Colostomy creation for fecal diversion is offered to patients for a range of clinical situations and a variety of diseases. Obstruction of the colon can occur as a result of neoplasms of the colon or rectum or because of other pelvic and abdominal malignancies. Complex fistulas such as rectovaginal or rectourethral fistulas or severe fistula-in-ano disease may require diversion. Traumatic injury to the anorectum, pelvic sepsis, or perineal soft-tissue infections may necessitate colostomy. Functional conditions such as fecal incontinence, intractable constipation, or decubitus ulcer may require palliative colostomy creation. Radiation proctitis with severe intractable bleeding or pain is another somewhat uncommon but described indication for colostomy creation. Depending on the anticipated future treatment of the underlying condition, colostomies may be permanent or temporary. Fecal diversion in the case of distal obstruction requires a loop colostomy or a divided end-loop colostomy with venting mucous fistula to avoid a closed-loop obstruction of the defunctionalized limb. Reports describing laparoscopic stoma creation for fecal diversion were described as one of the earliest ideal applications of minimally invasive surgery for colon rectal surgery.

Absolute contraindications against the use of the laparoscopic technique are rare. Hemodynamic instability represents such a situation because the pneumoperitoneum may exacerbate hypotension because of its effect on the cardiovascular system. Complete or high-grade large bowel obstruction with a competent ileocecal valve leads to a tensely distended bowel. This setting should be considered a contraindication for laparoscopic colostomy because massive dilation of the colon may lead to loss of domain and compromised videoscopic view of the peritoneal cavity. Moreover, marked elongation of the colon due to obstruction may confound accurate colonic segment identification; lastly, and most importantly, tense distension of the bowel leads to marked thinning of the wall, making manipulation of the bowel with miniaturized end effectors hazardous with increased risk of perforation—a catastrophe in the setting of a massively distended and obstructed colon. In the author’s opinion, high-grade large bowel obstruction with massive distension is best managed by laparotomy and open surgical technique, with the initial step being controlled decompression of the massively distended bowel. Unfortunately, other limitations notwithstanding, reliable means of laparoscopic decompression and avoidance of contamination remains a critical limitation of the existing minimally invasive technique and therefore is not advisable.

Identification of the patient at risk for a challenging stoma remains paramount when considering a minimally invasive approach because these situations represent relative contraindication and can impact open surgery as well. Thick, foreshortened mesentery and/or increased abdominal wall thickness cause central difficulty in bringing the colon to the skin. Similarly, patients with inflammatory bowel disease, mesenteric desmoid tumors, history of mesenteric or peritoneal abscess, or prior radiation therapy also may suffer from short mesenteric length making exteriorization difficult. Patients having undergone prior resection present unique challenges given prior mobilization and mesenteric division. All of these situations increase the risk of a more complex operation, both from a technical standpoint as well as from the point of operative decision making. A surgeon must be cognizant of own clinical experience as well as the skill level when considering the application of laparoscopic technique for colostomy creation because the platform employed—minimally invasive or open—must always enable and not hinder the surgeon’s ability to create a well-formed, functioning stoma.

In the elective setting, one cannot overemphasize the importance of preoperative consultation with an enterostomal specialist for education and marking. The role of such an interaction remains critical to patient preparation. The anticipation of life with a stoma, even if temporary, understandably causes fear and anxiety; the ability of a patient to discuss concerns before surgery eases this transition and reduces such feelings.

Proper stoma marking also cannot be overstated. Preoperative consultation with an enterostomal therapist helps ensure that the stoma is optimally located, improving stoma pouching and reducing occasions of leakage. Lastly, preoperative counseling provides the initial interaction for a long-term relationship benefiting the ostomate.

Ideally, bowel preparation should be performed before elective colostomy creation. Although laparoscopic surgery generally offers the benefit of reduced wound infection, the author and editors prefer bowel preparation to include both mechanical cathartic cleansing and oral and IV antibiotics.

One of the key concepts for preparation before surgery includes surgeon preparation. Again, it is imperative that a surgeon considers patient factors placing them at risk for a challenging stoma. The obese patient represents the most common such situation, given the rates of severe obesity observed in Western industrialized countries. Stoma marking must take into account abdominal skin creases resulting from the panniculus, increased thickness inferior to the umbilicus with a thinner abdominal wall often present cephalad to this landmark, and one must anticipate movement of the panniculus and abdominal wall upon standing. An experienced enterostomal therapist again provides critical assistance regarding optimal stoma siting in the obese patient.

In addition, when considering the obese patient, one must anticipate intraoperative challenges. Surgeon preparation should include specific strategies for the type of stoma (loop, end loop, divided loop, or end colostomy) to be created, as well as preparation for issues related to adequate bowel and mesenteric mobilization, accurate vessel and mesenteric division, and ensuring adequacy of length for exteriorization. In the obese patient, one must strongly consider the use of the descending colon as opposed to the sigmoid colon. This requires specific steps related to (1) mesenteric division to include high ligation of the inferior mesenteric artery, division of the ascending left colic artery and proximal ligation of the inferior mesenteric vein; (2) full splenic flexure mobilization with complete dissection from the retroperitoneum and inferior border of the pancreas back to the ligament of Treitz; and (3) lastly, one must anticipate the challenge of mobilizing the omentum from the transverse colon and splenic flexure. When utilizing the descending colon as the conduit for colostomy, the arterial blood supply is provided by the marginal artery of Drummond; and one can resect and tailor the mesentery medial to this vessel, resulting in a narrowed and trim descending colon containing the marginal artery that is close to and parallels the medial edge of the bowel. This trim profile assists greatly in reducing the volume of tissue to be exteriorized through a thick abdominal wall. Amputation of appendices epiploica also can reduce the volume of tissue, facilitating exteriorization. Wound protectors used at the stoma site, with lubricating gel, can ease passage of the bowel through the aperture. A last consideration for stoma creation in the obese patient should include mention of abdominal wall contouring or formal panniculectomy. This should be considered an option of last resort.

A surgeon must take into account his or her own experience and skill set when contemplating a minimally invasive approach to colostomy creation in the patient at high risk for a challenging repair. The operative platform for creating a colostomy must enable the surgeon to reliably and precisely perform each operative step. The obese patient clearly benefits from small incisions offered by a laparoscopic approach. However, this patient group imposes considerable technical challenge to such an approach whether it is related to obtaining adequate exposure, accurate vessel identification and mesenteric division, or contending with a large omentum. One must always remember that the highest priority remains creation of a well-vascularized, adequately mobilized portion of bowel that can be exteriorized through an appropriately sized aperture in good position on the abdominal wall, exteriorized above the skin and everted for pouching. A laparoscopic colostomy that is poorly constructed and is at high risk for complication, reoperation, and revision should be condemned if a better stoma would have been provided by an open technique.

Supine or lithotomy: Consider the need to access the perineum for examination purposes, treatment of pathology, or access for endoscopy when choosing supine or lithotomy position.