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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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272 Atlas of Gastrointestinal Surgery: The Small Bowel
Stapled Ileostomy
An alternative method for making a loop ileostomy is to
bring the loop through the abdominal fascia, placing a
gastrointestinal stapling device through the mesenteric
defect, and dividing the distal terminal ileum (6).
The proximal bowel limb should be much longer
than the distal limb. After the proximal limb staple
line is excised, an end ileostomy is created in
the traditional Brooke method.
End ileostomy
of proximal limb
Distal
limb
Proximal
limb
6
Stapled
distal
limb
The shorter, stapled distal limb is tucked just beneath
the skin (7). Because this ileostomy is intended to be
temporary, a full-thickness stitch is taken from the intes-
tinal edge and brought to the dermis directly without
7
an intervening additional bowel wall stitch as per-
formed during a permanent Brooke ileostomy.
Laparoscopic Loop Ileostomy
Operative Indications
The operative indications for the laparoscopic loop ileostomy are the same as for the open procedure. It is important to
have an enterostomal therapist meet with the patient prior to surgery to mark the stoma site. Perioperative antibiotics and
prophylaxis against deep vein thrombosis should be used.
Operative Technique
The patient is placed in the supine position, and the sur-
Stoma
site
geon stands to the patient’s left. Three ports are placed:
the camera port in the supraumbilical site; a 5-mm port in
the left lower quadrant; and a 5-mm port in the midline,
suprapubic position.
274 Atlas of Gastrointestinal Surgery: The Small Bowel
Distal
limb
of ileum
Orientation
sutures
Cecum
Proximal
limb
1
The procedure begins with the identification of the terminal ileum. Often the ileum is mobile enough that mobilization of
the right colon is not necessary. The portion of the terminal ileum that will most easily reach the stoma site is identified and
grasped with a laparoscopic Babcock clamp. It is important to mark the orientation of the bowel, since twisting during the
creation of the stoma can occur easily. One stitch is placed to mark the proximal limb and two stitches are placed to mark
the distal limb (1).
Laparoscopic Loop Ileostomy 275
The first step in making the stoma opening is to remove the disk of skin necessary to bring the bowel through. A #15
blade scalpel is used to cut a circle of skin approximately 2 cm in diameter. If the patient has abdominal wall fat, a cylin-
der of fat can be excised with the skin. This aids in visualization of the fascia. The insufflation of the abdomen will assist
in identifying the fascia. The fascia is opened transversely to expose the rectus abdominis muscle below. The rectus muscle
is split using a large Kelly clamp. The posterior fascia is then opened. It is important to check for hemostasis prior to bring-
ing the bowel through the stoma opening.
A handheld Babcock clamp is inserted
through stoma opening to grasp the loop of ter-
minal ileum, and the laparoscopic Babcock is
released (2). The bowel should come
through the stoma opening with minimal dif-
ficulty. The orientation of the bowel is con-
firmed, and a window is created in the
mesentery through which the stoma rod is
passed. At this point, the fascia of the 10-
mm camera port site is closed with 2-0
absorbable suture material. All port site skin
incisions are closed with a 4-0 absorbable
suture and dressings are applied.
2
276 Atlas of Gastrointestinal Surgery: The Small Bowel
Stoma rod
3
4
The ileum is opened in a manner so that the bowel lumen can be everted. The technique used is a modification of the
original Turnbull ileostomy. The distal bowel is opened transversely approximately 2/3 the circumference of the bowel, at
a distance of about 5 mm above and parallel to the skin (3 and 4).
The distal end is secured directly to the dermis,
while the proximal end is everted over the remaining
bowel and secured with 3-0 absorbable suture (5
and 6). This secures the stoma rod without sutur-
ing the rod itself. Securing the rod with sutures can
make replacement of the appliance more difficult
and painful for the patient. The appliance is then
placed over the stoma opening.
Distal
Proximal
limb
5
Loop Ileostomy Reversal
Operative Indications
Once healing of the distal intestines has occurred, reversal of a loop ileostomy may take place. The integrity of the distal intes-
tine may be checked prior to reversal by performing a contrast enema. A clear liquid diet the day prior to surgery is all that is
required to prep the bowel. Perioperative antibiotics and prophylaxis against deep vein thrombosis should be used.
Operative Technique
For this procedure, the patient is placed in the supine position. The
ileostomy site and surrounding skin is prepped and draped with towels.
An incision around the stoma is made with a #15 blade knife a few mil-
limeters away from the mucocutaneous border. Toothed forceps are used
to elevate the skin, and the dissection is continued with the electrocautery
device or Metzenbaum scissors until the bowel wall within the subcuta-
neous tissue is identified.
278 Atlas of Gastrointestinal Surgery: The Small Bowel
The adhesions between the bowel wall and subcuta-
Bowel
freed from
abdominal wall
neous tissue, abdominal fascia, and muscle are divid-
ed circumferentially (1). A Weitlaner retractor aids
in identifying this plane. The bowel should be
released from the surrounding tissues so that the peri-
toneal cavity can be entered with an index finger.
This will allow for plenty of length of bowel for the
intestinal anastomosis and for safe closure of the
abdominal fascia.
1
Once the ileum is free, the everted intestine and
mucocutaneous border is released (2). This is best done
with a Metzenbaum scissors. Complete release will pre-
vent a residual stricture of the small intestine.
Mucocutaneous
border trimmed
off bowel
Proximal
ileum
Distal
ileum
2
Loop Ileostomy Reversal 279
The edges of the remaining enteroto-
Inner
row
Outer
row
3 4
my are closed with interrupted 3-0
absorbable sutures (3) followed by a sec-
ond row of 3-0 nonabsorbable Lembert
sutures (4).
The bowel wall is inspected for any missed
serosal injuries and then replaced into the peri-
toneal cavity (5).
Distal
ileum
Proximal
ileum
5
280 Atlas of Gastrointestinal Surgery: The Small Bowel
Stapled
distal limb
Ostomy in
proximal limb
Closure of Stapled Ileostomy
For closure of the stapled loop ileostomy, the dis-
section may be more tedious since the buried sta-
pled distal end of small bowel may be more adher-
ent. The adhesions between the bowel wall and sub-
cutaneous tissue, abdominal fascia, and muscle are
6
Once free, the proximal end of bowel is divid-
ed with a gastrointestinal stapling device (7).
divided circumferentially (6).
Proximal limb
resected
Gastrointestinal continuity is restored with either
a hand-sewn or stapled anastomosis.
7
Posterior
outer row
Loop Ileostomy Reversal 281
For a hand-sewn anastomosis, the stapled ends of the
bowel are approximated. A posterior layer of 3-0 non-
absorbable seromuscular Lembert sutures is placed
(8). The staple lines are removed, and a posterior
inner layer of continuous 3-0 synthetic absorbable
sutures is placed in a locking fashion.
Distal
This is continued anteriorly with a
Connell suture (9). The final outer
layer consists of interrupted 3-0 silk
Proximal
limb
8
Inner
anterior row
Outer
anterior row
Lembert sutures (10).
9
10
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