Enterostomy in the high jejunum may be used for feeding purposes in malnourished patients either before or after major surgical procedures. Enterostomy in the low ileum may be clinically indicated in the presence of adynamic ileus when intubation and other methods of bowel decompression have failed to relieve the obstruction or when the patient's condition will not permit removal of the cause. Enterostomy also may be done to decompress the gastrointestinal (GI) tract proximal to the point of major resection and anastomosis or to decompress the stomach indirectly after gastric resection by directing a long tube in a retrograde fashion back into the stomach. Bile, pancreatic juice, and gastric juice lost from intubation or a fistula can be re-fed through the tube.
Preoperative preparation is determined by the underlying conditions found preoperatively. Often an enterostomy is done in conjunction with another major surgical procedure on the GI tract.
The patient is placed in a comfortable supine position.
The skin is prepared routinely. Sterile drapes are applied according to the surgeon's specifications. Then a time-out is performed.
As a rule, a midline incision is placed close to the umbilicus. If the enterostomy is performed for adynamic ileus in the presence of peritonitis, the incision should be so small that only few sutures are necessary for closure. When the procedure is part of a major intestinal resection or for feeding purposes, the enterostomy tube is brought out through a stab wound, preferably some distance away from the original incision. If the enterostomy is primarily for feeding purposes or for draining the stomach, the incision should be made in the region of the ligament of Treitz in the left upper quadrant.
When used for feeding purposes, either preliminary, complementary, or supplementary to a major resection, a Stamm enterostomy should be made close to the ligament of Treitz in the jejunum. When intended to relieve distension in adynamic ileus, the first presenting dilated loop may be used.
In an enterostomy used as a means of feeding, a loop of jejunum close to the ligament of Treitz is delivered into the wound, and the proximal and distal ends of the bowel are identified. The bowel is stripped of its contents, and enterostomy clamps are applied. Two concentric purse-string 00 nonabsorbable sutures are placed in the submucosa of the antimesenteric surface (FIGURE 1). A small stab wound is made through the intestinal wall in the center of the inner purse-string suture (FIGURE 2), through which the catheter is slipped into the lumen of the ...