Incise skin around mucocutaneous border with cutting diathermy
Dissect through subcut fat around ileostomy, freeing it up from skin
Approximate ileostomy edges togeter with an Ellis to reduce leakage
Dissect through into the plane containing the bowel loop and define
the fascial edge
Free it from the fascia with careful diathermy dissection,
At this point if in the right plane, can often insert a finger into
the space around the ileostomy and progressively dissect around it
onto that finger
So mobilising the loop completely from fascia.
Sometimes more dense adhesions will require time spent dissecting
At this point I take a divide a band of mesentery, close to the
bowel, that directly underlies the iloestomy site.
This makes the join more straightforward and reduces the mesentery
potentially caught in the join, which can bleed.
Ensure bowel mobile and not twisted, then do the anastomosis.
I prefer a stapled anastomosis for its speed and the reliability and
integrity of the stapled join.
Approximate the bowel adjacent to the ileostomy in a side to side
Make two small enterotomies at the antimesenteric border, insert the
stapler arms, ensure mesentery clear down the middle, wait 20s and
fire straight down bowel.
Watch during stapler removal to ensure no bleeding at staple lines
Grasp enterotomy bowel ends with three babcocks, one on the staple
line and retract back to straighten join.
Apply a linear TA 90 stapler to the ends in front of the babcocks,
fire, divide bowel beyond staple line.
Underun TA staple line with a 3-0 prolene continuous suture.
Interrupted trouser sutures with 3-0 prolene.
Close fascia with interrupted 1 nylon.
Skin with interruted dermal 3-0 moncryl sutures, leaving a gap in
the middle for gauze packing of the dirty wound
Alternatives and Controversies