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Colostomy (sigmoidostomy), loop, laparoscopic construction
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Stoma site marking
Ideally, the stoma should be marked and the subsequent instructions for stoma care given by specially trained enterostomal therapists or an experienced surgeon.
- 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!
Skin incision and dissection down to the fascia
Establishing the pneumoperitoneum and inserting the optical trocar and camera
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.
Inserting the working trocars
Mobilizing the bowel segmented selected for stoma construction
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.
- 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.
Skin incision for stoma and dissection down to the fascia.
Dissecting the rectus sheath, muscles and peritoneum
Delivering the colon/sigma through the abdominal wall
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.
Suturing the stomal edges
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.