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13
Minimally Invasive Stomas
Martin Luchtefeld
Michigan State University and Ferguson Clinic/MMPC
Grand Rapids, Michigan, U.S.A.
I. INTRODUCTION
The creation of a stoma for diversionary purposes without a resective pro-
cedure has usually been done with a separate laparotomy incision. Since
the first reports of laparoscopic cholecystectomy in 1987, there has been a
tremendous amount of interest in minimally invasive approaches to surgery
[1]. In the field of colon and rectal surgery, minimally invasive techniques
have been used for almost every intra-abdominal procedure including the
creation and reversal of stomas [2].
II. INDICATIONS AND CONTRAINDICATIONS
The indications and contraindications for a minimally invasive stoma are
similar to those for open surgery. Colonic obstruction, peritonitis, and mul-
tiple adhesions are all relative contraindications to a minimally invasive
approach. In addition to patient factors, the decision to create a stoma with-
out a separate laparotomy will depend on the surgeon’s skill and familiarity
with these optional approaches.
III. TREPHINE STOMAS
It is worth mentioning trephine stomas at the outset. Even before the advent
of laparoscopy, there was interest in the minimally invasive approach to
forming stomas. Trephine (“hole”) stomas, in which the bowel is exterior-
ized through a small laparotomy incision, have been done almost since sto-
mas were first reported (see Chap. 1), for many years with good success.
The technique of a trephine stoma involves making a single incision
in the abdominal wall at the site of the intended stoma. Most commonly,
259
260 Luchtefeld
this will be in the left lower quadrant for a sigmoid colostomy or in the
upper abdomen for a transverse colostomy. The bowel that is intended to
be used for the stoma is then grasped (and perhaps minimally mobilized)
and brought up through the stoma site. If technically possible, placement of
a flexible sigmoidoscope can facilitate recognition, mobilization and correct
orientation of the bowel. The stoma can then be matured in the desired
fashion. Any type of stoma, from a loop ileostomy to an end colostomy,
can be fashioned. Trephine stomas are created successfully in 80–90% of
those patients in whom they are attempted [3–5]. When a laparotomy is
needed, it is usually because of adhesions that prevent adequate mobiliza-
tion. Like stomas formed in any fashion, there can be long-term complica-
tions, such as parastomal hernias and prolapse [3].
IV. LAPARASCOPY-ASSISTED STOMAS
A. Operative Technique
The technique for creating a stoma with laparoscopic assistance has not
been standardized, but certain general principles apply. Preoperatively, the
patient should receive stoma instructions and should be marked for a stoma
site to ensure optimal placement. The bowel preparation (mechanical as
well as antibiotic coverage) should be done as the surgeon normally would
do for a bowel resection. The patient should be placed in stirrups to allow
for placement of a colonoscope at the end of the procedure should there be
any question regarding the orientation of the bowel. Once adequate anesthe-
sia and a sterile field have been established, the trochars can be placed.
A port for the camera is usually placed in the periumbilical region. It is
advantageous to place another port at the site of the proposed stoma. Once
adequate pneumoperitoneum is established and the camera port inserted,
the surgeon can determine how many additional ports are necessary (see
Fig. 1). For those patients with a mobile bowel, a single port can be placed
at the site of the proposed stoma and a grasper passed through it to deliver
the bowel up to the abdominal wall. For many patients, an additional port
or two may be necessary to allow for adequate adhesiolysis and mobiliza-
tion of the bowel.
Once the trocars are placed, any adhesions that will impede the opera-
tion are lysed. If a sigmoid colostomy is to be done, the sigmoid colon and
the left colon can be mobilized completely to the splenic flexure if neces-
sary by incising the lateral peritoneal attachments (Fig. 2). The adequacy
of the mobilization can be checked by grasping the proposed loop of the
bowel and lifting it up toward the abdominal wall. The intestinal segment
selected for stoma creation is then grasped with a “bowel type” grasper and
correct orientation ensured. The distal end may be marked with cautery, a
clip, or suture in order to prevent maturation of the incorrect end due to
Minimally Invasive Stomas 261
Figure 1 Most colonic laparoscopic surgery requires three to five ports. Placeing
port and location of anticipated stoma (i.e., left lower quadrant) as shown here is
advantageous.
twisting when the bowel is elevated through the abdominal wall. Once there
is convincing evidence of adequate mobilization, the skin is excised in a
circular fashion at the stoma site, the fascia is incised and the loop of bowel
is delivered upward through the abdominal wall. The colostomy can then
be matured in the fashion preferred by the surgeon. The same steps and
principles can be applied to formation of ileostomies as well.
V. RESULTS
The expected benefits of laparoscopic surgery include decreased pain, de-
creased need for narcotic analgesia, quicker return of bowel function, and
decreased length of stay. There is currently little information (and no pro-
spective randomized trials) to support these claims in the setting of place-
ment of diversionary stomas.
When laparoscopy-aided stoma formation is attempted, the success
rate is high (84–97%), with most of the conversions being necessary be-
cause of dense adhesions [6,11] (Table 1). In those studies that compared
the laparoscopy group to an open control group, the operative times were
longer in the laparoscopic group. In a report by Young et al. [10] operative
times were 176 vs. 194 min, whereas Hollyoak et al. [11] actually found
the opposite (54 vs. 72 min). Hospital stays were shorter for the laparo-
scopic patients in both of these studies (Table 1). In all the remaining re-
ports on laparoscopic stomas, the length of stay tends to be rather longer
262 Luchtefeld
Figure 2 A, Distal sigmoid colon and rectum are grasped with forceps prior to
dissection. B, Sigmoid colon is grasped with Babcock forceps and lateral peritoneal
reflection is incised.
than expected, which the authors attribute to the need for education regard-
ing stoma care and factors related to the disease state that led to the stoma
[6–11].
Complication rates are low. Morbidity potentially related to the lapa-
roscopic approach include one case of a stoma outlet obstruction that
was found to be caused by a twist in the bowel as it exited the abdominal
cavity [6].
VI. COLOSTOMY CLOSURE
Although take-down of a loop ileostomy or colostomy can usually be done
through a peristomal incision, closure of a colostomy following a Hartman
procedure requires a laparotomy. Alternatively, the laparoscopic approach
may be used in this setting. Even though this procedure does not require a
bowel resection, it is often technically demanding. The conditions that led
to the Hartman procedure initially (such as diverticulitis or colonic obstruc-
Minimally Invasive Stomas 263
Table 1 Series of laparoscopy-Aided Stomas
Length Length
Number of Stay of Stay OR Time OR Time
of Percent Percent (days) (days) (min) (min)
Author, Year Patients Completion Complications (lap) (open) (lap) (open)
Oliveira, 1997 [6] 32 84 6 6 na 76 na
Ludwig, 1996 [7] 24 95 5 6 na 60 na
Almqvist, 1995 [8] 18 89 6 na na 49 na
Schwander, 1998 [9] 42 98 9.5 13 na 74 Na
Young, 1998 [10] 19 84 5 8 11 176 104
Hollyoak, 1998 [11] 40 95 20 7.4 12.6 54 72
264 Luchtefeld
tion) can result in formidable adhesions, which make the laparoscopic ap-
proach difficult or even untenable.
VII. TECHNIQUE
The patient is placed in the lithotomy position with the legs in Allen stir-
rups. A periumbilical port is placed with an open approach. An alternative
is to make a peristomal incision first and begin colostomy mobilization.
The anvil can be placed in the end of the newly mobilized sigmoid colon
and placed back in the abdominal cavity. The stoma site can then be used
to place a trocar and establish pneumoritoneum. Additional trochars are
placed as needed so that an adhesiolysis can be performed. The rectal stump
must be identified and freed up sufficiently from small bowel adhesions
and other surrounding structures to allow for a safe anastomosis. Transanal
passage of the EEA instrument (United States Surgical Corporation, Nor-
walk, CT) or the ILS instrument (Ethicon Endo-Surgery, Cincinnati, OH)
can facilitate mobilization of the rectum. Once the rectum is sufficiently
mobilized, the spike is advanced out through the rectal stump (Fig. 3). The
anvil in the sigmoid colon is then mated with the transanal stapling device
and an anastomosis is completed in a standard end-to-end fashion (Fig. 4).
The anastomotic rings should be checked for completeness and the anasto-
mosis air-tested under water to evaluate for leaks. If an anastomotic leak is
Figure 3 Rectal stump has been stapled. Spike of an end-to-end stapling device
protrudes through rectal stump. Spike is grasped and removed by forceps.
Minimally Invasive Stomas 265
Figure 4 A, Proximal colon has been joined to rectal stump with anvil. B, Triple
staple technique allows anastomosis of proximal colon to rectal stump prior to
approximation.
found, the defect must be identified and repaired. Options for repair include
laparoscopic suturing, recreation of the anastomosis, proximal diversion, or
proceeding with an open laparotomy. Decision making in this circumstance
will be guided by the surgeon’s experience as well as the nature of the
anastomotic defect.
VIII. RESULTS
Most of the studies of laparoscopy-aided colostomy take-down are quite
small. Conversion rates are reported to be anywhere from as low as 0% to
as high as 22%, with operating times being 130–230 min. Complication
rates (0–40%) have been comparable to or better than historical results of
open Hartmann’s take-down. Intraoperative complications have included
stapler-related rectal perforation and incomplete anastomotic rings [15].
Hospital stays range from 4–8 days [12–15].
IX. SUMMARY
There will continue to be a role for minimally invasive approaches to colon
and rectal surgery. More studies are needed to determine the optimal appli-
cation of laparoscopic techniques in the formation and reversal of stomas.
266 Luchtefeld
REFERENCES
1. Filipi CJ, Fitzgibbons RJ Jr, Salerno GM. Historical review: diagnostic lap-
aroscopy to laparoscopic cholecystectomy and beyond. In: Zucker KA, ed.
Surgical Laparoscopy. St. Louis, MO: Quality Medical Publishing, 1991:
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2. Bohm B, Milson JW. Laparoscopic Colorectal Surgery. New York: Springer-
Verlag, 1996.
3. Stephenson ER, Ilahi O, Koltun W. Stoma creation through the stoma site: a
rapid safe technique. Dis Colon Rectum 1997; 40:112–115.
4. Anderson ID, Hill J, Vohra R, Schofield PF, Kiff ES. An improved means of
faecal diversion: the trephine stoma. Br J Surg 1992; 79:1080–1081.
5. Nylund G, Oresland T, Hulten L. The trepine stoma: formation of a stoma
without laparotomy. Eur J Surg 1997; 163:627–629.
6. Oliveira L, Reissman P, Nogueras J, Wexner SD. Laparoscopic creation of
stomas. Surg Endosc 1997; 11:19–23.
7. Ludwig KA, Milsom JW, Garcia-Ruiz A, Fazio VW. Laparoscopic tech-
niques for fecal diversion. Dis Colon Rectum 1996; 39:285–288.
8. Almqvist PM, Bohe M, Montgomery A. Laparoscopic creation of loop ileos-
tomy and sigmoid colostomy. Eur J Surg 1995; 161:907–909.
9. Schwander O, Schiedeck TH, Bruch HP. Stoma creation for fecal diversion:
is the laparoscopic technique appropriate? Int J Colorect Dis 1998; 13:251–
255.
10. Young CJ, Eyers AA, Solomon MJ. Defunctioning of the anorectum: histori-
cal controlled study of laparoscopic vs open procedures. Dis Colon Rectum
1998; 41:190–194.
11. Hollyoak MA, Lumley J, Stitz RW. Laparoscopic stoma formation for faecal
diversion. Br J Surg 1998; 85:226–228.
12. Sosa JL, Sleeman D, Puente I, McKenney MG, Hartmann R. Laparoscopic-
assisted colostomy closure after Hartmann’s procedure. Dis Colon Rectum
1994; 37:149–152.
13. Delgado GF, Garcia LA, Domingo PC, Grau CE, Martin DJ. Laparoscopic
reconstruction of intestinal continuity following Hartmann’s procedure. Rev
Esp Enferm Dig 1998; 90:499–502.
14. Macpherson SC, Hansell DT, Porteous C. Laparoscopic-assisted reversal
Hartmann’s procedure: a simplified technique and audit of twelve cases. J
Laparoendosc Surg 1996; 6:305–310.
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oscopically assisted colorectal anastomose post-Hartmann’s procedure. Surg
Laparosc Endosc 1996; 6:1–4
14
Ilestomy and Pouch Dysfunction
Peter W. Marcello
Lahey Clinic, Burlington, Massachusetts, U.S.A.
Amanda M. Metcalf
University of Iowa, Iowa City, Iowa, U.S.A.
INTRODUCTION
While patients requiring proctocolectomy can expect to have a normal life
expectancy, many may suffer from complications related to ileostomy, con-
tinent ileostomy, or ileoanal pouch dysfunction. With the loss of the colon’s
absorptive surface, every patient is vulnerable to complications resulting
from excessive salt and water losses. This is likely to be the most common
complication associated with a conventional ileostomy, continent ileos-
tomy, or pelvic ileoanal pouch. Diarrhea, due to either an infectious pro-
cess, or a primary disease of the gut or secondary to the postoperative state,
can be life-threatening for the patient who has lost the dynamic absorptive
capacity of the colon. This chapter discusses some common dysfunctions
of conventional ileostomy and restorative procedures, each of which centers
around the potential for excessive fluid and electrolyte losses.
CONVENTIONAL ILEOSTOMY
Diarrhea
Diarrhea in a patient with a conventional ileostomy or continent stoma can
be defined as a fecal volume of more than 1 L per day. The same definition
can be applied to those patients with an ileoanal pouch, although such pa-
tients will often complain more of the frequent evacuations and the perineal
irritation than about the dehydration associated with diarrhea. Patients who
have undergone proctocolectomy are chronically dehydrated and have ele-
vated mineralocorticoid levels. The terminal ileum responds to elevated
mineralocorticoids by increasing absorption of water and sodium, with
compensatory losses of potassium [1]. This is believed to account for the
267