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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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End Sigmoid Colostomy
Operative Indications
An end colostomy is usually created following an abdominoperineal resection or a Hartmann’s procedure for diseases such
as diverticular disease, an obstructing neoplasm, congenital abnormalities, or fecal incontinence. The end sigmoid colostomy
is the easiest ostomy to manage. An end transverse colostomy will have more liquid content and, therefore, will be more dif-
ficult to manage. Prior to surgery, an enterostomal therapist marks the patient’s abdominal wall at an appropriate site for best
application of an appliance. The proper location of a colostomy can prevent stoma prolapse, hernia, or skin irritation. This
procedure can be performed laparoscopically or through an open wound. The open procedure is described below.
Stoma site
Operative Technique
As previously mentioned, an end colostomy is usually performed in
conjunction with another abdominal procedure. The end colostomy
is formed just prior to closure of the abdominal wall incision.
An elliptical disk of skin is removed from the abdominal wall at the
site where the stoma marking was placed (1), and the subcutaneous
End Sigmoid Colostomy 483
tissue is separated using the electrocautery.
Using right-angle retractors, the skin is
retracted allowing the anterior fascia to be
visualized.
Anterior
fascia of
rectus m.
1
The anterior fascia is opened vertically with the electrocautery at
least 3–4 cm lateral to the midline incision (2). If this distance
is not preserved, it will be more difficult to close the midline
abdominal wound. The underlying rectus muscle is gently
spread with a Kelly clamp and the posterior fascia is opened
with the electrocautery. To prevent injury to underlying struc-
tures, a Mikulicz sponge can be placed in the abdomen direct-
ly underneath the stoma site.
2
Once all layers have been opened, the colostomy should allow
passage of two fingers (3). If the sigmoid colon has been ade-
quately mobilized for stoma formation, it should come through the
ostomy site without any tension and in the correct orientation with the
mesentery posterior.
3
484 Atlas of Gastrointestinal Surgery: The Colon
4
Sigmoid
colon
At this point, seromuscular tacking sutures of
3-0 silk can be placed between the sigmoid
colon and the posterior fascia. The midline inci-
sion can then be closed.
The staple line on the bowel is removed with
the electrocautery (4). The bowel wall is secured
to the dermis using a full thickness 3-0 absorbable
suture (5 and 6). An end colostomy may be flush
with the skin because the effluent is noncorrosive (7).
A transparent ostomy appliance is attached.
6
5
End colostomy
7
Loop Colostomy
Operative Indications
The purpose of a loop colostomy is to temporarily divert the
fecal stream while a portion of the intestine beyond the colosto-
my heals, as in the case of a distal intestinal anastomosis or peri-
anal fistulae. The diverting loop colostomy is made by bringing a
loop of sigmoid colon through the abdominal wall. Typically, the
left lower quadrant is used for colostomy placement. This proce-
dure can be done open or laparoscopically. The benefit of a loop
colostomy over an end colostomy is that both ends of the bowel
Stoma site
are brought through the abdominal fascia, and therefore, it is eas-
ier to reverse the stoma. 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.
486 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
Often a loop colostomy is made in combination with a bowel resection and the abdominal incision has already been made.
If no incision has been made, a 7-cm periumbilical midline incision is used with the patient in the supine position. The sig-
moid colon is identified and the portion of the bowel with the best likelihood of reaching the stoma site is identified. Some
mobilization of the left colon may be required.
Once a loop of bowel is identified, a defect is created in the mesentery and an umbilical tape is passed through this
window. This facilitates bringing the stoma through the abdominal wall. Attention is turned to creating the opening in the
abdominal wall. The first step is to remove a disk of skin. A scalpel is used to cut a circle of skin approximately 2 cm in
diameter.
If the patient has abdominal wall fat, a cylinder of fat can be excised
with the skin (1). This aids in visualization of the fascia. A laparo-
tomy pad is placed underneath the fascia at the stoma site to avoid
injury to the underlying bowel. The left lower
quadrant is elevated by the operating
surgeon’s left hand to facilitate identifica-
tion of the fascia. The fascia is opened
to expose the rectus abdominis muscle.
The rectus muscle is split using a Kelly
clamp. The posterior fascia is then
1
opened. It is important to check for hemostasis prior to bringing the bowel
through the stomal opening. The umbilical tape is grasped with a Kelly clamp,
and the bowel should come through the stomal opening with minimal diffi-
culty (2). The orientation of the bowel is confirmed and the stomal rod
placed. The midline abdominal incision is irrigated and closed in layers.
2
Loop Colostomy 487
The sigmoid colon is opened in a manner so that the bowel
3
The cut edge of the colon wall is secured directly to
the dermis with 3-0 absorbable sutures (4 and 5).
This secures the stoma rod without suturing the rod
lumen can be everted. The colon is opened in the midline over
the stoma rod (3).
itself. Securing the rod with sutures can make
replacement of the appliance more difficult and
painful for the patient. The appliance is placed over
the stoma opening.
Loop
colostomy
Proximal
limb
Distal
limb
4
5
488 Atlas of Gastrointestinal Surgery: The Colon
Stapled Colostomy
An alternative method for making a loop
colostomy is to bring the loop through the
abdominal wall placing a linear stapling device
through the mesenteric defect, and dividing the
sigmoid colon (6). When forming a stapled
colostomy, 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
6
the distal limb. The proximal bowel limb should be
much longer than the distal limb. After the proximal
Distal
limb
Proximal
limb
limb staple line is excised, an end colostomy is cre-
ated. The shorter, stapled distal limb is tucked
just beneath the skin (7).
Proximal
limb
Distal
limb
(stapled)
7
Laparoscopic Loop Colostomy
Operative Indications
The operative indications for the laparoscopic loop colostomy 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 right. Three ports are placed:
the camera port in the supraumbilical site; a 5-mm port in
the right lower quadrant; and a 5-mm port in the midline,
suprapubic position. The procedure begins with the iden-
tification of the sigmoid colon.
490 Atlas of Gastrointestinal Surgery: The Colon
Sigmoid
colon
The portion of the sigmoid colon that will most eas-
ily reach the stomal site is identified and grasped
with a laparoscopic Babcock clamp (1). It
may be necessary to release the lateral
attachments of the sigmoid colon.
The first step in making the
stoma opening is to remove a
Proximal
1
disk of skin. A scalpel is
used to cut a circle of
skin approximately
2 cm in diameter. If
the patient has abdom-
Distal
inal wall fat, a cylinder
of fat can be excised with
the skin. This aids in visual-
ization of the fascia. The
insufflation of the abdomen
will also assist in identifying the
fascia. The fascia is opened to
expose the rectus abdominis muscle below. The rectus muscle is split using a
Kelly clamp. The posterior fascia is then opened. It is important to check for
hemostasis prior to bringing the bowel through the stoma opening.
Laparoscopic Loop Colostomy 491
A handheld Babcock clamp is inserted
through the stomal opening to grasp the loop of
sigmoid colon, and the laparoscopic Babcock is
released (2). The bowel should come through
the stomal opening with minimal difficulty. The
orientation of the bowel is confirmed, and a
window is created in the mesentery through
which the stomal rod is passed. At this
point, the fascia of the 10-mm camera port
Distal
Proximal
2
is closed with 2-0 absorbable suture mate-
rial. All port site skin incisions are closed
with a 4-0 absorbable suture and dressings
are applied.
The sigmoid colon is opened in a
manner so that the bowel lumen can be
everted. The colon is opened in the mid-
line over the stomal rod (3).
3
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