Protect an anastomosis
Palliate a bowel cancer.
Time out, Prophylactic ABs, prep drape in supine position
Where should I site a stoma?
~10cm toward umbilicus from ASIS for L stomas
Not in a skin fold.
Key Operative Points : General End Colostomy
- Grasp skin over site with a Kocher clamp.
- Lift and make a circular skin incision.
- Incise dermis with diathermy.
- Remove block of subcut tissue (don't undermine).
- Incise anterior rectus sheath with a linear incision.
- Spread rectus to show posterior sheath and make further
- The defect should allow 2 fingers.
- Colostomy hole must allow for distended oedematous bowel in
- When colostomy hole is kept open with retractors, the bowel
end should pass easily between and not retract if retractors
- Pass 2 babcocks through to grasp bowel end & pull
- Closed proximal end should easily reach several cm beyond
the skin without support.
- Left colon should be mobilized up to (and sometimes
including) the splenic flexure to allow this.
- Mucocutaneous suture of colon to skin edge with absorbable
suture (e.g. 3-0 vicryl or 3-0 monocryl).
Key Operative Points : End
- Lloyd Davis (lithotomy Trendelenburg)
- Consider doing laparoscopic
- excellent vision; much less likely to bring out wrong end.
- umbilical port, 10-12mm trochar through stoma side, grasp
- Trephine as above
- Find sigmoid, ensure not twist; no omentum here obviously but
are appendices epiploicae to help define it.
- can check lateral white line for orientation help.
- can even do a sigmoidoscopy or a loop colostomy if still
- Divide loop of sigmoid across (Stapled e.g. nTLC), with 5-6 cm
- Closed distal end is pushed into cavity; can oversew but no
- Fashion colostomy by suturing to skin edge with interrupted
- Fit stoma appliance.
Key Operative Points : Loop Transverse Colostomy
- Transverse incision, 5cm, upper right rectus between umbilicus
and costal margin
- or 10cm transverse incision midway b/n umbo and costal
margin (3-5cm lateral to linea alba) if targeting the mobile
midsection of R colon
- Cut rectus, cauterize fibres,control epigastric artery, enter
- Draw right side of transverse colon and omentum out of wound.
- recognizing colon by haustra, taeniae coli, epiploic
- Loop should sit without tension.
- Separate omentum, expose colon, turn upward to expose
- Create mesenteric window below wall and pass a penrose sling
- ensure loop not twisted; proximal to right and distal to
- Pass a plastic colostomy rod through the mesentry to form a
- don't damage the marginal artery of Drummond, which runs a
variable distance from the bowel edge (e.g. 1-8 cm).
- no internal / fascia sutures.
- Cut open colostomy, half way through circumference.
- Turn back edges and suture whole thickness of colon to edge of
skin with interrupted 2/0 Vicryl sutures on a cutting needle.
- Insert a finger in each loop to make sure it isn't too narrow
- Fix stoma appliance.
Remove bridge device in 7 days
Longer if obesity and difficulty in bringing up the stoma.
1. Retraction due to
inadequate mobilization of the bowel.
- can cause disruption of the mucocutaneous suture line,
subcutaneous contraction and progressive stenosis.
- Leave out enough 'anchor warp' for when the tide goes out.
- i.e. allow laxity for oedema / stretch post op.
3. Bringing out wrong end.
Alternatives and Controversies
- Note that stoma nurses dislike Abcarian stomas
- distal end pulls in, retracting the stoma and leaving problematic