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INDICATIONS

Laparoscopic colostomy creation is indicated for patients in need of primary fecal diversion. Clinical scenarios include near-obstructing rectal cancers prior to definitive surgery, large sacral decubitus or other wounds at risk of persistent contamination, severe fecal incontinence, or anorectal trauma.

PREOPERATIVE EVALUATION

A bowel prep is not required. The patient should be examined in lying, sitting, and standing positions by an enterostomal therapist and be marked for potential ostomy sites. The markings should avoid skin creases, scars, or bony prominences. The patient must be able to see each marking. In obese patients, the upper abdominal wall tends to be thinner and is a better site for ostomies.

ANESTHESIA

Thromboembolism prophylaxis, either pharmacologic or mechanical, is started prior to induction of general anesthesia. Prophylactic antibiotics that cover intestinal flora are given within 1 hour prior to skin incision. After induction of general anesthesia, an orogastric tube and urinary catheter are placed.

POSITIONING

Some surgeons prefer having a beanbag under the patient. The patient is in a supine position. Each elbow (ulnar nerve) is covered with a gel pad, and both arms are adducted. Care must be taken to avoid compromising or kinking the intravenous lines. The beanbag is cradled above both shoulders and around the arms to prevent the patient from falling while in extreme positioning. The air is suctioned from the beanbag so it retains that shape.

A gel pad covered by a towel is placed on the upper chest. Tape is placed under the bed, over each shoulder, and across to the other side of the bed. If the peak airway pressures become elevated, the tape should be loosened. Security of the patient on the table should be confirmed by testing maximal Trendelenburg and left-side-down positioning prior to prepping and draping. The entire abdomen is prepped from nipples to groin and widely, to allow lateral placement of trocars as needed.

For most of the operation, the surgeon and assistant will both be on the patient’s right. The assistant will be near the patient’s right shoulder. One monitor should be placed near the feet, and another should be placed near the head on the patient’s left. The cautery foot pedal is placed on the patient’s right (Figure 1).

The preoperative markings for ostomy sites are reinforced by scratching the skin with a needle.

DETAILS OF THE PROCEDURE

Trocar Placement

The peritoneal cavity can be accessed with a Hasson technique or Veress needle above the umbilicus. Pneumoperitoneum to a pressure of 15 mm Hg is established. With observation through a 30-degree laparoscope, two 5-mm trocars are placed in the right lateral abdominal wall, just ...

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