When creating the skin aperture, making the aperture too small makes it technically difficult to mature the stoma, while making it too large makes it harder to obtain stoma eversion. In most patients, making a skin aperture roughly the same size as the diameter of the bowel to be used to create the stoma or several millimeters larger will provide for a suitably sized skin aperture.
In most patients, a two-finger breadth opening in the abdominal wall is all that is required for a loop ileostomy. However, in patients in whom there is excessive tension or particularly in obese patients, where the small-bowel mesentery may be very large, it is important to create a large enough fascial defect in order to permit the bowel to pass easily through the abdominal wall. Since this is a temporary ileostomy, the larger fascial defect and the common paras-tomal hernia can easily be closed at the time of ileostomy closure.
Babcock or other types of clamps should be used for as brief a time as possible to grasp the bowel while it is brought through the abdominal wall. These clamps tend to rip through the bowel and cause an excessive amount of trauma even if they may be soft or "atraumatic". Once a clamp has been used to pass the bowel through the abdominal wall, it is quickly released and a dry gauze sponge or pad can be used to further manipulate the bowel, since this is much gentler to the bowel wall. If a significant amount of traction on the bowel is required, an umbilical tape passed immediately underneath the bowel, just at its mesenteric margin, will usually provide sufficient traction without disrupting the bowel wall, tearing it or interfering with or damaging its blood supply. One should always start with the small bowel just proximal to the ileal J-pouch and determine the most distal loop of small bowel that can reach and be adequately exteriorized through the ileostomy aperture. For an adequate loop ileostomy, 6-8 cm of bowel should be present above the skin surface depending upon the diameter of the small bowel.
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