The Colostomy Formation and Laparoscopic Closure

Pneumoperitoneum is reestablished. The preselected colostomy site is prepared from the skin level down to the posterior sheath in standard manner, then a 5-mm cannula is inserted. From the right side of the patient, the laparoscopic surgeon grasps the distal end of the descending colon through the right lower quadrant cannula site, and passes this up to the anterior wall beneath the stoma site. The colon is transferred to another grasper there, with a final check that there is no tension on the colon. The colostomy then is created by withdrawing the cannula from this site, dilating the fascia up to a width of two finger breadths, and then pulling the bowel end up to the skin level. After pulling the colon through the abdominal wall, the laparoscope is inserted into the right lower quadrant cannula, and the left colon is examined to ensure that it has not twisted as it passed from the left side of the abdomen to the anterior wall. The pelvis is then once again irrigated by placing the patient in the head-up position and using the right lower quadrant cannula site for insertion of an irrigation catheter. The abdominal cavity is carefully assessed lapa-

Fascia Perineal

Figure 8.6.15. Just as in the rectal mobilization, the perineal phase of the operation is most safely performed in a pattern of 1) posterior, 2) lateral, and 3) anterior dissection. Inset: Anatomic view of the coccyx posteriorly and the pelvic floor and anal sphincter muscles with the perineal dissection.

Figure 8.6.15. Just as in the rectal mobilization, the perineal phase of the operation is most safely performed in a pattern of 1) posterior, 2) lateral, and 3) anterior dissection. Inset: Anatomic view of the coccyx posteriorly and the pelvic floor and anal sphincter muscles with the perineal dissection.

roscopically for any sign of hemorrhage, particularly at all vascular pedicles and areas of dissection.

The cannula sites are closed, including at the skin level, and occlusive dressings are placed over them. The colostomy is matured in a standard manner and the operation is completed.

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