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158 Hyman
Figure 8 Cruciate incision in anterior fascia.
Figure 9 Rectus muscle fibers separated.
End Ileostomy 159
intra-abdominal hand, the posterior sheath is incised (Fig. 10). The result-
ing defect should be approximately two finger breadths in diameter (Fig.
11).
A large Kelly clamp may be placed through the stoma site and lifted
upward, providing for excellent visualization of the stoma aperture should
bleeding be encountered. A Babcock clamp is placed through the hole and
the ileum is gently delivered for subsequent maturation, taking care to en-
sure that the bowel and its mesentery have not been twisted (Fig. 12). The
mesentery should be angled in a cephalad direction. Absorbable sutures
may then be placed to affix the mesentery to the anterior abdominal wall
from the level of the stoma to the falciform ligament, although this step is
probably unnecessary (Fig. 13).
The midline incision, including the skin, is then closed and a towel
placed over it for protection. With the stoma site quarantined by surround-
ing towels or drapes, the staple line is excised. Four absorbable sutures of
3.0 or 4.0 are then placed 90 degrees apart to create an everted stoma (Fig.
14). The suture is first passed through the full thickness of the cut edge of
the bowel, then placed seromuscularly approximately 3–4 cm below the cut
edge, and then through the subcuticular layer of the skin (Fig. 15). The
Figure 10 Posterior sheath incised.
160 Hyman
Figure 11 Stoma site admits 2 fingers.
suture should not be placed through the epidermis, since this can create
mucosal islands or dense scar that may ultimately impair pouching of the
stoma (Fig. 16).
These four sutures are clamped, rather than tied, to facilitate place-
ment of additional four sutures: one between each of the corner sutures
(Fig. 15). These need not include a seromuscular bite and may be tied as
they are placed, utilizing the four corner sutures to evert the stoma and take
the tension off the sutures as they are tied. The four corner sutures are then
tied and a postoperative appliance is affixed (Fig. 16).
VI. COMPLICATIONS
Many stoma complications can be prevented by careful technique and atten-
tion to detail. Nonetheless, even a well-constructed end ileostomy may be
associated with a technical complication, or a problem may arise related to
the patient’s intrinsic disease (e.g., Crohn’s disease). These stoma-specific
complications are covered in later chapters.
End Ileostomy 161
Figure 12 Ileum delivered through stoma site.
VII. FOLLOW-UP
Patients undergoing an end ileostomy need to be properly followed and
supported after surgery. The initial follow-up appointment should be sev-
eral weeks after hospital discharge and should include the enterostomal
therapist. Much of the initial postoperative edema will have resolved and
the appliance will often need to be “downsized” for proper skin protection.
Careful early follow-up is often of particular importance to the new osto-
mate, who may feel isolated owing to new physical and emotional chal-
lenges. Each new season in the first year brings forth somewhat different
issues (e.g., clothing, diet) that may require experienced assistance. There-
after, follow-up may be individualized.
162 Hyman
Figure 13 Suture of mesentery to anterior abdominal wall.
Figure 14 Everting the stoma.
End Ileostomy 163
Figure 15 Intervening sutures placed.
Figure 16 Completed stoma.
164 Hyman
REFERENCES
1. McLeod RS, Lavery IC, Leatherman JR, Maryland PA, Fazio VW, Jagelman
DG, Weakley FL. Factors affecting quality of life with a conventional ileos-
tomy. World J Surg 1986; 10:474–479.
2. Roy PH, Sauer WG, Beahrs OH, Farrow GM. Experience with ileostomies.
Evaluation of long-term rehabilitation in 497 patients. Am J Surg 1970; 119:
77–82.
3. Hyman NH, Fazio VW, Tuckson WB, Lavery IC. Consequences of ileal pouch
anal anastomosis for Crohn’s colitis. Dis Colon Rectum 1991; 34:653–657.
4. Jimmo B, Hyman NH. Is ilea pouch anal anastomosis really the procedure of
choice for patients with ulcerative colitis? Dis Colon Rectum 1998; 41:41– 45.
5. Unti JA, Abcarian H, Pearl RK, et al. Rodless end-loop stomas a seven-year
experience. Dis Colon Rectum 1991; 34:999–1004
10
Continent Stomas
Stephen R. Gorfine
Mount Sinai School of Medicine and Mount Sinai Hospital, New
York, New York U.S.A.
INTRODUCTION
The achievement of continence, the ability to control the time and place of
evacuation of intestinal waste, is one of the earliest developmental mile-
stones in nearly all human societies. Until relatively recently, surgical cre-
ation of any kind of intestinal stoma was virtually certain to result in the
loss of this most basic function. Over the past 30 years considerable effort
has been devoted to the development of means by which continence can be
re-established for the person with an intestinal stoma.
CONTINENT ILEOSTOMY
Early work in the field of stomal continence was performed in the 1960s
by Professor Nils G. Kock at Sahlgren’s Hospital in Goteborg, Sweden [1].
Kock found that a double-folded ileal pouch provided a low-pressure reser-
voir capable of “storing” the intestinal effluent [2]. Early clinical results
using this technique were encouraging, but not all patients achieved satis-
factory continence. Reliable stomal continence was realized in 1972 with
the addition of a “nipple valve,” formed by intussusception of the intestinal
segment distal to the reservoir [3].
The Kock pouch was enthusiastically embraced by patients who
would otherwise have required a permanent Brooke ileostomy. Most conti-
nent ileostomies were performed for young adults suffering from chronic
mucosal ulcerative colitis. The majority of these patients felt that the reser-
voir ileostomy significantly improved the quality of their lives. Many were
quite willing to undergo multiple revisional procedures rather than return
to an external ostomy device.
Initial enthusiasm for the Kock pouch was tempered by numerous
early failures. Many surgeons found that the procedure was technically de-
165
166 Gorfine
manding and difficult to master. These obstacles placed this operation out
of the reach of all but the most dedicated and interested surgeons. Even
technical mastery did not guarantee good functional results. The intussus-
cepted nipple valve proved to be an unreliable closing mechanism. Incon-
tinence caused by slippage or desusception of the valve was reported in
nearly 50% of early cases [4–7].
Despite early failures, growing patient demand for a reliable continent
ileostomy stimulated the pursuit of improved long-term results and de-
creased morbidity. Novel experimental and clinical techniques were con-
ceived with these goals in mind. For example, continence was achieved in
nonreservoir ileostomies by intestinal intussusception [8] and indwelling
catheter occlusion [9]. Although both techniques provided continence, nei-
ther approach gained widespread acceptance.
Most investigators concentrated on improving the valve mechanism
of the reservoir ileostomy. Many believed that the intussuscepted nipple
valve was basically a sound concept and that improved long-term stability
could be achieved by modifying the construction techniques. Others rea-
soned that the intestinal valve was intrinsically flawed and that its replace-
ment by a prosthetic occlusive device would be a better option. The middle
ground was taken by those who felt that supporting the intussuscepted nip-
ple with a prosthetic or natural girdle would offer a better solution.
Steps to improve the reliability of the original Kock nipple valve were
undertaken early in the evolution of the procedure. Stripping the serosa
from the intussuscepted segment, staple fixation of the valve, and applica-
tion of a special “rotational suture” proved to be useful and effective ad-
juncts [1]. Prolonged postoperative pouch intubation also helped to reduce
valve complications [10].
Complete replacement of the valve by various prosthetic mechanisms
was also investigated. The Mayo Clinic group found that a cuffed Silastic
catheter, similar to an endotracheal tube, restored continence in “failed”
Kock ileostomies [11] (Fig. 1) Fendel and Fazio [12] replaced the nipple
valve by a porcine aortic valve in an experimental model. A mucosal “flap”
valve was created in another experimental setting [13]. Magnetic closing
caps were implanted successfully in two patients [14]. Although the devices
subjected to clinical trials were able to maintain continence, various com-
plications and limited patient acceptance prevented widespread adoption of
these techniques.
A different approach was taken by Fazio, Cohen, Barnett, and others.
They found that the intussuscepted nipple valve was more stable when it
was mechanically supported at its function with the pouch and the outflow
tract. A strip of fascia [15], Marlex, or Prolene [16] and, later, an ileal limb
[17] was used to buttress the valve. Short-term results were promising. A
dramatic decrease in the rate of valve desusception was reported. However,
Continent Stomas 167
Figure 1 Inflatable cuffed Silastic occlusion catheter in place in “failed” conti-
nent (Kock) ileostomy. (Courtesy Gauthier, Rochester, Minn.)
an equally dramatic rise in the rate of late fistula formation was associated
with use of the various plastic materials [18,19].
Despite improved functional results, interest in the continent ileostomy
faded during the 1980s with the revival of a procedure abandoned three de-
cades previously. In 1977 Martin et al. [20] reported successful preservation
of continence after total colectomy by mucosal proctectomy and ileoanal
anastomosis. In 1978, Sir Alan Parks combined abdominal colectomy and
mucosal proctectomy with an ileal pouch and pouch-anal anastomosis [21].
This new procedure completely elimina ted the need for a permanent abdomi-
nal stoma. Use of the anal sphincter as the pouch closing mechanism effec-
tively solved the valve problem. Although the new procedure had its own
complications, enthusiasm for restorative proctocolectomy by ileal pouch—
anal anastomosis grew quickly among patients and surgeons. By the late
1980s, call for the continent ileostomy had virtually cease [22].