter 28 • End Ileostomy and Loop Ileostomy
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The ileum is everted, and the sutures are tied.
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The ostomy appliance is applied (Figure 28-11). The size of the appliance opening is usually
1
1
1 inch or
inches in diameter using the cutting guides on the appliance. The appliance
8
should touch the stoma on all sides but should not cut the mucosa.
Loop Ileostomy
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The chosen loop of ileum is pulled out through the prepared abdominal wall opening using
a Babcock clamp with gentle pushing intra-abdominally and external traction. Care is taken
to ensure that the ileostomy is correctly oriented and that the mesentery is not twisted. The
ileostomy is pulled out with the proximal limb oriented cephalad (Figure 28-12). If a rod is
needed for support in patients with a thick abdominal wall, a small opening is made in the
mesentery, and an ileostomy rod is passed beneath the bridge of bowel close to the distal
limb. A suture can be placed through the eyes of the rod to create a loop of suture to allow
retrieval if the rod slips.
Chapter 28 • End Ileostomy and Loop Ileostomy 359
Figure 28-11
Proximal
Figure 28-12
Distal
360 Chapter 28 • End Ileostomy and Loop Ileostomy
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The bowel is incised 80% around the circumference at the level of the skin on the inferiorly
placed distal (bypassed) limb (Figures 28-13A and 28-14). Simple full-thickness sutures are
placed through the distal ileal limb and subcuticular skin to secure the distal limb flush to
the skin (Figure 28-15). The proximal ileal limb is everted in a Brooke fashion using a fullthickness suture through the terminal ileum, followed by a seromuscular bite of the ileum a
distance of 5 cm from the edge, followed by a subcuticular skin suture (Figure 28-16). This
process is repeated around the upper limb four times equidistant around the bowel to evert
the proximal limb (Figures 28-13B and 28-17). The bridge of bowel wall between proximal
and distal limb is secured to the lower portion of the skin opening to keep the midportion
of the bowel from retracting and to close the distal limb partially when the rod is not needed
(Figures 28-13C and 28-18).
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The sutures are tied to evert the spigot of the stoma (Figure 28-19), and an appliance is
applied (Figure 28-20).
A
Figure 28-13A-C
B
C
Chapter 28 • End Ileostomy and Loop Ileostomy 361
Figure 28-14 Figure 28-15
Figure 28-16 Figure 28-17
Distal limb
Bridge stitch
Figure 28-18
Figure 28-19
Figure 28-20
362 Chapter 28 • End Ileostomy and Loop Ileostomy
Step 3: Postoperative Care
Diet may be advanced when bowel function returns. An enterostomal therapist should be
involved in the postoperative care and training of the patient. The ileostomy rod should be
removed at postoperative day 5.
Step 4: Pearls and Pitfalls
The fascial opening should be widened sufficiently to allow the ileum to be pulled out an
adequate length without compromising the mesenteric blood supply. An overly large opening
can lead to stomal prolapse or hernia formation. Poor placement of sutures can result in stomal
retraction. Sutures placed too deep into the wall of the ileum at the level of the skin can cause
a fistula.
The ileostomy rod is needed only in patients with a thick abdominal wall when there is
obvious tension on the loop brought through the opening. The thickened mesentery may require
a larger abdominal wall opening to facilitate passage. A more proximally placed stoma along
the length of the ileum may provide more mobility. Finally, if it is absolutely necessary, the
stoma site can be moved to the upper abdomen where the subcutaneous fat is thinner.
Selected Readings
Güenaga KF, Lustosa SA, Saad SS, et al. Ileostomy or colostomy for temporary decompression of colorectal anastomosis. Cochrane Database
Syst Rev 2007;(1):CD004647.
Rondelli F, Reboldi P, Rulli A, et al. Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a
meta-analysis. Int J Colorectal Dis 2009;24:479–88.
Step 1: Clinical Anatomy
C H A P T E R
29
Colostomy: End and
Divided Loop
Anne Y. Lin and Elisa H. Birnbaum
The left colon lies along the left side of the abdomen suspended from the splenic flexure to the
pelvic brim by lateral peritoneal attachments. The mesentery of the left colon arises from the
midline of the abdomen along the aorta. The sigmoid colon has no lateral peritoneal attachments
other than some congenital adhesions that fix the apex of the sigmoid to the pelvic brim and
the iliac fossa. The sigmoid colon is attached to the retroperitoneum through a midline mesentery arising from the inferior mesenteric artery (IMA) and extending down into the pelvis to
the mesorectum. The splenic flexure is attached to the undersurface of the tip of the spleen,
the lower edge of the tail of the pancreas, and the anterior surface of the left kidney by various
levels of suspensory ligaments and peritoneal extensions. The blood supply to the left colon is
based on the IMA, which arises from the anterior surface of the aorta just above the bifurcation
of the common iliac arteries. The IMA extends anteriorly and bifurcates to produce the superior
rectal artery feeding the sigmoid colon and the rectum. The left colic artery extends cephalad
to provide the left colon and distal splenic flexure with blood supply through the arcade at the
mesenteric edge known as the marginal artery of Drummond. The retroperitoneum behind the
left colon contains the left ureter and the gonadal vessels lying over the psoas muscle. The ureter
crosses the iliac vessels at the bifurcation of the iliac vessels into the external and internal iliac
branches.
Step 2: Preoperative Considerations
End colostomies are constructed typically when an abdominal perineal resection is performed
for rectal carcinoma or when a Hartmann procedure is performed for treatment of diverticulitis
or obstructing carcinoma. Typically, the descending colon is used as the end stoma. The sigmoid
colon is usually removed because it has been irradiated during neoadjuvant treatment of rectal
carcinoma or involved with the disease process in the case of diverticulitis. A divided loop stoma
can be performed as an end loop colostomy. These stomas provide complete diversion of stool
and decompression of the distal end. The stomas also provide an advantage, in that laparotomy
363
364 Chapter 29 • Colostomy: End and Divided Loop
is not required for takedown. An end loop stoma can also be used to overcome lack of reach
for a loop colostomy in an obese patient with a thick abdominal wall.
Ideally, the stoma site should be marked in the left lower quadrant within the rectus outline
on the infraumbilical fat fold by an enterostomal therapist or an individual well versed in creation of stomas. Care should be taken to avoid skin folds, scars, and bony protuberances, which
would dislodge the ostomy appliance. The patient’s preference on waistline should be taken
into account when placing an ostomy. A bowel preparation is unnecessary if a patient is undergoing an operation that will not result in an anastomosis. Prophylactic antibiotics are given
within 1 hour of the incision.
Step 3: Operative Steps
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The patient is typically placed in the lithotomy position, and the site is marked on the skin
with parallel scratch marks so that the site can be identified at the end of the procedure
(Figure 29-1A). The sigmoid and left colon are mobilized by incising the lateral peritoneal
reflection as for a left colectomy, and the colon and its mesentery are mobilized away from
the retroperitoneum toward the central vessels. After selecting the most distal colonic segment,
the bowel is mobilized until the segment reaches the abdominal wall. This maneuver may
require mobilization of the colon to the splenic flexure and occasionally mobilization of the
splenic flexure to get adequate length.