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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1784_Библиотеки_им_академика_М_И_Перельмана.pdf
168 Gorfine
Indications and Patient Selection
Continent ileostomy remains a therapeutic option open to selected patients
who would otherwise require a permanent end ileostomy. Most candidates
for this procedure have chronic mucosal ulcerative colitis or familial ade-
nomatous polyposis. Some of these patients will choose the continent stoma
as a primary or secondary procedure because of personal lifetyle consider-
ations. For others, reservoir ileostomy may be the only continence-preserv-
ing alternative when the anal sphincter is unsuitable because of weakness,
disease, surgical extirpation, or failure of a previous ileoanal procedure [23].
Selection of appropriate candidates for reservoir ileostomy is of the
utmost importance. The risk of complication is significantly greater in cer-
tain patient populations. Long-term management of the stoma requires both
cognitive and manual skill. All candidates must demonstrate the physical
and emotional maturity needed to cope with ordinary and occasionally ex-
traordinary stomal maintenance.
Patient education is equal in importance to patient selection. The me-
chanics of the reservoir ileostomy, as well as its potential risks and benefits,
must be clearly, completely, and honestly explained to all suitable candi-
dates. Candidates must become familiar with the concept of the reservoir
and the valve. They must accept the possibility that the procedure may be
abandoned intraoperatively because of unexpected findings or circumstances.
The risk that repeated revisional surgery may become necessary must be
clearly understood. We find it helpful to have a candidate for surgery speak
to a patient who has undergone the procedure.
Continent ileostomy is not recommended in patients with Crohn’s dis-
ease, suboptimal nutritional or immunological status, or short bowel syn-
drome [22,24,25]. These conditions raise the risk of complication to an unac-
ceptably high level. Emergency surgery, extremes of youth or age, obesity,
and inability to intubate the pouch because of mental or physical impairment
are also considered contraindications to a reservoir ileostomy [22,24,25].
Operative Technique
Preoperative preparation includes standard mechanical and antibiotic bowel
preparation and enterostomal counseling. WIth the patient under general
anesthesia, the abdomen is entered through a midline incision. When indi-
cated, proctocolectomy, proctectomy, or take-down of a standard ileostomy
is performed in the standard fashion. In all cases, every effort is made to
preserve the ileal blood supply and conserve maximal ileal length.
The complete continent ileostomy is constructed from the terminal 45
cm of ileum. The nipple valve, outflow segment, and stoma are created
from the most distal 15 cm. The reservoir is made from the proximally
adjacent 30 cm of intestine.
Continent Stomas 169
The pouch is created first. The antimesenteric border of the ileum is
grasped with a Babcock clamp 30 cm from the cut end. This distance should
be accurat ely measured with a marked scalpe l handle or ste rile ruler. The bowel
is then folded upon itself with the 30-cm point resting at the apex of the loop.
The antimesenteric borders of the ileal loop are approximated with
either staples or sutures. When sutures are used, a running layer of 3-0,
long-term absorbable suture is used to approximate the antimesenteric bor-
ders of the opposed limbs. This suture line runs for a distance of 15 cm from
the loop’s apex (Fig. 2). The approximated ileal limbs are opened with
electrocautery parallel to the suture line. The incision in the afferent limb
is continued proximally 2–3 cm beyond the distal termination of the inci-
sion in the efferent limb. This method will allow the afferent and efferent
limbs to be separated when the pouch is closed. Both enterotomies are
continued to the tip of the loop, where they meet. A second layer of run-
ning, 3-0, long-term absorbable suture joins the two cut edges, leaving a
U-shaped pouch of small bowel open toward the inflow and outflow tracts
(Fig. 3).
Alternatively, a 90-mm linear stapler can be used to fashion the pouch.
In this case, the bowel is opened with electrocautery along the antimesen-
teric borders of both of the opposed ileal limbs for a distance of 15 cm
Figure 2 Construction of continent ileostomy from distal 45 cm of ileum. Most
distal 15 cm is used to form the valve and the outflow tract. Adjacent 30 cm of
small bowel is folded on itself to form the pouch. Running 3-0 absorbable sutures
approximate the antimesenteric borders. Both limbs are then opnened parallel to
the suture line (dashed line). Note that incision in proximal limb extends 2 to 3 cm
beyond the end of the suture line.
170 Gorfine
Figure 3 Continent ileostomy with cut edges joined, leaving U-shaped pouch of
small bowel. A second layer of running sutures is place.
from the apex. The cut edges of the adjacent limbs are stapled with two
applications of the 90-mm stapler. The incision in the afferent limb is con-
tinued proximally 2 to 3 cm beyond the end of the staple line,
The nipple valve is constructed from the 10 cm of distal ileum adja-
cent to the reservoir. The intussuscepted valve will be about 5 cm long.
Multiple techniques are employed to promote permanent fixation of the
valve in the intussuscepted position. These include thinning of the valve
mesentery, scarification of the intestinal surface, and placement of sutures
and staples.
Preparation of the ileal segment for intussusception begins by reduc-
ing its mesenteric bulk. This reduction is accomplished by excising the fat
between the blood vessels (Fig. 4). Exceptional care must be exercised dur-
ing this maneuver so that injury to the segment’s blood supply is avoided.
The serosa is then abraded with a fine rasp and scored with electrocautery.
Scattered subserosal injections of a concentrated tetracycline solution are
also helpful in promoting adhesion between the opposing surfaces.
Three 3-0 silk seromuscular sutures are placed on both sides of the
mesenteric border, equidistant from the point of intussusception (Fig. 5).
When tied, these sutures will help to maintain the intussusception. Rotation
of the valve is not necessary. A Babcock clamp is passed from the pouch
into the distal ileal segment and the wall is grasped 5 cm from its junction
with the reservoir. Gentle traction applied in the direction of the pouch
lumen will cause intussusception of the segment. The previously placed silk
Continent Stomas 171
Figure 4 Mesenteric fat between blood vessels is excised in preparation for
valve intussusception.
Figure 5 Serosal surface of the valve segment is abraded. Silk seromuscular
sutures are placed on both sides of the mesentery.
172 Gorfine
seromuscular sutures are sequentially tied as the segment is intussuscepted
(Fig. 6A and B).
The valve is further stabilized by three rows of staples, one placed on
either side of the mesentery and the third on the antimesenteric border (Fig.
7). These staples are most easily placed with a bladeless linear stapler-
cutter. In addition, six to eight 3-0 silk sutures are passed through all layers
of the valve. To minimize the risk of nipple fistula, these sutures should
enclose only a small bridge of tissue and should not be tied so tightly as to
strangulate the encircled bowel. Lastly, a row of interrupted 3-0 silk sutures
fixes the base of the valve to the surrounding pouch wall at its point of exit
(Fig. 8).
The pouch is closed by bringing the apex of the U to the base of the
valve (Fig. 9A). A double layer of running 3-0 long-term absorbable su-
tures is used to close the enterotomy (Fig. 9B). Alternatively, two applica-
tions of the 90-mm stapler can be used to close the pouch. When the reser-
voir is complete, competence of the valve is tested. The inflow tract is
occluded with an intestinal clamp. A bullet-nosed catheter is passed into
the pouch through the outflow tract and valve. Air is insufflated and the
catheter removed. The pouch should remain distended.
Barnett recommends encirclement of the outflow tract with an ileal
“collar,” thereby creating a “Barnett continent intestinal reservoir” (BCIR)
[26]. In Barnett’s modification, the U-shaped pouch and intussuscepted
valve are made as previously described. The ileal segment in continuity
with the proximal bowel is transected 10 cm from the pouch. The 10-cm
segment of ileum that remains connected to the pouch will be fashioned
Figure 6 A. Valve is intussuscepted and seromuscular sutures are tied. B. Intus-
suscepted valve.
Continent Stomas 173
Figure 7 Valve is secured with three rows of staple or silk sutures. Staples are
placed with a bladeless instrument.
Figure 8 Interrupted silk sutures are used to secure the base of the valve to the
outflow tract.
174 Gorfine
Figure 9 a. Pouch is closed by folding the apex of the U to the base of the valve.
b. Pouch is completed by placing running absorbable sutures from the corners to
the apex.
Continent Stomas 175
Figure 10 Continuity between the pouch and the terminal part of the ileum
established with EEA (U.S. Surgical Corp.) instrument.
into a collar supporting the valve. After the inflow segment is transected
and prior to closure of the anterior pouch wall, the apex of the pouch is
stapled to the cut end of the distal ileum (Fig. 10).
The collar is created as follows:
A defect in the mesentery at the base of the valve [is] created, and
the end of the distal segment of intestine [is] drawn through and sewed
around the base of the valve to form a collar (Fig. 11a,b). Cotton sutures
Figure 11 a. Access segment mesenteric defect has been created. b. The intesti-
nal segment is passed through the mesenteric defect at the base of the valve.
176 Gorfine
[are] used to fix the collar to the access segment above and to the pouch
below. The end of the collar [is] sutured to its origin to form a complete
circle. A snug fit of the collar should be accomplished and additional
sutures [are] placed if necessary. The optimal level of collar constriction
[is] achieved by placing the index finger through the access segment and
palpating each degree of incremental tightening [26] (Fig. 12).
The flush stoma is created from the pouch outflow segment. The posi-
tion of the stoma on the abdominal wall is determined after placing the
reservoir in the pelvis. The outflow tract should traverse the midportion of
the right rectus muscle without angulation or redundancy. In most cases,
the stoma will lie just above the pubic hairline. The stomal defect in the
anterior abdominal wall is made by excising a 2-cm disk of skin. The sub-
cutaneous fat is retracted and the fascia opened by a cruciate incision. The
fibers of the rectus muscle are split and the peritoneum is incised. The defect
should easily admit two fingers.
Before bringing the outflow tract through the abdominal wall, the
pouch is rendered heart-shaped by pushing the lateral “ears” into the leaves
of the mesentery. Four 3-0 silk anchoring sutures are passed from the pouch
to the peritoneum surrounding the stomal site (Fig. 13). The outflow tract
is passed through the abdominal wall defect and the anchoring sutures are
tied. A closed suction drain is placed in the right gutter, lateral to the pouch.
The end of the drain is brought out through a separate abdominal wall stab
wound.
The stoma is matured before the abdominal wound is closed. The ex-
teriorized ileum is trimmed until the cut edge is flush with the skin. The
Figure 12 Collar stoma allows free communication with the pouch.
Continent Stomas 177
Figure 13 Outflow tract is brought through the abdominal wall. Silk sutures are
used to anchor the pouch to the parietal peritoneum.
ileal edge is anchored to the dermis with interrupted 3-0 long-term absorba-
ble sutures. An ileostomy catheter introduced through the stoma should en-
ter the pouch without difficulty.
A crosspiece is fashioned from a 3-in. segment of 32F rubber tubing
by cutting 1-cm holes in the middle of the opposing walls. The crosspiece
is used to anchor the ileostomy catheter to the abdominal skin. The ileos-
tomy catheter is passed through the holes in the crosspiece and then inserted
into the pouch. The catheter’s position within the pouch is ascertained by
palpation. The catheter is held in this position and the crosspiece is brought
to skin level. The crosspiece is then sutured to the abdominal wall skin.
The abdominal wound is closed and dressed in standard fashion (Fig. 14).
The ileostomy catheter is attached to gravity drainage.
Postoperative Management
The pouch is irrigated with 20 mL of normal saline instilled through the
catheter every 4 hr for the first 24 hr after surgery. Continuous gravity
drainage is maintained between irrigations. On the second day, the fre-
quency of irrigation is reduced to every 8 hr. This irrigation schedule is
continued for the remainder of the hospital stay. In the early postoperative