Construction of Intestinal Stomas

Hermann Kessler

Mariane G. M. Camargo

Eric G. Weiss

Perioperative Considerations

Mark the patient’s abdominal wall for a proper stoma site, ideally by a trained enterostomal therapy nurse, after positioning the patient in supine, sitting, and standing postures (Fig. 43-1).

FIGURE 43-1 ▪ A and B. Stoma site tattoo with Indian ink.
The appropriate location of a stoma on the abdominal wall may be the most important factor in allowing optimal function of the stoma (Fig. 43-2).
Education, teaching, and familiarization of a new stoma by an enterostomal therapy nurse will help patients accept and manage their stomas better.

FIGURE 43-2 ▪ The optimal stoma site is located over the rectus sheath, on the flat surface of the infraumbilical fat mound, away from irregular surfaces such as scars, incisions, umbilicus, and bony prominences. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Instruments and Equipment

Laparoscopic or open approaches may be used to create stomas, although the laparoscopic approach is favored, if feasible.
For laparoscopic stoma creation, the following equipment is needed or should be readily available:
- Video instrumentation:
  - Video camera unit
  - 5- or 10-mm 30-degree laparoscope
  - A light source
  - Monitoring and recording devices
- A gas insufflator
- A suction and irrigation device (have available)
- A laparoscopic 5-mm dissecting device
- Electrocautery
- Kocher clamp
- Right-angle retractors
- Three Allis clamps
- 12-mm Hasson or balloon trocar
- Two to three 5-mm trocars
- Laparoscopic scissors
- Laparoscopic 5- or 10-mm Babcock clamps
- 5-mm Maryland dissector
- 5-mm bowel grasper
- Plastic rod or red rubber catheter for loop ostomies
- 3-0 absorbable braided sutures

Available instruments (as needed):

10-mm trocar
Laparoscopic stapler
Laparoscopic biopsy forceps
For open surgery, a standard set for colorectal surgery that has all the needed instruments for the stoma construction

LAPAROSCOPIC

Technique

Ileostomy

Patient is placed in modified lithotomy position (Fig. 43-3). Surgery is begun in Trendelenburg position (head-down tilt), and after cannula insertion, the patient is tilted left side down, which will allow the small intestine to fall into the left upper quadrant for creation of the ileostomy.

FIGURE 43-3 ▪ Position of the equipment and the personnel for ileostomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
For jejunostomy, patient is placed right side down.
The surgeon initially stands on the side where the stoma will be created, with the first assistant positioned on the other side.

Technique

The peritoneal access is achieved through the preoperatively chosen ostomy site, nearly always planned within the rectus sheath. For loop ileostomy formation, the right lower quadrant site (below the level of the umbilicus) is generally preferred, but may vary based on the preoperative marking.

Cannulas are positioned at the proposed stoma site (12-mm Hasson/balloon trocar) and on the side opposite to the stoma in the mid-abdomen, lateral to the rectus sheath (5-mm trocar) (Fig. 43-4).

FIGURE 43-4 ▪ Positions of the cannulas for laparoscopic ileostomy formation. Use of optional cannulas (*) with a low threshold if this makes the procedure easier, especially when adhesions are present.

A disk of skin is excised with a size of 3-4 cm, depending on the intended diameter for the stoma creation site and the size of the patient and the thickness of the bowel loop that will traverse the stoma aperture (Fig. 43-5A and B).

FIGURE 43-5 ▪ A and B. Ostomy skin aperture. A circular skin incision is made with a diameter of ˜3-4 cm. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

The subcutaneous tissue is divided vertically onto the abdominal fascia, right-angle retractors are used (Fig. 43-6).
The anterior leaf of the rectus sheath is divided vertically using electrocautery, and the rectus muscle is spread open along the muscle fibers, exposing the posterior rectus sheath (Fig. 43-7A and B).

The peritoneum is entered using an open technique by dividing the posterior rectus sheath and peritoneum between the two Allis clamps by scissors or electrocautery, large enough to accommodate insertion of two fingers.

FIGURE 43-6 ▪ The subcutaneous tissue is generally divided down to the anterior fascia of the rectus muscle, does not need to be removed.

FIGURE 43-7 ▪ A and B. Abdominal wall aperture for ileostomy. A. The anterior fascia is divided in a cephalad to caudal direction, exposing the underlying rectus muscle. B. The rectus muscle fibers are separated using the retractors or alternatively a blunt clamp, avoiding injuries of the epigastric vessels. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Three Allis clamps are then used to grasp the edges of the posterior rectus sheath equidistant from each other.
A 12-mm Hasson balloon trocar is inserted, and the balloon is inflated to aid in creation of the pneumoperitoneum (Fig. 43-8).

FIGURE 43-8 ▪ A 12-mm balloon cannula is inserted.
The patient is then tilted left side up.
An additional 5-mm cannula is inserted on the contralateral side in the left mid-abdomen under laparoscopic vision (Fig. 43-9).

FIGURE 43-9 ▪ An additional 5-mm cannula is inserted on the contralateral side in the left mid-abdomen.
The camera is inserted through the left mid-abdomen 5-mm cannula, and the right side is tilted up again.
A segment of ileum ˜10-20 cm proximal to the ileocecal valve is identified and gently grasped using a laparoscopic Babcock grasper (Fig. 43-10A and B). Identification of the terminal ileum is facilitated by retracting the small intestines cephalad according to gravity in Trendelenburg position.

FIGURE 43-10 ▪ A and B. The ileum is grasped with a Babcock clamp through the cannula at the ileostomy site.
If adhesiolysis is required, one or two additional 5-mm cannulas should be placed in the left side of the abdomen approximately four fingerbreadths or closer above and below the left mid-abdomen cannula.
The suitable segment of ileum in the intended orientation is gently grasped using a Babcock clamp and brought up toward the abdominal wall (Fig. 43-11A).
Pneumoperitoneum is released by deflating the balloon, and the bowel is exteriorized through the ostomy site keeping its orientation.

FIGURE 43-11 ▪ A and B. A loop of terminal ileum is brought through the abdominal wall aperture.
A stoma rod or red rubber catheter may be placed under the loop by creating a small opening in the mesentery (Fig. 43-11B).
Reinsufflation and confirmation of the proper orientation of the stoma is performed following the efferent limb distally to the cecum.

The remaining trocars are removed, and the incisions closed and dressed. The ileum is then opened on top of the efferent loop by a transverse incision using electrocautery or scissors (Fig. 43-12).

FIGURE 43-12 ▪ Loop ileostomy. After opening the distal aspect of the intestinal loop from one mesentery margin to the other, sutures used to mature the active half of the ileostomy occupy two-thirds of the skin aperture circumference, while sutures used to mature the inactive half occupy only one-third of the circumference. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

The mucosa is everted, and the ileostomy is “Brooked” and matured using 3.0 absorbable suture (Fig. 43-13).

FIGURE 43-13 ▪ Matured loop ileostomy. The efferent limb opening is small and flush with the skin, while the everted afferent limb occupies most of the aperture and protrudes above the skin. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)