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Colonic integrity.
Stool spillage.
Spleen, duodenum (mobilization of flexures).
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Complications
Anastomotic leak, prolonged postoperative ileus, sepsis, secondary need for ostomy.
Cross-Reference
Large bowel obstruction (LBO, 560.9) (Ch. 1), (Ch. 4)
Contrast enema (Ch. 2)
Colorectal cancer—colon cancer (Ch. 4)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
(Sub-)total colectomy, ileorectal anastomosis (open) (Ch. 5)
Colonoscopic stent placement (Ch. 5)
CREATION OF END-ILEOSTOMY OR -COLOSTOMY
Principle
Mobilization of colon or terminal ileum end to adequately reach the abdominal wall, to allow functional maturation. Typically
done (1) as part of a discontinuous emergency resection (eg, Hartmann-type resection, total abdominal colectomy), (2) as a
definitive procedure (abdominoperineal resection, total proctocolectomy), (3) occasionally for the same reasons as a
diverting loop ostomy but with the intent to close off the efferent limb and achieve a complete diversion.
Setting
Inpatient, OR procedure.
Alternatives
End-ileostomy vs Prasad-type ileostomy.
End-colostomy vs Prasad-type colostomy.
Indication
Discontinuous resection: Hartmann-type resection or total abdominal colectomy.
Complete diversion of stool from distal area of concern.
Preparatory Considerations
Elective situation: marking of possible stoma sites, prophylactic antibiotics.
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Urgent/emergency: therapeutic antibiotics, resuscitation, stoma site marking if possible (otherwise "educated guess").
Surgical Steps
1. Patient position: supine or modified lithotomy position (depending on surgeon's preference and need to have
perineal access).
(A) End-Ileostomy (Brooke) with ~3-Cm Nipple (Figure 5–15A)
2. Mobilization of terminal ileum so that it reaches beyond abdominal wall at planned ostomy site.
3. Excision of skin disk at planned ostomy site: not larger than diameter of small bowel.
4. Dissection of fat and crosswise incision of anterior rectus sheath.
5. Longitudinal splitting of rectus muscle fibers (caveat: epigastric vessels!) and opening of posterior
sheath/peritoneum.
6. Width: general 2-finger rule may be too large for ileostomy. Better: as large as necessary, as small as possible (so
that loop can be brought through without strangulation), about the diameter of small bowel.
7. Pull-through of bowel and fixation to fascia with three to four seromuscular sutures.
8. For all permanent ostomies: closure of lateral aspect along terminal bowel segment (to avoid internal wrapping of
small bowel around that segment), running absorbable suture between bowel and peritoneum.
9. Closure of laparotomy or access ports.
10. Maturing of stoma: avoid stitching through skin because of risk of creating fistulae (particularly in IBD).
a. Planning of roughly 3-cm symmetric nipple.
b. Pre-laying of four everting sutures: dermis
base full-thickness bowel edge.
c. Gentle traction on all four sutures results in eversion and nipple formation; consecutive tying.
d. Placement of two to three dermis-bowel edge sutures in between.
11. Appliance.
(B) End Colostomy with ~0.3–0.5-Cm Flat Elevation (Figure 5–15B)
2. Mobilization of colon so that it reaches without tension 1–2 cm beyond abdominal wall.
3. Verification that loop reaches planned ostomy site.
4. Excision of skin disk at planned ostomy site: diameter about two fingers wide.
5. Dissection of fat and crosswise incision of anterior rectus sheath.
6. Longitudinal splitting of rectus muscle fibers (caveat: epigastric vessels!) and opening of posterior
sheath/peritoneum.
7. Width: general 2-finger rule, but better—as large as necessary, as small as possible (so that loop can be brought
through without strangulation).
8. Pull-through of bowel and fixation to fascia with three to four seromuscular sutures.
9. For all permanent ostomies: closure of lateral aspect along terminal bowel segment (to avoid internal wrapping),
running absorbable suture between bowel and peritoneum.
10. Closure of laparotomy or access ports.
11. Maturing of stoma:
avoid stitching through skin.
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a. Planning of roughly 0.3–0.5-cm symmetric nipple.
b. Four slightly everting sutures: dermis
base full-thickness bowel edge.
c. Placement of two to three dermis-bowel edge sutures in between.
12. Appliance.
Figure 5–15A.
Creation of an end-ileostomy.
Figure 5–15B.
Creation of an end-colostomy.
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Anatomic Structures at Risk
Mesenteric tears, injury to epigastric vessels, bowel strangulation.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated. Stoma
care education.
Complications
Bleeding (surgeon-dependent): eg, traction on mesenteric vessels.
Stoma retraction (obesity), stoma necrosis (insufficient mobilization, strangulation)
stricture (epifascial) or abdominal
sepsis (subfascial)
Small bowel wrapping around ostomy-bearing bowel, prolapse, herniation.
Cross-Reference
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Complications—stoma necrosis (569.60) (Ch. 4)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
Ileostomy takedown (Ch. 5)
Hartmann reversal (laparoscopic vs open) (Ch. 5)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
Abdominoperineal resection (APR) (Ch. 5)
CREATION OF LOOP ILEOSTOMY OR COLOSTOMY
(LAPAROSCOPIC/OPEN)
Principle
Mobilization of a loop of colon or terminal ileum to adequately reach the abdominal wall, to allow functional maturation.
Either done as the last part of a more extensive abdominal surgery (eg, LAR, IPAA) or as a separate independent procedure.
A laparoscopic approach generally is suitable for elective circumstances, an open approach as part of a major procedure or
for emergency situations with significant bowel distention or expected dense adhesions (eg, after recent exploration,
abdominal catastrophe, pelvic sepsis).
Setting
Inpatient, OR procedure.
Alternatives
Ileostomy: preferred stoma if colon empty, no distal obstruction.
Colostomy: preferred in emergency with colon full of stool.
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Indication
Diversion of stool from distal area of concern:
At time of distal surgery, eg, LAR/coloanal, IPAA, etc.
Independent/elective: fecal diversion to protect distal anastomosis or divert stool from problem area (eg,
rectovaginal/-urinary fistula, incontinence, stricture).
Independent/urgent-emergency: pelvic sepsis from anastomotic leak, perineal wound infection, acute rectovaginal
fistula, LBO (eg, in very frail patient).
Preparatory Considerations
Elective: bowel cleansing for all elective cases to avoid stasis of stool, marking of possible stoma sites, prophylactic
antibiotics.
Urgent/emergency: therapeutic antibiotics, resuscitation, stoma site marking if possible (otherwise "educated guess").
Surgical Steps
1. Patient position: supine or modified lithotomy position (depending on surgeon's preference and need to have
perineal access).
(A) Loop Ileostomy with ~3-Cm Nipple of Afferent Limb (Figure 5–16)
2. Access:
a. Indirect access, ie, through laparotomy.
b. Laparoscopic: (1) midline camera port at some distance from elected stoma sites, (2) one working port
through planned stoma site, (3) additional separate working port.
c. Direct access through planned site: not recommended as opening ends up larger than ideal and carries
increased risk of parastomal hernia or stoma prolapse.
3. Open or laparoscopic mobilization of terminal ileum (or in IPAA the most distal small bowel loop proximal to pouch)
such that it reaches beyond abdominal wall.
4. Creation of small mesenteric window and placement of Penrose drain.
5. Marking of absolute orientation (eg, one stitch in efferent limb, two stitches in afferent limb).
6. Verification that loop reaches planned ostomy site, adjustment of site if necessary.
7. Excision of skin disk at planned ostomy site: not larger than diameter of small bowel.
8. Dissection of fat and crosswise incision of anterior rectus sheath.
9. Longitudinal splitting of rectus muscle fibers (caveat: epigastric vessels!), opening of posterior sheath/peritoneum.
10. Width: general 2-finger rule may be too large for ileostomy. Better: as large as necessary, as small as possible (so
that loop can be brought through without strangulation), about diameter of small bowel.
11. In clean cases: possible wrapping/spraying of loop with antiadhesive (to facilitate later takedown).
12. Pulling through loop with help of Penrose drain, correct orientation/rotation, and possible fixation to fascia with
three to four seromuscular sutures.
13. Closure of laparotomy or access ports.
14. Maturing of stoma: avoid stitching through skin—risk of fistulae in IBD.
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a. Planning of roughly 3-cm symmetric nipple.
b. Transverse incision of efferent limb at skin level, placement of ~3 sutures from dermis to full-thickness
efferent bowel edge.
c. Pre-laying of four everting sutures to afferent limb: dermis
base full-thickness afferent bowel edge.
d. Gentle traction on all four sutures with eversion and nipple formation, followed by consecutive tying.
e. Placement of two to three dermis-bowel edge sutures in between.
15. Appliance.
(B) Loop Colostomy
2. Access:
a. Indirect access: through laparotomy.
b. Laparoscopic: (1) midline camera port at some distance from elected stoma sites, (2) one working port through
planned stoma site, (3) additional separate working port.
c. Direct access through planned site: loop transverse colostomy—half-way between midclavicular costal margin and
umbilicus; sigmoid colostomy—LLQ.
3. Open or laparoscopic mobilization of target colon so that it reaches without tension 1–2-cm beyond abdominal wall.
4. Creation of mesenteric window, placement of Penrose drain.
5. Marking of absolute orientation (eg, one stitch in efferent limb, two stitches in afferent limb).
6. Verification that loop reaches planned ostomy site, further mobilization or adjustment of site if necessary.
7. Excision of skin disk at planned ostomy site: diameter about 2 fingers wide.
8. Dissection of fat and crosswise incision of anterior rectus sheath.
9. Longitudinal splitting of rectus muscle fibers (caveat: epigastric vessels!), opening of posterior sheath/peritoneum.
10. Width: general 2-finger rule, but better—as large as necessary, as small as possible (so that loop can be brought
through without strangulation).
11. In clean cases: possible wrapping/spraying of loop with antiadhesive (to facilitate later takedown).
12. Pull-through with help of Penrose drain, correct orientation/rotation.
13. Placement of a colostomy bridge and/or a few seromuscular fixation sutures (3–4) to fascia.
14. Closure of laparotomy or access ports.
15. Maturing of stoma: avoid stitching through skin.
a. Planning of roughly 0.5-cm symmetric nipple.
b. Transverse or longitudinal incision of bowel.
c. Four slightly everting sutures to afferent limb: dermis
base full-thickness afferent bowel edge.
d. Placement of two to three dermis-bowel edge sutures in between.
16. Appliance.
Figure 5–16.
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Creation of a loop ileostomy.
Anatomic Structures at Risk
Mesenteric tears, injury to epigastric vessels.
Sigmoid and ileum: ureters.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated. Stoma
care education.
Complications
Bleeding (surgeon-dependent): eg, traction on mesenteric vessels.
Stoma retraction (obesity), stoma necrosis (insufficient mobilization, strangulation)
stricture (epifascial) or abdominal
sepsis (subfascial).
Small bowel wrapping around ostomy-bearing bowel, prolapse, herniation.
Cross-Reference
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
Complications—stoma necrosis (569.60) (Ch. 4)
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Rectovaginal fistula repair—advancement flap (Ch. 5)
Proctocolectomy, ileal J-pouch anal anastomosis (open) (Ch. 5)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
ILEOSTOMY TAKEDOWN
Principle
Restoration of the intestinal continuity that was interrupted at the level of an ileostomy. The degree of difficulty of such a
surgery depends on the extent of adhesions and the actual type of construction of the stoma, in particular whether the two
ends to be connected are located in close proximity or not. The more common loop ileostomy is taken down once the distal
area of concern (anastomosis, inflammation, etc) has fully recovered. Takedown of an end-ileostomy may involve a more
complex surgery with reconnection to a preserved rectum or colon (ileorectostomy), or a completion proctectomy (or
proctocolectomy) with ileoanal reconstruction (eg, ulcerative colitis, FAP).
Timing is dependent on general recuperation after first surgery and potential priority need for adjuvant chemotherapy or
chemoradiation.
Setting
Inpatient, OR procedure.
Alternatives
Leaving the ileostomy: by choice or if distal problem persists.
Technical variations: laparoscopically assisted, takedown during full laparotomy.
Indication
Existing loop ileostomy with confirmed integrity of distal anatomy/ reconstruction, > 6 weeks after creation (unless
earlier need for reexploration), normalized nutritional status, completely tapered off steroids.
Existing end-ileostomy with preserved anal sphincter complex and ability to perform reconstruction/reconnection.
Existing "temporary" loop ileostomy, but unresolvable distal colonic/ pelvic problem definitive APR with conversion
of loop ileostomy into end colostomy.
Preparatory Considerations
Loop ileostomy: appropriate evaluation of distal anatomy of concern; rule out leak or stricture digital rectal exam,
endoscopy, water-soluble contrast enema, or other imaging.
End-ileostomy: appropriate evaluation, discussion about further resection/reconstruction.
Overnight fasting vs low-dose bowel cleansing.
Prophylactic antibiotics.
Stress dose of steroids (eg, IBD patients) if on steroids within last 6 months.
Surgical Steps
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1. Patient position: supine or modified lithotomy position (depending on surgeon's preference and need to have
perineal access).
(A) Loop Ileostomy
2. Limited transverse eye-shaped incision around stoma, tangentially touching mucocutaneous junction at cephalad
and caudad border.
3. Division of dermis.
4. Careful dissection through all layers of abdominal wall using sharp Metzenbaum scissors, avoidance of inadvertent
injury to bowel segment (excess of traction, cautery injury), otherwise risk of inadvertent enterotomy.
5. Mobilization of bowel through fascia until peritoneal cavity is reached.
6. Completion of dissection all the way around, again with care not to cause inadvertent enterotomies: if this is not
adequately and safely possible (10–15% of cases)
midline laparotomy and dissection from inside.
7. Once adequate mobilization of ileostomy-bearing bowel loop achieved: limited division of mesentery to apex of loop.
8. Anastomosis:
a. Stapled functional end-to-end: creation of enterotomy at base of nipple for insertion of two branches of 75-
mm linear stapling device into afferent and efferent limb, device closure and firing without incorporating
mesentery
removal of stapler and transverse firing of stapler reload for closure and resection of ileostomy-
baring segment at same time; oversewing of stapler line or at least selected areas—stapler edges and cross-
points, crotch; closure of mesenteric gap.
b. Hand-sewn end-to-end: indicated particularly if not adequate length and mobility achieved
excision of
ileostomy-baring segment or unfolding of nipple followed by 1- or 2-layered anastomosis.
9. Return of bowel into peritoneal cavity, limited irrigation.
10. Loose approximation of rectus muscle, closure of fascia.
11. Subcuticular closure of skin (alternative: leaving skin open for healing by secondary intention).
(B) End-Ileostomy
2. Laparotomy
careful lysis of intraperitoneal adhesions.
3. Avoid causing enterotomies, but if they occur
immediate repair to minimize risk of leaving enterotomies unfixed.
4. Careful takedown of ileostomy: Limited transverse eye-shaped incision at mucocutaneous junction and dissection
through all layers of abdominal wall.
5. Reconnection vs resection/reconstruction:
a. Ileorectostomy or ileocolostomy: identification of receiving bowel segment
functional end-to-end
anastomosis (as described above).
b. Resection of distal segment (eg, completion proctectomy)
creation of new storage area, ie, IPAA with
possible rediverting proximally (ie, loop ileostomy).
6. Closure of the incision.
7. Appliance (if another ileostomy was created)
Anatomic Structures at Risk
Enterotomies, mesenteric tears, injury to epigastric vessels.
Aftercare
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Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
If loose stool expected
preemptive perianal skin care.
Complications
Bleeding (surgeon-dependent), anastomotic leak 1% ( abscess and enterocutaneous fistula formation), SBO up to 25%,
stricture, unsatisfactory function of anal function, need to recreate another ileostomy, incisional hernia formation. Stoma site
infection: ~20%.
Cross-Reference
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Complications—stoma necrosis (569.60) (Ch. 4)
Total abdominal colectomy with end-ileostomy (open) (Ch. 5)
Proctocolectomy, ileal J-pouch anal anastomosis (open) (Ch. 5)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
LOOP COLOSTOMY TAKEDOWN
Principle
Reversal of a temporary loop colostomy once the distal area of concern has recovered. Timing is dependent on general
recuperation after first surgery and potential priority need for adjuvant chemotherapy or chemoradiation.
Setting
Inpatient, OR procedure.
Alternatives
Leaving the colostomy: by choice or if distal problem persists.
Technical variations: laparoscopically assisted, takedown during full laparotomy.
Indication
Existing loop colostomy with confirmed integrity of distal anatomy/reconstruction, > 6 weeks after creation (unless earlier
need for reexploration), normalized nutritional status.
Preparatory Considerations
Loop colostomy: appropriate evaluation of distal anatomy of concern: rule out leak or stricture digital rectal exam,
endoscopy, water-soluble contrast enema or other imaging.
Full bowel cleansing, possibly an enema into distal limb.
Prophylactic antibiotics.
Surgical Steps