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208 Strong
a supine manner, a modified lithotomy position being preferred if the rec-
tum will be used for the distal limb of the anastomosis or endoscopic access
to the large bowel is necessary. If the rectum has been transected below the
superior rectal valve or a difficult pelvic dissection is anticipated, ureteral
stents might enable the surgeon to avoid or recognize ureteral injury. Fol-
lowing induction of general or regional anesthesia, the abdominal cavity is
entered through a midline wound and exploration is conducted following
appropriate enterolysis. Generally, the stoma must be taken down prior to
abdominal exploration to facilitate evaluation of the pertinent structures.
An elliptical incision is made at the ostomy’s mucocutaneous junction, and
the dissection then proceeds along the bowel wall with circumferential mo-
bilization continued into the peritoneal cavity. Sharp dissection and appro-
priate retraction are used throughout this portion of the procedure. After
delivery of the bowel into the peritoneal cavity, the open lumen is occluded
with an atraumatic clamp to prevent fecal contamination of the peritoneal
cavity and wound.
With an end ileostomy, the neoterminal ileum is typically joined to a
segment of colon or the rectum. This ileocolostomy can be constructed in
any number of configurations with sutures or staples, whereas an ileoproc-
tostomy should generally be oriented as an end-to-end or side-to-end anas-
tomosis. With the ileocolostomy, the mesentery of the two bowel limbs
must be inspected to assure that there is no torsion, and a tongue of omen-
tum can be mobilized to quarantine the anastomosis. The omental pedicle
may help to minimize the morbidity associated with a subsequent anasto-
motic leak. For the ileoproctostomy, the rectal remnant must be identified
and readied. Many surgeons endorse passing a circular stapling instrument
transanally and performing the anastomosis with the bowel that readily ac-
commodates the end of the stapler. However, this sometimes creates an
end-to-side anastomosis characterized by a blind end of proximal rectum
lying cephalad to the ileoproctostomy. This type of anastomosis is prone to
stricturing, requiring hydrostatic dilatation or operative revision. Even worse,
the vagina can be included in the anastomosis with disastrous results. Con-
sequently, it is best to mobilize the upper rectum and assure that the sta-
pling instrument incorporates the top of the rectum. Personal preference
may dictate that the upper rectum ought to be amputated and a purse-string
suture placed to verify that the end of the rectum is used. In mobilizing the
upper rectum, the surgeon must recall that the ureters and iliac vessels can
be medially drawn from their usual location. Thus, careful dissection is
essential to avoid damage to these structures. In especially difficult situa-
tions, a dilator can be passed transanally or the rectum can be transillumi-
nated with a fiberoptic endoscope to facilitate the dissection. Following
completion of the anastomosis, the bowel is occluded proximal to the anas-
tomosis and air is insufflated transanally while the ileoproctostomy is sub-
merged in saline. As the bowel distends, air bubbles rising out of the saline
Ostomy Take-Down 209
point toward an anastomotic leak, which requires suture repair prior to clo-
sure. A hand-sewn ileoproctostomy should be similarly approached and the
same cautionary advice considered. The peritoneal cavity is then irrigated
with warmed saline and the bowel returned in an orderly manner. The old
stoma aperture is closed, assuring that the anterior sheath is included, and
the fascial margins of the midline wound are approximated. The subcutane-
ous tissues are also irrigated and the skin edges are typically abutted with
metal clips.
An end colostomy take-down usually entails either a hand-sewn or
stapled end-to-end coloproctostomy. The operation is conducted similarly
to the method described for ileoproctostomy. However, if the colostomy
was created at the time of surgery for perforated diverticular disease, which
is most common, the initial operative resection may have been limited to
the perforated bowel segment. In this case it is imperative to resect the
proximal bowel in an area where muscular hypertrophy is absent and to
divide the distal bowel below the level where the teniae coli become conflu-
ent, demarcating the true rectum. To leave distal sigmoid colon unresected
almost doubles the risk of problems with recurrent diverticulitis.
In the past decade, a laparoscopic approach to end ostomy take-down
has been described by several groups [24–27]. The same surgical principles
are upheld, and the operation can often be performed without conversion
to laparotomy. Although the operative time is increased over that associated
with laparotomy, retrospective studies suggest that the duration of ileus and
length of stay are shortened without compromising safety.
Loop Stoma
Loop stomas are typically constructed from the terminal ileum, but more
proximal small bowel or large bowel can be utilized. Three techniques can
be employed for closure of a loop ileostomy; they include suture closure of
the enterotomy, limited resection of the loop with end-to-end hand-sewn
enteroenterostomy, and limited resection of the loop with side-to-side sta-
pled enteroenterostomy. Regardless the technique, the patient is generally
placed in a supine position with the entire abdominal wall prepared and draped
in case a formal laparotomy becomes necessary, as witnessed in 1–3% of
cases [28]. A general anesthetic is typically employed, but regional or local
anesthesia with concomitant conscious sedation can be utilized if the clini-
cal situation mandates [29]. An elliptical incision is made in the skin sur-
rounding the remaining stoma >3 mm from the mucocutaneous junction.
Clamps may be placed on the skin edge attached to the loop to facilitate
retraction without traumatizing the bowel wall. The dissection is then car-
ried adjacent to the bowel wall with circumferential mobilization of the
loop continued into the peritoneal cavity. Sharp dissection and appropriate
retraction are used throughout this portion of the procedure. The loop is
210 Strong
usually first mobilized from the lateral fascia and peritoneum because adhe-
sions to the midline wound can make the medial dissection more tedious.
After the peritoneal cavity has been entered, a finger can gently be inserted
alongside the loop to identify any potentially troublesome adhesions and
facilitate mobilization of the loop ostomy. The surgeon is often tempted to
use this guiding finger to disrupt adhesions that might be encountered.
However, this urge must be ignored, because blunt dissection may result in
unrecognized damage to the loop stoma or nearby segments of intestine.
This advice is substantiated by the finding that postoperative intra-abdomi-
nal sepsis more often originates from an injured segment of adjacent bowel
than from the closure site [30]. It is not uncommon for the most difficult
dissection to occur at the superior and inferior aspects of the wound, where
the rectus muscle is intimately adhered to the bowel wall. If the poor visual-
ization is compromising safe stoma mobilization, the wound can be enlarged
by extending the skin incision or fascial aperture. Once the loop has been
freed from its attachments and sufficient intraperitoneal fascia has been
cleared of adhesions, dilute povidone-iodine solution is infused into the oc-
cluded bowel limbs to determine whether a significant seromuscular injury
or enterotomy has occurred.
If the ostomy is to be closed by suturing of the enterotomy, the
everted loop is reduced and the mucocutaneous junction excised. The edges
of the enterotomy are transversely approximated in a one- or two-layer
manner depending upon the surgeon’s preference. Alternatively, significant
stricturing of the loop, associated enterotomy, or surgeon’s choice may dic-
tate that the loop be excised and continuity restored by creating an enter-
oenterostomy. The bowel is sharply transected proximal and distal to the
ostomy and the associated mesentery divided with electrocautery; suture
control of the mesenteric vessels is occasionally needed. A hand-sewn anas-
tomosis can be created in an end-to-end configuration with the particulars
dictated by the surgeon’s familiarity with the various techniques. Care must
be taken to assure that an adequate lumen persists at the procedure’s com-
pletion. A stapled anastomosis is typically performed in a side-to side man-
ner, with particular attention directed at rotating the bowel to assure that the
mesentery is not incorporated into the anastomosis. If this occurs, recog-
nized bleeding from the staple line must be suture-controlled. Also, ade-
quate lengths of small bowel must be delivered into the wound so that the
distal end of the stapling instrument can be visualized and any adjacent
bowel segments be excluded from the anastomosis.
Following closure of the loop ostomy, the intestine and wound are
irrigated and hemostasis is assured. The bowel is returned to the peritoneal
cavity without torsion to the mesentery, and the fascial margins are approx-
imated with absorbable suture. The wound may be primarily closed or left
open to heal by secondary intention in 3–4 weeks.
Ostomy Take-Down 211
Loop colostomies are usually closed in a manner similar to that de-
scribed for loop ileostomies except that a stapled anastomosis is rarely em-
ployed because it is more difficult to mobilize sufficient large bowel to
facilitate a tension-free anastomosis. The stoma aperture also tends to be
larger with a loop colostomy, more commonly located in the upper abdo-
men, and prone to postoperative hernia [31]. Particular care must be taken
to assure that both the anterior and posterior rectus sheaths are included in
the fascial closure, and appropriate technique is employed to minimize the
potential for future incisional hernia.
In this era of safe yet cost-effective medicine, some investigators have
tried to discern the better method for loop stoma take-down. Hull and col-
leagues from the Cleveland Clinic randomized 61 consecutive patients to
hand-sewn or stapled closure of their loop ileostomy [32]. No difference
was found in return of bowel function, length of stay, postoperative morbid-
ity, or readmission rate between the two groups. Furthermore, the added
cost of the stapling instruments was more than offset by a significantly
shorter operative time. Hasegawa and associates from Birmingham in the
United Kingdom randomized 141 consecutive patients in a similarly designed
trial [33]. While postoperative bowel obstruction occurred with signifi-
cantly less frequency in the stapled group compared to the hand-sewn group
(3 vs. 14%), the mean hospital stay and reoperation rate did not differ.
Lastly, Moran has suggested that loop ileostomy closure can be safely per-
formed as a same-day discharge in selected patients [34]. This approach,
which apparently reduces the cost of the procedure without compromising
the patient’s safety, requires further evaluation before it can be widely
endorsed.
COMPLICATIONS
The complications associated with ostomy take-down include bowel ob-
struction, stoma site herniation, wound infection, anastomotic leak/fistula/
abscess, anastomotic stricture, and intestinal hemorrhage [35,36]. Although
these complications are well recognized, little prospective information is
available that details the incidence of each complication for a particular type
of stoma closure. This is related to the relatively infrequent nature of these
complications and the fact that the risk of complications might be influ-
enced by myriad factors, including patient age, underlying indication for
diversion, type of ostomy, timing and technique of closure, and wound
management.
In a review of the literature, Shellito reported that generalizations are
difficult because of differences in important variables, definitions, and fol-
low-up intervals [37]. While each of the following trends can be debated,
it seems that loop ileostomy closure is safer than loop colostomy take-down,
212 Strong
and loop ostomy closure is less risky than end stoma take-down. Age and
underlying stoma indications (i.e., cancer, diverticulitis, trauma) do not
likely impact morbidity when their contribution is individually considered
using multivariate analysis.
Despite the inherent limitations mentioned above, the complication
rates for ileostomy closure are as follows: bowel obstruction, 1–5%; stoma
site herniation, 0–0.9%; wound infection, 0.5–6%; anastomotic leak/fistula/
abscess, 0–10%; anastomotic stricture, N/A; and intestinal hemorrhage, 0–
0.7% [37,38]. The corresponding rate ranges for colostomy closure are as
follows: bowel obstruction, 1–5%; stoma site herniation, 5–10%; wound
infection, 5–15%; anastomotic leak/fistula/abscess, 2–10%; anastomotic
stricture, 1–9%; and intestinal hemorrhage, N/A [37].
SUMMARY
Temporary ostomies can be created from small or large bowel in a variety
of manners and serve a valuable role in persons undergoing surgery for
acute infectious events, malignancy, or trauma. Take-down of these stomas
mandates careful preoperative assessment and individualized preparation.
While loop stomas can be closed with relative ease and acceptable morbid-
ity, end ostomy take-down is more complicated, with relatively greater risk
for associated complications.
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16. Ferguson CM, Siegel RJ. A prospective evaluation of diversion colitis. Am
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17. Orsay CP, Kim DO, Pearl RK, Abcarian H. Diversion colitis in patients
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18. Mileski WJ, Rege RV, Joehl RJ, Nahrwold DL. Rates of morbidity and mor-
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12
Methods of Urinary Diversion
Jeffrey A. Stern and Daniel P. Dalton
Northwestern University Medical School, Chicago, Illinois, U.S.A.
INTRODUCTION
Supravesical diversion of the urinary tract to the abdominal wall, with
bowel used as a conduit, was introduced in the 1950s by Bricker [1] and
Gilchrist [2] et al. The concepts described by these pioneers in urinary
diversion (i.e., Bricker’s ileal conduit and Gilchrist et al. ’s use of the ileoce-
cal segment) remain the basis of most cutaneous urinary diversions used
today. The recent introduction of continent urinary diversion, bladder sub-
stitution, and intermittent catheterization and the recognition of long-term
complications of ileal conduits in the pediatric population have led to a
decrease in the use of the standard ileal conduit.
Cutaneous urinary diversion or orthotopic neobladders are used most
commonly in patients with pelvic malignancy. Bladder carcinoma is the
most common lesion, but occasionally patients with urethral, prostatic, co-
lonic, or gynecological cancer require diversion, as does the occasional pa-
tient with a pelvic sarcoma. Severe radiation damage to the pelvic viscera
and recalcitrant fistulas are occasional entities necessitating diversion. The
advent of intermittent catheterization, enterocystoplasty, and the artificial
urinary sphincter has rendered urinary diversion a procedure of last resort
in patients with neurological disorders. Certain congenital anomalies (e.g.,
bladder exstrophy) require urinary diversion, as does the rare patient with
interstitial cystitis, intractable incontinence, or severe pelvic injury.
TECHNIQUES WITH INCONTINENT STOMAS
Although various segments of bowel have been used as urinary conduits,
the terminal ileum and the ileocecal segment are most commonly used.
When nonrefluxing ureteroenterostomies are desired or previous radiation
therapy has damaged the small bowel, colonic conduits are used.
215
216 Stern and Dalton
As with any major surgical procedure, the patient’s medical and nutri-
tional status is optimized. Important historical information—such as prior
bowel surgery, gastrointestinal illnesses, and prior radiation therapy—must
be carefully sought, because significant alteration of the procedure may be
necessary in certain settin gs. A mechanical and oral antibiotic bowel prepara-
tion is performed on all patients and prophylactic systemic antimicrobial ther-
apy is initiated before surgery, although its utility is debatable [3]. Preopera-
tively, antithrombotic precautions (i.e., elastic stockings and intermittent
compression boots) are initiated, and the enterostomal therapist introduces
the patient to collection devices, and various acceptable stoma sites are
marked (Fig. 1).
ILEAL CONDUIT
A midline incision is made and exploratory laparotomy is performed. Pri-
mary procedures (i.e., cystectomy) are performed first. The ureters are iso-
lated as they cross the iliac vessels; they are carefully mobilized and di-
vided several centimeters above the bladder. If malignancy is present,
frozen-section analysis of the proximal margins is performed. The end of
the proximal ureter is secured with chromic sutures or hemoclips to allow
slight ureteral dilation and prevent continuous soiling of the pelvis with
urine (Fig. 2).
Figure 1 Selection of stoma site should take into consideration factors such as
body habitus, scars, and planned bowel segment. Typical site for ileal conduit (a)
and sigmoid conduit (b).
Methods of Urinary Diversion 217
Figure 2 Following division and frozen-section analysis (if indicated), the ure-
ters are temporarily occluded to allow dilatation.
Attention is then directed to preparing the ileal segment. The mesen-
tery of the terminal ileum is transilluminated and the ileocolic artery is
identified. The distal end of the loop should be 10–15 cm proximal to the
ileocecal junction (Fig. 3). A stay suture is placed. A segment of ileum that
has at least two vascular arcades supplying it and is of sufficient length to
reach the abdominal wall is identified. If a Turnbull-type stoma is to be
constructed, an additional 8–10 cm of ileum should be used [4]. A second
stay suture marks the proximal extent of the loop, and the mesentery is
examined again to ensure adequate blood supply. The mesentery is then
divided at right angles to the bowel in standard fashion. To provide greater
mobility of the distal segment, the mesentery should be divided to a greater
degree, with care taken not to injure a major vascular arcade.
After the ends of the proposed ileal segment are cleared of attached
mesentery and fat, the bowel is divided so that a slightly shorter antimesen-
teric border results. The isolated loop is brought down toward the pelvis,
and the proximal stay suture is removed so that the distal end of the seg-
ment is easily identifiable, allowing isoperistaltic placement of the conduit.
A standard ileoileostomy is performed according to the preference of the
surgeon, although the use of stapling techniques shortens operative time.
The mesentery is closed with 3-0 chromic suture (Fig. 4).