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Minimally Invasive Approach for Stoma Creation
Seth I. Felder , Zuri Murrell , and Phillip Fleshner
15
K e y P o i n t s
• Laparoscopy for fecal diversion is safe, feasible, and
effective.
• Laparoscopy does not change the indications for stoma
construction [
principles.
• In comparison with conventional stoma creation, the benefi ts of laparoscopic stoma creation may include decreased
morbidity rates in the form of lower complication rates,
reduction in postoperative analgesia, shorter hospitalization, comparable operating time, and improved cosmesis.
• Although most laparoscopic techniques for stoma construction use two or more port sites, single-port techniques
have also been described with favorable outcomes.
• Stomas created for obstructing lesions create unique challenges such as creating adequate pneumoperitoneum to
provide space and visualization.
1 – 3 ] nor does it alter the basic surgical
Introduction
As laparoscopy is increasingly adopted into the colorectal surgeon’s practice, the application of minimally invasive techniques for stoma construction has gained added relevance
[ 1 – 3 ]. Intestinal stomas are considered a vital element as either
a permanent means for stool evacuation or as a temporary
bridge in order to treat complicated abdominal problems or
heal more distal anastomoses or wounds [ 4 ]. In comparison
with conventional stoma creation, the benefi ts of laparoscopic
Electronic supplementary material: Supplementary material is
available in the online version of this chapter at
1581-1_15
com/videos/978-1-4939-1580-4
S. I. Felder , M.D. • Z. Murrell , M.D. • P. Fleshner , M.D. (*)
Department of Colon and Rectal Surgery , Cedars-Sinai Medical
Center , 8737 Beverly Boulevard, Suite 101 , Los Angeles ,
CA 90048 , USA
e-mail:
. Videos can also be accessed at http://www.springerimages.
.
pfl eshner@aol.com
10.1007/978-1-4939-
stoma creation likely include decreased morbidity rates in the
form of lower complication rates, reduction in postoperative
analgesia, shorter hospitalization, comparable operating time,
and improved cosmesis [ 5 – 11 ]. In addition, the entire abdomi-
nal cavity is easily accessible for inspection. Particularly in a
healthcare climate emphasizing fast-track protocols [ 12 ] and
cost containment, the implications of a minimally invasive
approach promoting quicker return of bowel function and consequently time in the hospital, along with potential reductions
in long-term adverse outcomes such as bowel obstruction due
to surgical trauma resulting in adhesion formation, a laparoscopically created stoma may in time become regarded as the
preferred, standard technique.
Laparoscopy does not change the indications for stoma
construction [ 3 ] nor does it alter the basic surgical principles.
The exteriorized bowel must be well vascularized without
excessive mesenteric tension, pass through the rectus sheath
and fascia properly oriented, and adequately reach the
abdominal wall for maturation. A laparoscopic technique is
ideally suited for stoma creation since it often does not
require extensive dissection or specimen extraction [ 4 ].
Several intestinal sites may be chosen for stoma formation,
although the terminal ileum and sigmoid colon are most
commonly used. The decision regarding site placement
depends on the operative indications as well as subsequent
procedures planned [ 2 ]. Like other laparoscopic procedures,
extensive intra-abdominal adhesions and comorbidities making general anesthesia prohibitive are relative contraindications. The creation of a laparoscopic stoma in the setting of
an obstructing rectal cancer is dependent upon the degree of
bowel distention as this directly impacts the ability to create
adequate working space.
A variety of minimally invasive techniques for stoma
creation have been described, demonstrating laparoscopy
for fecal diversion to be safe, feasible, and effective.
Although most laparoscopic stomas are created using two or
more port sites, single-port techniques have also been
reported with favorable outcomes [ 1 , 10 ]. Laparoscopic
stoma creation has been compared to open stoma creation in
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_15, © Springer Science+Business Media New York 2015
169
170
S.I. Felder et al.
Fig. 15.1 Ischemic ostomy. Courtesy of Philip Y. Pearson, MD, with
permission
several retrospective studies [ 5 – 11 ]; however, prospective
trials have not yet been conducted. The available literature
suggests that using a laparoscopic approach does not compromise functional outcomes, and the avoidance of a laparotomy and reduction in recovery time remain signifi cant
advantages.
Complications reported following laparoscopic stoma
construction are similar to those following conventional,
open construction. Stoma retraction, generally resulting
from poor adhesion between the serosal surfaces of the
everted stoma, stoma ischemia and necrosis due to excessive
division of mesenteric blood vessels, tension on the stoma
from inadequate mobilization or a tight fascial aperture,
stoma stenosis (a consequence of postoperative ischemia),
and stoma prolapse/hernia are all well-characterized postoperative complications (Fig. 15.1 ).
Parastomal hernia remains an especially signifi cant
problem following stoma creation (Fig. 15.2 ). In fact, the
creation of a defect in the abdominal wall for a stoma by
defi nition places a weakness in the abdominal wall where
there once was complete continuity. Associated complications may be relatively minor, such as skin breakdown near
the stoma site or diffi culty fi tting an appliance around the
stoma, or can be life-threatening such as incarcerated intestine within the hernia [ 4 ]. Although seemingly a logical
approach to reduce parastomal hernia, Level I evidence in
support of prophylactic mesh placement at the time of open
stoma construction is limited and comprised various types of
mesh, placed in different abdominal positions [ 13 – 18 ]. A
meta-analysis evaluating three of these studies included 128
patients and demonstrated a statistically signifi cant reduction
of parastomal hernia incidence between the mesh group
(12.5 %) compared with the control group (53 %) without a
difference in mesh-related morbidity. Beck et al. presented a
prospective, randomized, controlled third-party blinded
Fig. 15.2 Parastomal hernia. Courtesy of Peter Cataldo, MD, with
permission
study of 113 patients comparing mesh inlay for parastomal
reinforcement in patients undergoing surgery for permanent
abdominal wall ostomies to standard end stomal construction at the 2013 American Society of Colon and Rectum
Surgeons meeting [ 19 ]. Although reinforcement was found
to be safe, the incidence of parastomal hernia formation was
not statistically lower after 24-month follow-up [ 16 ].
However, studies evaluating prophylactic mesh placement in
laparoscopically created stomas are extremely limited, with
initial experiences demonstrating safety and feasibility and
potentially favorable outcomes [ 17 , 18 ]. Solid evidence for
prophylactic placement of mesh in laparoscopic stoma construction is not yet available.
Preoperative Planning
In the elective setting, preoperative stoma site selection and
marking is essential. A stoma located incorrectly predisposes
the patient to problems that cannot be managed conservatively (i.e., with changes in the stoma equipment). Since body
habitus varies greatly between individuals, the ideal stoma
site(s) must be modifi ed, avoiding scars and skin creases [ 4 ].
To ensure skin folds do not interfere with appliance fi tting, site selection should be done in supine, sitting, and
bending positions, with attention also given to the individual’s beltline [
the apex of the subumbilical fat roll, in either the right or left
iliac fossa (Fig.
able to visualize the stoma in order to care for it.
4 ]. The usual site in an average individual is on
15.3 ) [ 20 ]. Finally, the patient needs to be
15 Minimally Invasive Approach for Stoma Creation
Operating Room Setup and Patient Positioning
Two video monitors are placed angling toward the patient at
the shoulder level if constructing an ileostomy and placed
toward the foot of the bed or the patient’s knees if planning a
sigmoid/descending colostomy. The procedure is performed
Fig. 15.3 Stoma position marked on the abdomen
171
with the patient in the supine position although a modifi ed
lithotomy position is also acceptable. If the latter position is
utilized, the hips and knees are gently fl exed to an angle no
greater than 15° to avoid the patient’s thighs interfering with
the laparoscopic instruments. If an ileostomy is planned, the
left arm is tucked to the side, and the surgeon stands on the
left side of the patient or between the patient’s legs (Fig.
If a sigmoid/descending colostomy is planned, the right arm
is tucked, and the surgeon stands on the patient’s right or
between the legs. The site of peritoneal access is dependent
upon the type of stoma being created and the patient’s prior
surgical history. For patients with prior abdominal surgery,
accessing a “free” quadrant is usually the safest approach.
After intra-abdominal access is obtained, the patient is
placed in Trendelenburg position to augment visualization.
15.4 ).
Technique: Laparoscopic Ileostomy
1 , 2 , 4 , 20 ]
[
Variations in multi-port placement positioning and sequence
have been described; however, most approaches use 2 or 3
ports, taking advantage of the principle of trocar triangulation
to facilitate exposure and mobilization. The fi rst trocar inserted
is a 5-mm cannula placed just inferior to the umbilicus. Once
15-mmHg pneumoperitoneum is established, a (30°) laparoscope is inserted to inspect the abdomen and direct the remaining port positions (Fig. 15.5 ). The patient is placed right side
up in Trendelenburg position. The surgeon can visually ensure
that the planned ostomy site is suitable and free of adhesions.
Fig. 15.4 Room setup
demonstrating monitor sites
172
Fig. 15.5 Ileostomy and port sites
S.I. Felder et al.
If the previously selected right iliac fossa stoma site is
acceptable, a 12-mm port is then placed after making a 2.5cm incision at the predetermined stoma site, excising the
skin and subcutaneous fat as a cone of tissue down to the
anterior rectus sheath and then dividing the sheath in a cruciate fashion. The fi bers of the rectus muscle are then split longitudinally by opening an instrument perpendicular to the
line of the fi bers. This procedure results in little or no bleeding unless the deep inferior epigastric vessels are encountered and divided deep to the rectus muscle. After the rectus
muscle is split, the posterior rectus sheath is incised to
accommodate the 12-mm trocar. The 12-mm trocar provides
the ability to accommodate a laparoscopic stapler for intracorporeal division if creating an end ileostomy, rather than
exteriorizing the intestines for extracorporeal division. If the
ileum requires further mobilization not possible with a single
working port, additional 5-mm trocar(s) may be placed either
in the left lower quadrant, lateral to the rectus muscle and
above the pelvic brim, or suprapubically.
The terminal ileum is located, and a point on the small
bowel about 15–20 cm proximal to the ileocecal valve is
identifi ed laparoscopically. Visualization of the ligament of
Treves, located on the antimesenteric border of the terminal
ileum just proximal to the ileocecal valve, is also helpful in
identifying the anatomy (Fig. 15.6 ). The terminal ileum is
inspected for any pathology as well as length of mesentery
available for loop stoma creation. The terminal ileum is
usually supplied by two arcades of vessels, which join the
ileocolic vessels adjacent to the cecum. These arcades must
Fig. 15.6 Terminal ileum with fold of Treves visible
be divided as close to the ileocolic vessels as possible to
preserve blood supply to the terminal ileum.
The proximal side (1 serosal thermal burn) and distal side
(3 serosal thermal burns) of the selected point on the small
bowel are marked by using laparoscopic electrocautery.
Alternatively, the future ileostomy site may be marked with
different colored sutures for orientation. Once mobilized, the
ileum can be grasped and divided with a laparoscopic stapler
through the 12-mm port and brought through the abdominal
wall or exteriorized through the fascial defect and divided
extracorporeally (for an end stoma). If constructing a loop
15 Minimally Invasive Approach for Stoma Creation
173
Fig. 15.7 Completed stoma
Fig. 15.9 Posterior sheath: dissection down through the subcutaneous
tissue, anterior rectus sheath, and rectus muscle, exposing the posterior
rectus sheath
Fig. 15.8 Anterior sheath
ileostomy, the ileum is grasped and brought through the fascia
with attention to maintaining proper orientation. To exteriorize the ileum in both cases, the fascial defect within the posterior rectus sheath must be opened and enlarged over the
trocar. Because the ascending colon usually tethers the ileocolic vessels to the right lower quadrant, optimal positioning
of the stoma requires the placement of the proximal end along
the inferior aspect of the stoma site in a loop ileostomy.
The ileostomy is then matured in the usual fashion
(Fig. 15.7 ). The surgeon places an index fi nger both along the
side of the stoma down to the fascia as well as into the stoma
itself and beneath the peritoneum to ensure the fascial opening is not excessively tight and the stoma is not angulated.
For single-port laparoscopic ileostomy construction, a
2.5-cm incision is made in the right iliac fossa at the predetermined stoma site (Video 15.1 ). The incision is carried
down to the anterior rectus sheath, which is then divided in a
cruciate fashion. The skin and subcutaneous fat are excised
as a cone of tissue down to the anterior rectus sheath
(Fig. 15.8 ). The rectus abdominis muscle is spread in the
direction of its fi bers exposing the posterior rectus sheath
and peritoneum, which are then divided in a cruciate fashion
over a distance of 2.5 cm, wide enough to accommodate 2
fi ngers (Fig. 15.9 ).
Fig. 15.10 Single-port access system
The single-port access system is then inserted through
this incision (Figs. 15.10 and 15.11 ). The abdomen is
insuffl ated with CO 2 to 15 mmHg. A 5-mm laparoscope
with a fl exible steerable tip is used to visualize the abdomen. Single-incision laparoscopic instruments may be
used, but standard laparoscopic instruments are suitable in
most cases.
The terminal ileum is located, and a point on the small
bowel about 15–20 cm proximal to the ileocecal valve is
identifi ed laparoscopically. The proximal side (1 serosal
thermal burn) and distal side (3 serosal thermal burns) of this
174
S.I. Felder et al.
Fig. 15.11 Single-port access system inserted through stoma site
Fig. 15.13 Ileum with laparoscopically created thermal burns indicat-
ing superior (distal) and inferior (proximal) orientation. The head of the
patient is directed toward the top of the photo
Fig. 15.12 Marking distal and proximal ileum to maintain orientation
of future stoma
point on the small bowel are marked by using laparoscopic
electrocautery (Figs. 15.12 and 15.13 ). With a laparoscopic
grasper (e.g., Babcock clamp), the bowel is delivered through
the ileostomy incision and exteriorized, with particular attention directed to maintaining proper orientation. Because the
ascending colon usually tethers the ileocolic vessels to the
right lower quadrant, optimal positioning of the stoma
requires the placement of the proximal end along the inferior
aspect of the stoma site.
The single-port access system is removed (Fig. 15.14 ).
The ileostomy is then matured in the usual fashion. The surgeon places an index fi nger both along the side of the stoma
down to the fascia as well as into the stoma itself and beneath
the peritoneum to ensure the fascial opening is not excessively tight and the stoma is not angulated.
Fig. 15.14 Ileum exteriorized from single-access port site
Technique: Laparoscopic Colostomy
1 , 2 , 20 , 21 ]
[
Variations in multi-port placement positioning and sequence
have been described; however, most approaches use 2 or 3
ports, taking advantage of the principle of trocar triangulation
to facilitate exposure and mobilization. The fi rst trocar inserted
is a 5-mm cannula placed just inferior to the umbilicus
15 Minimally Invasive Approach for Stoma Creation
175
Fig. 15.15 Placement of the initial 5-mm laparoscopic trocar at the
umbilicus to enter and visualize the abdomen. Blue marks , from medial
to lateral, represent the midline, the anticipated location of the colostomy, and the border of the rectus sheath
(Fig. 15.15 ). Once 15-mmHg pneumoperitoneum is estab-
lished, a (30°) laparoscope is inserted to inspect the abdomen
and direct the remaining port positions. The patient is placed
left side up in the Trendelenburg position. The surgeon can
visually ensure that the planned ostomy site is suitable and
free of adhesions.
If the previously selected left iliac fossa stoma site is
acceptable, a 12-mm port is then placed after making a 2.5cm incision at the predetermined stoma site, excising the skin
and subcutaneous fat as a cone of tissue down to the anterior
rectus sheath and then dividing the sheath in a cruciate fashion. The fi bers of the rectus muscle are then split longitudinally
by opening an instrument perpendicular to the line of the
fi bers. After the rectus muscle is split, the posterior rectus
sheath is incised to accommodate the 12-mm trocar
(Fig. 15.16 ). The 12-mm trocar provides the ability to accom-
modate a laparoscopic stapler for intracorporeal division if
creating an end colostomy, rather than exteriorizing the intestines for extracorporeal division. A bowel grasper placed
through the 12-mm trocar assesses bowel mobility by pulling
the colon toward the abdominal wall. If the sigmoid or
descending colon requires further mobilization not possible
with a single working port, additional 5-mm trocar(s) may be
placed either in the right lower quadrant, lateral to the rectus
muscle and above the pelvic brim, or suprapubically.
The additional trocars allow for countertraction while the
lateral attachments are mobilized using laparoscopic scissors
connected to an energy source. Mobilization commences at
the peritoneal refl ection in the left paracolic gutter, and the
dissection is carried medially in the avascular plane anterior
to the gonadal vessels and the ureter. Mobilization should be
suffi cient to enable several centimeters of bowel to protrude
without tension through the abdominal wall.
Fig. 15.16 After the rectus muscle is split, the posterior rectus sheath
is incised to accommodate the 12-mm trocar at the pre-marked ostomy
site
Fig. 15.17 Once mobilized, the colon can be grasped and exteriorized
through the 12-mm port site, with the fascial defect within the posterior
rectus sheath opened and enlarged over the trocar to easily accommodate the colon
Once mobilized, the colon can be grasped and divided
with a laparoscopic stapler through the 12-mm port or exteriorized through the fascial defect and then divided
extracorporeally (Fig. 15.17 ). To exteriorize the colon in
both cases, the fascial defect within the posterior rectus
sheath must be opened and enlarged over the trocar. The
opening in the abdominal wall should allow two averagesized fi ngers to pass through to the second phalanx. Before
maturing the colostomy, pneumoperitoneum is reestablished
to verify proper orientation and absence of twisting.
For single-port laparoscopic colostomy construction, a
2.5-cm incision is made in the left iliac fossa at the predetermined stoma site. The incision is carried down to the anterior
176
rectus sheath, which is divided in a cruciate fashion. The skin
and subcutaneous fat are excised as a cone of tissue down to
the anterior rectus sheath. The rectus abdominis muscle is
spread in the direction of its fi bers exposing the posterior
rectus sheath and peritoneum, which are then also divided in
a cruciate fashion over a distance of 2.5 cm, wide enough to
accommodate 2 fi ngers.
The single-port access system is then inserted through
this incision, and a 15-mmHg pneumoperitoneum is established. A 5-mm laparoscope with a fl exible steerable tip is
used to visualize the abdomen. Single-incision laparoscopic
instruments may be used, but standard laparoscopic instruments are suitable in most cases.
Using laparoscopic scissors connected to an energy
source, the lateral attachments are mobilized as needed. The
proximal side (1 serosal thermal burn) and distal side (3 serosal thermal burns) of the chosen point of colon are marked
using laparoscopic electrocautery. When an end stoma is
indicated, intracorporeal mesenteric division may be performed either with laparoscopic clips or an endoscopic vascular linear stapler, if necessary.
To avoid stapling of the afferent limb, the lithotomy position allows for intraoperative proctosigmoidoscopy and air
insuffl ation, which can identify the distal colon by distention when the colon at the site of the anticipated stoma is
occluded. With a laparoscopic grasper, the colon is delivered through the stoma incision and exteriorized, with attention to maintaining proper orientation in the case of loop
colostomy.
The single-port access system is removed. The colostomy
is then matured in the usual fashion, either as an end or loop
ostomy. The surgeon places an index fi nger along the side of
the stoma down to the fascia to ensure the fascial opening is
not excessively tight and down the stoma to ensure the bowel
is not angulated.
S.I. Felder et al.
Pearls and Pitfalls
• Pearls to ensuring adequate mobilization include full
mobilization of sigmoid attachments in the pelvic, suffi cient incision of the lateral peritoneum of the descending
colon, and suffi cient medial mobilization sigmoid colon.
Before exteriorization, the proposed site of the stoma
should be pulled up to the site of the stoma on the abdominal wall. If the bowel reaches this site without tension,
there will be more than adequate length to reach the skin
once the pneumoperitoneum is released.
• Prior to ligating any major vessels, ensure you have adequate collateral blood fl ow to avoid ischemia of the stoma.
• Prior to maturing the stoma, it is recommended to laparoscopically visualize the stoma to ensure proper orientation of the proximal and distal limb and that there is no
twist in the mesentery.
• For a diverting-loop ileostomy, ensure you are not too
close to the ileocecal valve. This will lead to the subsequent anastomosis being adjacent to the valve at the time
of takedown.
Summary
Laparoscopy is well suited for stoma creation, as neither
extensive dissection nor specimen extraction is usually
necessary. Although a variety of laparoscopic techniques
have been described, the basic tenets remain the same—
visualizing the appropriate intestinal segment, mobilizing
the segment, and ultimately exteriorizing through the abdominal wall in a proper orientation. When considered relative to
a conventional, open technique, laparoscopic stoma construction appears to be as safe and encourage quicker
recovery without compromising functional outcomes.
Gaining Length When It Would
Not Reach [
If standard mobilization fails to create a tension-free colostomy, several operative maneuvers can help to obtain left
colon length. Following division of the lateral attachments,
the splenic fl exure should be completely mobilized. Further
measures include transection of the medial peritoneal attachments at the base of the colon mesentery, transection of the
inferior mesenteric artery proximal to the left colonic arterial
takeoff to decrease tethering, and creation of “windows” in
the peritoneum overlying the colonic mesentery just below
the stoma to gain mesenteric length. If an end stoma was
initially intended, but unable to easily reach the proposed
stoma site, a loop stoma can be constructed to provide additional length, if necessary.
4 ]
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Laparoscopic Stoma Reversal
Emre Gorgun
16
K e y P o i n t s
• Laparoscopic surgery is now widely used in performing
colectomies both for benign and malignant conditions.
• Laparoscopic colorectal surgery has short-term benefi ts
over open colorectal surgery.
• Laparoscopic and open stoma reversals are challenging.
• Laparoscopic reversal of Hartmann’s procedure may be
associated with shorter hospital stay.
• The authors endorse preoperative bowel preparation for
laparoscopic Hartmann’s reversal.
• Preoperative fl exible sigmoidoscopy reveals useful information regarding the length of the distal segment and thus
facilitates operative planning.
• Initial access is gained by mobilizing the stoma from the
surrounding tissue and placing a purse-string suture in the
proximal bowel, which also helps to prevent stool or
mucous from spilling through the end of the bowel.
• The utilization of the hand-assisted approach is an alternative to a primary technique or to a conversion to manage
intra-abdominal adhesions and diffi culties with visualization that would preclude the straight laparoscopic approach.
Introduction
Since the introduction of laparoscopic surgery for the management of symptomatic cholelithiasis, the surgical approach
for many intra-abdominal diseases has dramatically changed.
Laparoscopic colectomy, for both benign and malignant
conditions, is now widely performed. The collective experience with laparoscopic colon surgery has demonstrated that
patients who undergo laparoscopic procedures have less
pain, decreased incidence of ileus, and a shorter hospital
stay. These trends have led some experienced surgeons to
apply their laparoscopic skills to colostomy closure after
Hartmann’s procedure, in an attempt to decrease operative
trauma—and possibly hospital stay as well—in this select
group of patients. Additionally, some advanced laparoscopic
surgeons have begun to apply their skills and available
technology to performing minimally invasive re-operative
surgery, including both complex lysis of adhesions and ileostomy takedown, with ileocolonic or ileorectal anastomosis.
Laparoscopic stoma reversal is technically demanding
due to intraoperative diffi culties caused by existing abdominal adhesions and, in many cases, a diffi cult pelvis. This
added challenge can lead to longer operative times and a
potential increase in complications, especially if such procedures are performed by inexperienced laparoscopic surgeons. By using laparoscopy, however, the operative trauma
usually associated with laparotomy can be minimized and
postoperative hospital stay potentially reduced. For example,
colostomy closure after Hartmann’s procedure is associated
with a high morbidity of 15 to 34 percent and a prolonged
hospital stay of 13 to 15 days [
after Hartmann’s procedure could be reduced, then it is likely
that the percentage of patients left with permanent stomas
would decline (Fig. 16.1 ). Therefore, Hartmann’s reversal
may benefi t from a laparoscopic approach.
1 , 2 ]. If complication rates
Electronic supplementary material: Supplementary material is avail-
able in the online version of this chapter at
. Videos can also be accessed at http://www.springerimages.com/
1_16
videos/978-1-4939-1580-4
E. Gorgun , M.D., F.A.C.S., F.A.S.C.R.S. (*)
Department of Colon and Rectal Surgery, Digestive Disease
Institute , Cleveland Clinic , 9500 Euclid Avenue/A , Cleveland ,
OH 44195 , USA
gorgune@ccf.org
e-mail:
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_16, © Springer Science+Business Media New York 2015
.
10.1007/978-1-4939-1581-
Preoperative Planning
Proper patient selection is crucial to preoperative planning,
and patients should be both medically fi t and able to tolerate
laparoscopy. All patients should undergo a detailed history
and physical examination, including a thorough review of
their surgical history. Such preparation is especially important if the original stoma creation was performed in a different
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