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INDICATIONS

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The right transverse colostomy is preferred by many over cecostomy for decompression of the obstructed colon due to a left-side lesion. This procedure completely diverts the fecal stream and permits an efficient cleansing and preparation of the obstructed colon proximal to the lesion. When simple diversion of the fecal stream is needed as a complementary component of an elective colonic operation, the surgeon should consider placement of a proximal diverting loop ileostomy (see Chapter 51).

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PREOPERATIVE PREPARATION

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Since this procedure is usually performed to relieve acute obstruction of the left colon, the preoperative preparation is limited to the correction of fluid and electrolyte imbalance as well as blood volume deficits. Flat and upright roentgenograms of the abdomen are made with a marker, such as a coin, on the umbilicus. An emergency water-soluble contrast enema is indicated to locate conclusively the left-sided point of obstruction. A sigmoidoscopic or colonoscopic examination may be done. Prophylactic antibiotics are administered intravenously within 1 hour of incision.

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ANESTHESIA

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Usually, endotracheal anesthesia, which provides a cuff for secure closure of the trachea, is indicated to avoid aspiration of regurgitated gastrointestinal contents.

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POSITION

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The patient is placed in a comfortable supine position with the proposed site for the incision presenting.

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INCISION AND EXPOSURE

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The incision is placed in the right upper quadrant. A vertical or transverse incision can be made in a location over the distended colon as indicated from a study of the abdominal roentgenograms. Currently it is believed that the opening should be made through the rectus muscle with consideration being given for the span of the ostomy appliance gasket, which should be away from skin folds, bony prominences, or the valley of the umbilicus. Marking is further discussed in the section on loop ileostomy. The tentative site should be checked with the patient standing and sitting and taking special note of the proximity to the patient’s belt line which should be avoided. The opening into the abdomen, while limited in length, must be large enough to permit easy identification and mobilization of the tightly distended transverse colon. If the bowel is tightly distended, it is essential to deflate it through a large needle or trocar, since the collapsed bowel can thus be handled more easily and safely.

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DETAILS OF PROCEDURE

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A knuckle of transverse colon is delivered into the wound, and the omentum is retracted upward. If the intestine is tremendously distended, a large-bore needle attached to a syringe is inserted obliquely through its wall to allow gas to escape. Decompression through a small trocar attached to a suction apparatus may be indicated before the distended bowel can be safely mobilized. If necessary to avoid contamination, the small opening is closed with a purse-string suture. Under such circumstances the decompression ...

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