Perioperative management - Ileostomy reversal (without resection) with skin closure using the gunsight technique

An intestinal stoma is a surgically created artificial opening in the intestine that allows for stool excretion.

A loop ileostomy might have been created for the following indications:

• As a protective ileostomy in the context of a low anterior resection (LAR) for rectal cancer
• In case of a threatened anastomosis during colon/rectal resection (e.g., perforation with peritonitis, colonic ileus, ischemia)
• After an anastomotic leak in colon/rectal resection
• In abdominal trauma with bowel injury
• In the management of complicated anal fistulas/rectovaginal fistulas
• After proctocolectomy for ulcerative colitis (three-stage procedure)
• Palliative ileostomy in ileus (e.g., peritoneal carcinomatosis)

Timing of Stoma Reversal

There is currently no clear recommendation for the optimal timing.

An early closure of a loop protective ileostomy 10 to 14 days after creation is theoretically possible after quick recovery from the primary surgery, with positive effects on quality of life and potential stoma complications. However, due to physiological inflammatory adhesions between the intestine and abdominal wall as well as between the intestinal loops themselves, reversal at this early stage is significantly more difficult. These adhesions typically resolve within 6-10 weeks, which is why reversal usually occurs 10-12 weeks after creation.

• Recurrence of a tumor disease or peritoneal carcinomatosis
• Anastomotic insufficiency
• High risk of incontinence
• Poor general condition of the patient
• Ongoing chemotherapy
• Acute flare-up of Crohn's disease/ulcerative colitis

• Re-staging (abdominal and thoracic CT) in neoplastic diseases
• Rectoscopy and clinical assessment (digital) of the anastomosis after low anterior resection of the rectum
• Assessment of the sphincter apparatus
• Abdominal CT with rectal filling of contrast medium to assess the anastomosis, possibly also contrast medium filling of the efferent limb, alternatively endoscopic control (colonoscopy).
• Laboratory with coagulation

For the relocation, no special preparations are usually necessary. Perioperative antibiotic prophylaxis to reduce wound infections is advisable.

• General surgical risks (bleeding, rebleeding, risk of thrombosis, risk of embolism, etc.)
• Wound healing disorders (common)
• Intraoperative bowel injury
• Anastomotic insufficiency
• Postoperative stenosis (too tight re-anastomosis)
• Postoperative ileus (paralysis, mechanical (see above))
• Irregular bowel movements
• Possible revision surgery
• Fistula formation (cutaneous fecal fistula)
• Incisional hernia
• Incontinence
• Adhesions

The procedure is performed under general anesthesia with intubation.

Supine positioning with both arms positioned outward, possibly lithotomy position if a proctological examination is required before stoma closure.

Surgeon on the side of the stoma (right) and assistant opposite (left).

No special holding systems or instruments required.

Postoperative Analgesia: Adequate pain management (Metamizole and if needed, a weak opioid such as Tilidine or Tramadol). Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management). Follow the link to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up: Laboratory check on the 3rd and 5th postoperative day.

Thrombosis Prophylaxis: e.g., Clexane 0.4 ml s.c. once daily. In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30 minutes duration), in addition to physical measures, low molecular weight heparin should be administered in prophylactic, possibly weight- or risk-adapted dosage until full mobilization is achieved.
Note: Renal function, HIT II (history, platelet control)
Follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization: immediately

Physical Therapy: Not necessarily required with immediate mobilization and uncomplicated healing process or hospital stay.

Diet Progression: 3 days of tea-soup-yogurt-Fresubin, then solid food.

Bowel Regulation: as needed (e.g., laxative drops)

Incapacity for Work: Depending on intraoperative findings, approximately 2-3 weeks.