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6
End Sigmoid/Descending
Colostomy
Thomas E. Cataldo
University of Medicine and Dentistry of New Jersey,
Robert Wood Johnson Medical School, Cooper Health System,
and Cooper Colorectal Care Center, Camden, New Jersey, U.S.A.
INTRODUCTION
The ability to create a healthy, well-functioning, easily manageable colos-
tomy is essential for all abdominal surgeons. Colostomy creation was one
of the first abdominal operations performed historically. It is a frequent part
of emergent colonic surgery, and almost any abdominal procedure carries
some risk of requiring a colostomy or ileostomy. Historically, in the case of
emergent colonic surgery, a transverse colostomy was created for proximal
diversion. Currently, end sigmoid colostomies are the most frequent diver-
sions in the case of sigmoid perforation. This itself is diminishing with the
increasing frequency of single-stage resection for acute diverticulitis. If a
distal anastomosis or surgical site requires proximal fecal diversion, a loop
or end-loop ileostomy is growing in popularity.
An ostomy is simply an anastomosis between an endothelially lined
organ (e.g., intestine, trachea) and the skin. However, a properly con-
structed stoma should be free of complications such as retraction, stricture,
and prolapse. Although often meant to be temporary, many colostomies are
in place for months to years. Every colostomy should be created as if it
were to be the patient’s only mode of defecation for life. As in all intestinal
surgery, the principles of tension-free construction with adequate blood
supply and minimal tissue manipulation result in the best functional out-
come.
A colostomy will frequently be a significantly life-altering event, even
if only temporary. Whenever possible, it is best to have the patient and
family well educated prior to surgery. When available, the preoperative
evaluation and marking by a qualified enterostomal therapist results in
greatly improved patient satisfaction and functional result [1,2].
111
112 Cataldo
INDICATIONS
Colostomies are created to be permanent or temporary; they are created
electively, emergently, or incidentally due to an unexpected event in sur-
gery. An elective, permanent end sigmoid colostomy is created as part of
an abdominoperineal distal rectal resection for cancer. Alternatively, one
creates the same stoma for improved hygiene in a paraplegic or an individ-
ual with permanent fecal incontinence. Here, a laparoscopic approach is
frequently employed. An elective but temporary sigmoid colostomy is indi-
cated in a patient with a near obstructing rectal cancer who is undergoing
preoperative radiation therapy prior to curative resection. A sigmoid colos-
tomy may be indicated in association with complex sphincter/perineal pro-
cedures. However, many surgeons prefer an ileostomy for elective tempo-
rary fecal diversion.
End sigmoid colostomies are frequently created as part of emergent
colonic surgery for obstruction, perforation, or trauma. After resection of a
diseased rectosigmoid, the remaining colon or the local environment may
not be suitable for immediate reconstruction. The classic example is Hart-
mann’s two-stage procedure for acute and/or perforated diverticulitis.
Lastly, one may need to create a rapid colostomy even if the tissue is ade-
quate in order to complete a procedure expeditiously in an unstable patient.
There are no contraindications to end colostomy creation per se other
than complete resection of the colon. Certainly bowel that is of questionable
viability or overly manipulated should not be used to create a colostomy.
There is little documented evidence in the literature to support the avoid-
ance of stoma creation in an individual with portal hypertension. However,
portosystemic shunting will frequently occur, creating a peristomal caput
medusae. This can result in gastrointestinal hemorrhage that is difficult to
control. Surgical judgment will dictate whether the risks associated with an
anastomosis outweigh the potential for anastomotic complications. Consid-
eration should be given to the patient’s ability to care for the colostomy,
especially when the location is being chosen. Examples include but are not
limited to visual impairment and severe arthritis.
OPERATIVE TECHNIQUE
Mobilization and Preparation of the Colon
The necessity of a colostomy should not alter the technique or extent of
resection. Once oncologic or infection control requirements are met, the
remaining colon is prepared for colostomy creation. It is my preference to
fully mobilize and prepare the colon prior to creation of the trephine. In
this way there will be adequate time for any compromise of the distal bowel
to present itself prior to maturation. Use of a liner stapler for proximal
End Sigmoid/Descending Colostomy 113
division of the colon is helpful in limiting contamination and provides a
closed end of bowel that is easy to manipulate through the abdominal wall.
At this point, the sigmoid attachments to the pelvis should be divided if not
already done. Frequently the left lateral peritoneal reflection of Toldt must
be incised as well. The posterior retroperitoneal plane is dissected to free
up the left colon and sigmoid mesenteries. Care should be taken to avoid
injury to the left ureter and gonadal vessels, as is done during all dissection
in this area. Dissection and mobilization should be limited to only that
which is necessary to bring the end of the colon 3–4 cm past the skin
without tension. Excessive mobilization may compromise blood supply or
contribute to stomal prolapse. In the event of complete sigmoid resection,
splenic flexure take-down will frequently be required. It may be necessary
to divide the to provide length. In this case the artery should be divided as
close to the aorta as is feasible so as to preserve blood flow through the
proximal arcade. If there is significant fat surrounding the end of the colon,
it is helpful to clear it at this time. A distance of up to 4 cm of serosa can
be cleared circumferentially without vascular compromise.
Siting the Colostomy
If at all possible, the site of the colostomy on the anterior abdominal wall
should be chosen preoperatively and marked by an enterostomal therapist.
In the case of an emergent or unplanned colostomy, the following is a
helpful rule in patients of almost any body habitus (Fig. 1). A triangle is
defined from the symphasis pubis to the umbilicus to the anterosuperior
iliac spine (ASIS). This triangle is bisected by a transverse line at the ASIS.
Choose the location at or slightly above the center of the upper triangle.
Alternatively, in a significantly obese patient, a stoma may be sited superi-
orly to the umbilicus through the rectus abdominis. This is only a rough
guide. If an ET nurse is not available to site the stoma, the surgeon should
mark the patient preoperatively. Beginning with the technique above, an
appliance is then placed on the patient. The patient is then evaluated sitting
and standing as well as supine. If the proposed site overlies a skinfold or
falls out of sight, the mark should be adjusted appropriately.
Creating the Trephine
Centered on the spot chosen, using knife or electrocautery a circular disk
of skin is removed approximately the size of a quarter. Although this may
seem small, the hole will enlarge once the disk is removed. I prefer not to
excise a core of subcutaneous fat. Because skin does not stretch equally in
all directions, holding the skin aloft and cutting with a scalpel parallel to
the floor will often produce an oval opening. This should be avoided. With
the skin disk excised, a longitudinal incision is made down to and through
114 Cataldo
Figure 1 When a site for ileostomy location is being chosen, scars, bony promi-
nences, and the umbilicus must be avoided. (Modified from Corman ML. Colon
and Rectal Surgery, 3d ed. Philadelphia: JB Lippincott, 1993, p. 939.)
the anterior rectus sheath. It is critical to keep the midline skin incision
aligned with the midline fascial incision. A helpful trick is to grasp the
fascia and the dermis with Oschner clamps. Holding the two clamps to-
gether will avoid placing the opening in the fascia too close to the midline
fascial closure (Fig. 2). With a 2- to 3-cm incision made in the anterior
sheath, the rectus muscle is split bluntly down to the posterior sheath/peri-
toneum. A reliable instrument for this is straight Mayo scissors. With the
scissors held closed and aligned in the direction of the rectus fibers, the
scissors are bluntly insinuated through the muscle to the posterior sheath.
Placing a folded lap pad under the abdominal wall and pressing upward
will protect the bowel and allow easy cautery dissection into the peritoneal
cavity. The scissors are rotated 90 degrees and opened, separating the mus-
cle evenly and allowing Army-Navy retractors to be placed through the
muscle to the posterior sheath. Once the abdomen is entered, the muscular
and fascial opening should be enlarged to allow easy passage of the bowel.
End Sigmoid/Descending Colostomy 115
Figure 2 Construction of end colostomy. A. Incision of abdominal wall at stoma
site to create a circular skin opening. B. Rectus sheath has been incised in a vertical
direction, and rectus muscle is split.
By holding the index and second digits of both hands together crosswise
through the defect one has a good rule of thumb.
With the trephine completed, a Babcock clamp is passed inward
through the hole and can be used as a retractor, lifting the jaws to inspect
for bleeding form the peritoneal side. Grasping the stapled end of the bowel
with the Babcock, the end of the colon is brought through the abdominal
wall and held at least 3–4 cm beyond the skin surface. If there is adequate
length of colon, more distance above the skin is preferred.
116 Cataldo
With the distal aspect of the colon held outside the abdominal wall;
one should reinspect for adequate blood supply, hemostasis, and lack of
tension. Some surgeons choose to employ methods designed to prevent par-
astomal herniation and prolapse. These methods include raising peritoneal
flaps and tacking the mesentery to the abdominal wall. My personal prefer-
ence is to avoid these steps. They take time, run the risk of their own
complications, and are of questionable value.
Maturing the Stoma
The abdominal wall and skin are closed prior to maturation of the colos-
tomy. Delayed maturation of the colostomy is mentioned only to be con-
demned. There is no reason in the twenty-first century other than hemody-
namic instability not to mature the colostomy during the initial operation.
With the midline incision protected, the distal aspect of the colon is
opened. Full-thickness sutures are taken at the cut edge of the colon. The
suture is brought down to a seromuscular bite 3–4 cm proximally and then
to a dermal bite. The suture should be taken in this order in order to avoid
implanting mucosal cells in the dermis (Fig. 3). Care should be taken not
to include a full-thickness bite of the skin. My preference is to place four
initial sutures—superiorly, inferiorly, medially, and laterally. Any absorb-
able suture material may be used, such as 3-0 or 4-0 Vicryl or Monocryl.
The sutures are placed without tying. With all four in place, the stoma is
then everted and inspected. At the surgeon’s discretion, one or two sutures
are placed between each of the other four (eight to twelve total). These
sutures may simply be from the full-thickness end of colon to the dermis,
as the bowel is already everted. When completed, the os, or opening of the
stoma, should be in the center. If not, the patient may have significant
problems with pouching or leaking under the appliance.
Figure 3 Colostomy maturation. Sutures are placed from the bowel (full thick-
ness) to the deep dermal layer of the skin.
End Sigmoid/Descending Colostomy 117
COMPLICATIONS AND PITFALLS
End sigmoid colostomies are easier to manage, with fewer complications
than other stomas. Complications are divided into early and late. Early
complications are frequently technical in nature and may require immediate
intervention. Frequently, observation alone is adequate. Late complications
may be the result of early complications but more often are part of the
natural history of colostomy. Surgical intervention is frequently required,
but enterostomal therapists provide much of the care. Risk factors are the
same as for most of abdominal surgery: advanced age, obesity, poor wound
healing secondary to diabetes, and poor nutrition. Disease process is not
an independent risk factor, but the creation of an emergency colostomy is
associated with a higher complication rate [3–5].
By the time one is ready to mature the colostomy, the blood supply
should have been unchanged for several minutes. Any demarcation or com-
promise from inadequate blood flow should be more than evident. Despite
this, some type of colostomy necrosis occurs in 2–17% of cases [4]. The
mucosa is more sensitive to arterial compromise, and this may become
more apparent when the colon is opened. At this point, transillumination is
a simple technique to establish adequacy. If the mucosa transmits light well,
it will most likely continue to be fine. If blood flow was adequate prior to
maturation or before passing the colon through the trephination, ischemia
may be due to compromise at the fascial level. An effort can be made to
enlarge the fascial opening slightly. If the patient or the colon is cold, arte-
rial spasm may make the mucosa appear marginal. Holding the colostomy
in a lap sponge soaked in warmed saline may improve its appearance. Small
needle pricks may also demonstrate adequate arterial supply. More com-
monly, and far less concerning, the venous outflow of the colostomy may
be compromised. This usually will not become apparent for many hours
after completion of the case. The colostomy appears dark and swollen, of-
ten with a purplish hue. Transillumination again is helpful. Despite a dark
color, colon with adequate arterial inflow and compromised outflow will
still transilluminate well. A colostomy with significant venous congestion
may slough its mucosa and appear nearly necrotic but in the end may heal
to a viable, well-functioning colostomy. If questions remain as to the colos-
tomy’s viability or if a return to the operating room is considered for revi-
sion, bedside endoscopy of the colostomy may be performed. This simple
and most rapid technique is performed with a phlebotomist’s test tube and
a penlight. After removing the stopper top, a well-lubricated tube is passed
through the colostomy. It may be passed through the fascia. If the stoma is
viable, shining the penlight down the tube should demonstrate healthy pink
mucosa.
A grossly ischemic or infarcted colostomy calls for a return to the
operating room for revision. If the vascular compromise goes below the
fascia, repeat laparotomy is in order. If the ischemia is limited to the distal-