The patient should meet with an enterostomal therapy (ET) nurse to be marked with a permanent marker on the abdomen at the site for the planned ileostomy to ensure proper stoma location. Any questions can be answered and concerns addressed during that visit with an ET nurse. Preoperatively meeting with an ET nurse has been shown to reduce postoperative complications and problems with stomas, especially ileostomies.

The patient is positioned in the supine position on the operating room table. A beanbag or pink memory foam pad can be safely used to help carefully secure the patient to the table. Preoperative antibiotics are administered within 1 hour of skin incision. The site of the planned ileostomy is scratched with a small needle because the marker ink can be wiped off during the prep of the skin. The operating surgeon stands on the left side of the table and a 5-mm trocar is placed superior to the umbilicus after pneumoperitoneum is established using a Veress needle. A 5-mm, 30-degree laparoscope is inserted through the supraumbilical port. Alternatively, a 10-mm trocar can be placed using a direct Hasson technique above the umbilicus. Placement of the camera port midway between the umbilicus and the xiphoid may facilitate visualization of the stoma site and facilitate any necessary dissection under it. A10-mm, 30-degree laparoscope is used (Fig. 46-1). An additional 5-mm port is placed on the left side of the abdomen two fingerbreadths medial and superior the left iliac crest (Fig. 46-1). An optional third 5-mm port can be placed through the planned ileostomy site on the right side of the abdomen (Fig. 46-2). Alternative port configurations include the single supraumbilical camera port and a 10-mm port through the ileostomy site. Mobilization of the terminal ileum may be facilitated by releasing the lateral attachments along the pelvic brim up to the right paracolic gutter. The site of a diverting loop ileostomy is chosen approximately 25-40 cm proximal to the ileocecal valve and grasped with an atraumatic bowel grasper (Fig. 46-3). The ileum is oriented with the grasper so as
not to twist the loop of ileum. The preselected stoma site on the right side of the abdomen is prepared by making a 2-cm-diameter skin opening. The rectus muscle is bluntly opened to allow 1½-2 fingers to pass with a muscle-splitting technique. The loop of ileum is delivered through the rectus muscle above the level of the skin (Fig. 46-4). A stoma rod may or may not be required to suspend the loop depending on the body habitus of the patient. The abdomen is then re-insufflated and the loop of ileum is visualized going into the stoma site to ensure that the ileostomy was not twisted during delivery through the abdominal wall. The distal limb is placed inferiorly and the functioning limb is placed
superiorly. At this point, the ileum can be divided using an open surgical linear cutter to create a divided end-loop stoma and the distal end tucked back into the abdomen below the fascia. This has the advantage of being completely diverting. The laparoscopic ports are removed, and the port site incisions are closed with absorbable, subdermal sutures. A sterile dressing or skin adhesive is applied before maturing the ileostomy. If a loop ileostomy is performed, an incision is made 80% around the circumference of the ileum. The proximal limb of the ileum will be everted as the functioning limb (Fig. 46-5). The proximal aspect of the stoma is Brooked above the level of the skin to the dermis with 3-0 absorbable sutures and the distal end is sutured flush to the dermis of the skin, gathering the bowel wall to a small portion of the circumference of the skin opening at the most inferior part of the stoma site (Figs. 46-6 and 46-7). A stoma appliance is subsequently applied. The editors’ preference is to place the camera port in the midline midway between the umbilicus and the xiphoid. The stoma can often be created through the right iliac fossa stoma site without any additional ports. The exception is if terminal ileal mobilization and/or adhesiolysis are necessary then an additional 20-mm left lower quadrant port can be placed as the authors suggest.