Ileostomy, construction of

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

1. Trial marking, with the patient supine or already sitting, within the right rectus abdominis (level of the umbilicus) in a 10×10cm skin area, preferably without folds and creases, scars and bony prominences.
2. Check of the planned site with the patient in motion (standing, stooping down).
3. The selected  site should be easily accessible to the patient and within his/her visual field and away from the natural beltline.
4. To allow for intraoperative complications marking a secondary location is recommended.
5.  Dressing the markings with sensitive skin bandages.

The site of the ileostomy deeply affects its management and thus the patient’s quality of life!

After opening the abdominal cavity or completion of the major procedure, locate the loop of the terminal ileum with which to construct the loop ileostomy. The loop selected for the stoma should be at least 20cm proximal to the ileocecal valve.

Pass a silicone tape through a mesenteric window created close to the bowel preferably in an avascular area.

While lifting up the skin with, e.g., a towel clamp make a circular skin incision at the preoperatively marked site. The diameter of the skin incision should not exceed 3cm. Then dissect the subcutaneous tissue down to the fascia.

After excision of skin and subcutaneous tissue, open up the anterior lamina of the rectus sheath in cruciform fashion. Stretching the fascia hereby will help avoid overlapping

Split the rectus muscle in the direction of its fibers until the posterior lamina of the rectus sheath is exposed.

Also divide the posterior lamina of the rectus sheath, together with the peritoneum, in cruciform fashion creating an opening just large enough to pass three fingers through ("three-finger test").

Pass the tape through the abdominal wall trephine and deliver the bowel loop, with the proximal limb located inferiorly. Some surgeon secure the loop with a rod.

After closing the laparotomy and sterile draping (to avoid fecal contamination), perform a transverse enterotomy, e.g., with diathermy. Do this asymmetrically centered on the distal limb because this will evert the proximal limb which then is sutured to the skin.

Suture the bowel to the skin with interrupted monofilament sutures (e.g., PGA) 3/0. The inferior (proximal) limb is markedly everted and then secured to the skin in order to prevent contact of the aggressive intestinal juice with the skin.