Diverting Loop Ileostomy

Loop Ileostomy

The peritoneal access is achieved through the preoperatively chosen ostomy site, nearly always planned inside the rectus sheath (Figure 10.2.2). For loop ileostomy formation, the right lower quadrant site is generally preferred. A 3-cm disk of skin is excised at the site. Subcutaneous tissue is divided longitudinally onto the abdominal fascia. The anterior leaf of the rectus sheath is divided longitudinally using a Bovie and the rectus muscle is spread in the direction of the muscle exposing the posterior rectus sheath. The peritoneum is entered using the open technique by dividing the posterior rectus sheath and peritoneum between the two Allis clamps. Posterior sheath is then divided to a length of 3 cm, large enough to accommodate insertion of two fingers. Three Allis clamps are then used to grasp the edges of the posterior rectus sheath equidistant from each other (Figure 10.2.3A). Three full-thickness bites of the posterior fascia are taken just underneath each Allis clamp, forming a "stay" purse-string suture (Figure 10.2.3B). The two ends of the purse-string suture are then drawn through a precut 2-inch-length 18-French red rubber catheter using a Rummel tourniquet (Figure 10.2.3C). A 12-mm cannula is inserted and the purse-string suture (Rummel tourniquet) is tightened around the cannula and secured using a hemostat clamp (Figure 10.2.4). A 12-mm cannula is best suited in terms of preventing leakage of pneumoperitoneum, and also allows any instrument to be inserted through it. It is not necessary to keep the size of this cannula small because it will be enlarged to accommodate the bowel at the end of the procedure anyway. An additional 5- to 10-mm cannula is inserted in the left lower quadrant of the abdomen lateral to the rectus sheath and above the level of pelvic brim under direct vision. An angled camera is inserted through the left lower quadrant cannula and a segment of ileum approximately 1020 cm proximal to the ileocecal valve is gently grasped using a bowel grasper.

Identification of the terminal ileum is facilitated by retracting the small intestines in the cephalad direction out the pelvis and by gently grasping the cecum in the anterior-lateral direction. Visualization of the ligament of Treves, located on the antimesenteric border of the terminal ileum just proximal to the ileocecal valve is also helpful in identifying the anatomy. If extensive adhesiolysis is required, an additional 5-mm cannula should be placed in the left side of the abdomen approximately 4 fingerbreadths above the left lower quadrant cannula.

Once the suitable segment of the ileum is identified, it is then gently brought up to the abdominal wall and exteriorized through the ostomy site. The proximal and distal limbs of the intestine are then marked

Rummel Tourniquet

Figure 10.2.3. Insertion of the cannula at the stoma site. A Three Allis clamps are used to grasp the posterior sheath in performing the initial cannula insertion using an "open" technique at the stoma site. B Three "bites" of the posterior sheath are taken in preparation for making a "stay" suture for placement of an occluding Rummel tourniquet at the stoma site. C Placement of the Rummel tourniquet permits minimal leakage after cannula placement.

Figure 10.2.3. Insertion of the cannula at the stoma site. A Three Allis clamps are used to grasp the posterior sheath in performing the initial cannula insertion using an "open" technique at the stoma site. B Three "bites" of the posterior sheath are taken in preparation for making a "stay" suture for placement of an occluding Rummel tourniquet at the stoma site. C Placement of the Rummel tourniquet permits minimal leakage after cannula placement.

Occlude Rummel Tourniquets

Figure 10.2.4. A 12-mm cannula is inserted and the Rummel tourniquet is tightened.

extracorporeally with different colored sutures for orientation. The marked intestinal loop is then replaced into the abdomen and a cannula is reinserted into the ostomy site and secured with the Rummel tourniquet. The proper orientation of the marking sutures is confirmed under pneumoperitoneum. Alternatively, the sutures may be placed laparoscopically (Figure 10.2.5). The left lower quadrant cannula site is closed and the stay suture at the ostomy site is removed. The ileum is exteriorized using an instrument placed through the stoma site, taking care to keep it oriented with the sutures placed properly. We use a purple or blue ("sky is up") colored suture material placed proximally, and a darker (chromic, "brown-is-down") colored one placed distally (Figure 10.2.6). Once a stoma bridge is placed under the loop, we dilate the fascia to 2 fingerbreadths, then exteriorize the loop onto the anterior abdominal wall. The ileostomy is then matured after placing sterile dressings over the other cannula sites (Figure 10.2.7).

In more complex cases such as in Crohn's disease, a thorough exploration of the small intestines, in addition to stoma formation is required. In this situation, more cannulae may be required to adequately inspect the entire length of the small intestines. The patients in this situation should be placed in the modified lithotomy position. Pneumoperitoneum is first established through the right lower quadrant ostomy site as described above. Two additional cannulae are placed in the left side

Laparoscopic Diverting Loop Ileostomy

Figure 10.2.5. Marking sutures are placed in order that the bowel is properly oriented when it is drawn out through the stoma site cannula. The proximal suture is purple or blue, and the distal suture is brown (chromic, "brown is down").

Figure 10.2.5. Marking sutures are placed in order that the bowel is properly oriented when it is drawn out through the stoma site cannula. The proximal suture is purple or blue, and the distal suture is brown (chromic, "brown is down").

Diverting Loop Ileostomy Picture
Figure 10.2.6. Careful orientation of the proximal and distal limbs of the intestine is necessary to be sure that the stoma is matured properly.
Laparoscopic Diverting Stoma
Figure 10.2.7. The stoma is matured after placing the occlusive dressings over the cannula site wounds.

of the abdomen, lateral to the rectus sheath. The inferior cannula is placed above the pelvic brim and the superior cannula is placed approximately 4 fingerbreadths above the inferior cannula. Placement of a 10-mm cannula in the left lower quadrant is useful if intracorporeal marking of the intestines is planned.

The patient is initially placed in the Trendelenburg position with the right side up to facilitate retraction of the small intestines into the left upper quadrant of the abdomen. The surgeon stands between the patient's legs and uses instruments placed through the two lower quadrant ports in order to run the bowel. For this, the patient is placed with the left side up and in a slight reverse Trendelenburg position (see Chapter 8.1). The ligament of Treitz is identified by placing the small intestinal loops over to the right upper quadrant of the abdomen. To best approach the terminal ileum, the surgeon operates through the two cannulae in the left side of the abdomen. Once the exploration of the small intestines is completed, a segment of the ileum can be exteriorized and the ostomy matured as described previously.

Sigmoid Colostomy

The technique for laparoscopic sigmoid colostomy formation is similar to that described for diverting loop ileostomy. The patient is placed in the modified lithotomy position. Two video monitors are placed at an angle near the patient's knees. A 12-mm cannula is inserted through the premarked left lower quadrant colostomy site as described earlier. After establishing pneumoperitoneum, a camera is inserted and a cannula is placed in the right lower quadrant lateral to the rectus muscle above the pelvic brim. In patients with a less mobile sigmoid colon, an additional cannula is inserted approximately 4 fingerbreadths above the right lower quadrant port. Using a pair of laparoscopic scissors, the lateral attachments of the sigmoid colon are mobilized. If the descending colon needs to be mobilized, addition of a cannula in the suprapubic area is useful. In this case, the surgeon can operate while standing between the patient's legs. The assistant facilitates the dissection by standing on the right side of the patient and retracting the sigmoid colon toward the right side of the patient. In obese patients, it may be necessary to divide the mesentery and colon in order to perform an end colostomy. Intracorporeal division of the intestines can be accomplished by introducing a laparoscopic GIA stapler through the 12-mm cannula placed usually in the right lower quadrant of the abdomen. Alternatively, a mobilized loop of the sigmoid colon can be exteriorized and divided extracorporeally using a GIA stapler. The procedure is then completed as is usual with an open procedure.

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Responses

  • Cerdic
    How to orientate a loop ileostomy?
    7 months ago
  • adaldrida
    How is a laparoscopic ileostomy performed?
    15 days ago

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