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PREOPERATIVE EVALUATION

Before colostomy takedown, the patient should have a colonoscopy or contrast enema to ensure the absence of pathology in the proximal colon. If pathology were found, that could be treated at the same time as the colostomy takedown.

A mechanical and antibiotic bowel prep is used, as well as irrigations of the rectum through the mucous fistula or through the anus, to ensure that the rectum is cleaned out before colostomy takedown. In addition, with a good bowel prep, the less distended bowel becomes easier to manipulate. Thromboembolism prophylaxis, either pharmacologic or mechanical, is started prior to induction of general anesthesia. Prophylactic antibiotics that cover intestinal flora are given within an hour prior to skin incision. After induction of general anesthesia, an orogastric tube and urinary catheter are placed.

POSITIONING

A beanbag is placed under the patient. The patient should be placed into a low lithotomy position with Allen stirrups. Each ankle, knee, and opposite shoulder should be aligned. No pressure should be placed on the peroneal nerves or calves. The angle between the thigh and the plane of the bed should be between 0 and 10 degrees. Any more flexion will limit range of motion for the instruments. Any more extension may lead to an anterior dislocation of the hip.

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. Then, 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 (Figure 1).

For most of the operation, the surgeon and the assistant are both on the patient’s right with the assistant 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.

DETAILS OF THE PROCEDURE

Via rigid proctoscopy, any residual mucus is suctioned from the rectal stump. If this step is not performed, the circular stapler may not reach the end of the rectal stump during ...

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