Colostomy (sigmoidostomy), loop, laparoscopic construction

Ideally, the stoma should be marked and the subsequent instructions for stoma care given by specially trained enterostomal therapists or an experienced surgeon.

Tips:

• Trial marking, with the patient supine or already sitting, within the left rectus abdominis (level of the umbilicus) in a 10×10cm skin area, preferably without folds and creases, scars and bony prominences.
• Check of the planned site with the patient in motion (standing, stooping down).
• The selected  site should be easily accessible to the patient and within his/her visual field and away from the natural beltline.
• To allow for intraoperative complications marking a secondary location is recommended.
• Dressing the markings with sensitive skin bandages.
• The site of the ileostomy deeply affects its management and thus the patient’s quality of life!

For establishing the pneumoperitoneum, a supraumbilical skin incision is generally recommended. Dissect down to the fascia with scissors and bluntly split with Langenbeck retractors.

Establish the pneumoperitoneum via a Veress needle after aspiration, flush and drop testing. To prevent the Veress needle from puncturing the bowel, elevate the fascia with a Backhaus towel clamp. Alternatively, access via minilaparotomy (e.g., after previous surgery) may be advisable.

After establishing the pneumoperitoneum with an intraabdominal pressure of 11–14mmHg remove the cannula and insert the 10mm trocar for the laparoscope. Advance the laparoscope through this trocar into the abdominal cavity.

After a 360° check and inspection for pathologies such as adhesions, lesions, etc., insert both 5mm working trocars under view and transillumination (caution: epigastric vessels) in the right lower quadrant and mid-abdomen respectively.

Grasp the colon segment (here: sigmoid) and pull it mediad. Now divide the peritoneal adhesions and dissect the descending colon down to the Gerota fascia. Carefully respect the ureter.

Comment: 

• When performing end colostomy, free the bowel and then close and divide it with an EndoGIA stapler. This then requires adequate mobilization of the proximal limb.

After sufficient mobilization (some surgeons pass a tape around the intestinal segment), make a circular skin incision at the marked site with a diameter of about 3cm. Dissect the subcutaneous tissue down to the fascia. Resect excess subcutaneous fatty tissue.

After resecting the excess subcutaneous tissue open up the anterior rectal sheath in cruciform fashion and bluntly split the muscles. Divide the posterior rectal sheath and peritoneum in cruciform fashion creating an opening just large enough to pass at least two fingers through.

Now deliver the selected bowel segment without tension beyond the skin level. This segment may now be secured with a clamp, rod or tape. Resect any excess epiploic appendices as these may not be have sufficient blood supply in the subcutaneous region or may possibly complicate subsequent restoration of intestinal continuity. This completes the laparoscopy part of the procedure (if necessary after a laparoscopic check of the bowel position). Remove the instruments and trocars and close the wounds.

After closure of the wounds and sterile draping, perform the transverse colotomy, e.g., with diathermy.

Taking full thickness bites now suture the intestinal wall to the skin. While the bowel does not have to anchored to the fascia, the suture should first pass through the skin and then through the serosa approx. 1cm away from the colotomy; subsequently pass the suture through all layers of the edge of the colotomy.