Chapter 21

• To defunctionalize bowel.
• Protection of distal anastomosis.
• Relief of obstruction.

• None.

### Relative

• Carcinomatosis precluding mobilization of bowel.
• Morbid obesity such that mesentery or stoma cannot reach the skin surface.

### Expected Benefits

• Decompression of bowel obstruction.
• Protection of distal anastomosis to allow healing with decreased risk of intra-abdominal sepsis.

### Relative Risks

• Bleeding.
• Intra-abdominal abscess.
• Wound infection.
• Parastomal hernia.
• Need for ostomy revision secondary to stenosis or ischemia.

• Standard general surgery set for major gastrointestinal surgery.

• Nasogastric tube in cases of perforation or obstruction.
• Resuscitation to correct any fluid and electrolyte abnormalities.
• Perioperative antibiotics and additional doses in the event operative time is prolonged.
• No bowel preparation is necessary for small bowel procedures.
• Preoperative evaluation and marking of optimal stoma position by an enterostomal therapist.

• The patient should be supine.

### Loop Colostomy

• Figure 21–1: When ostomy is performed for diversion of the fecal stream due to distal obstruction, the dilated colon may be decompressed with a needle or catheter attached to wall suction. The collapsed bowel is easier to manipulate, and there is decreased risk of injury and perforation.
• Figure 21–2: An incision is made along the apex of the selected loop of bowel to prepare for stoma creation on the antimesenteric wall of the bowel.
• Figure 21–3: The cut edges of the bowel are everted and interrupted sutures are placed using full-thickness bites of colon wall and subdermal bites of skin.
• A rod or red rubber catheter may be placed under the loop of colon being brought up; however, this step is not necessary and may interfere with placement of the ostomy appliance.

### End Ileostomy

• Figure 21–4A: For creation of an end ileostomy, a circular incision approximately 2.5 cm in diameter is made overlying the rectus muscle.
• Figure 21–4B: Blunt dissection is used to divide the soft tissue to the level of the fascia.
• A cruciate incision is made in the fascia and carried 2 cm in both directions.
• The rectus muscle fibers are split using the clamps and retractors.
• Figure 21–4C: The posterior sheath is opened with a cruciate incision sufficient to permit passage of two fingers.
• Figure 21–4D, E: The small bowel is brought through this fascial opening using a Babcock clamp until 5 cm of ileum protrudes above the surface, with care taken to avoid twisting the mesentery.
• Four Brooke-type sutures are ...

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