Loop Ileostomy Creation and Closure

Abstract

This chapter describes the technical aspects of loop ileostomy creation and closure including patient positioning, instrumentation, type of incision, and approach and steps of the procedures. The authors also offer pearls and pitfalls.

Creation

Preference Card

• Number 15 blade scalpel with handle

• Toothed and non-toothed forceps (Adson-Brown, DeBakey, rat tooth, Bonney)

• Electrocautery

• Kocher, Allis, and Babcock clamps

• Kelly, mosquito hemostats

• Needle holders

• Curved Metzenbaum and Mayo scissors

• Retractors (small Richardson, Deaver, Army Navy)

• Ileostomy rod – for loop ileostomy creation

• Suction

• Sutures

  • 3.0 polyglactin or catgut

  • 0 silk sutures (to secure stoma rod if needed)

Patient Positioning/Operating Room Setup

• This procedure is usually performed at the conclusion of various other intestinal procedures; patient positioning will vary.

Nodal Points

Procedure Steps

• Identify the loop of ileum that reaches without any tension to the anterior abdominal wall, at the preoperatively marked stoma site.

• Excise a skin disk.

• Dissect down to the anterior rectus fascia.

• Make a vertical or cruciate incision in the fascia overlying the rectus muscle.

• Split the rectus fibers bluntly until the posterior rectus sheath and peritoneum are identified. The bowel needs to be protected with a dry lap on assistant’s left hand underneath the stoma site while creating the opening.

• Incise the fascia and peritoneum to create an opening that can accommodate two fingers.

• Check for hemostasis of the muscle.

• Carefully bring the chosen ileostomy loop (or end) through the opening ensuring proper proximal and distal orientation.

For a loop ileostomy (Fig. 21.1)

• Create a mesenteric window abutting the ileal wall and insert a stoma rod for support.

• Secure the stoma rod in place with 0 silk sutures.

• Make a curvilinear incision over the efferent limb of the stoma.

• Mature the afferent limb in a Brooke fashion using 3-0 catgut or polyglactin sutures.

Fig. 21.1

(a–e) Loop ileostomy creation steps

Brooking the ileostomy is done in three steps: (1) a full-thickness bite of the edge of the ileum; (2) a seromuscular bite of the ileum at the level of the skin; and (3) a dermal bite to secure the stoma to the skin.

The edges of the ileum are then everted and the sutures are tied down.

• The efferent limb is secured to the dermis

For an end ileostomy , the ileum is matured in a Brooke fashion circumferentially, as described above.

Pearls and Pitfalls

• Ileostomy site should be marked bilaterally, prior to surgery, with the patient awake in the sitting and supine position.

Closure

Preference Card

• Number 15 blade scalpel with handle

• Toothed and non-toothed forceps (Adson-Brown, DeBakey, rat tooth, Bonney)

• Electrocautery

• Kocher, Allis, and Babcock clamps

• Kelly, mosquito hemostats

• Needle holders

• Curved Metzenbaum and Mayo scissors

• Retractors (small Richardson, Deaver, Army Navy)

• Mechanical linear cutting stapler (60–100 mm)

• Suction

• Sutures

  • 2.0/3.0 polyglactin

  • 0 polyglactin ties

  • 0 polypropylene

  • Skin stapler or 2.0 absorbable sutures for skin

Patient Positioning/Operating Room Setup

• Supine position, no bean bag needed.

• Left arm abducted on arm board to provide intravenous access.

• Prep and drape the abdomen.

• Surgeon is to the patient’s right.

• Assistant is to patient’s left.

• Scrub nurse to surgeon’s right.

Nodal Points

Type of Incision

• Circular- or diamond-shaped incision along the mucocutaneous junction of the ileostomy (Fig. 21.2)

Fig. 21.2

Incision around the ileostomy

Dissection Step

• Dissect through the subcutaneous tissue and fascia with a sharp technique (Metzenbaum).

• Take down the adhesions from the emerging bowel and surrounding tissues circumferentially, avoiding serosal tears.

• Enter the peritoneal cavity; extract the ileum loops gently.

Resection Step

• Excise the mucocutaneous junction and fibrotic/nonviable tissue.

Reconstruction Stage

• Create an antiperistaltic ileo-ileal side-to-side anastomosis stapling the antimesenteric sides of the ileum with a linear stapler, carefully inserted through the already existing enterotomies (Fig. 21.3).

• Transect the service enterotomies using a linear stapler.

• Return the bowel to the peritoneal cavity.

• Close the fascia defect with long lasting absorbable sutures.

• Skin is closed with a pursestring suture or completely after a subcutaneous drain is left in place.

Fig. 21.3

Antiperistaltic anastomosis creation

Pearls and Pitfalls

• If the stoma is viable and not fibrotic, an end-to-end anastomosis without transecting might be performed.

• Extra care should be taken to avoid mesenteric stretching and/or twisting during the procedure.

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