Chapter 57: Closure of Colostomy

INDICATIONS

In every instance an interlude of at least 12 weeks should be allowed between performance of a colostomy and its closure. This enables the patient's general condition to improve, the site of the colostomy to become walled off, local immunity to the infected contents of the intestine to develop, any infection in the wound to subside, and the wounds from technical procedures carried out on the distal colon to heal. This time may be drastically shortened if the colostomy was performed to decompress or exteriorize a traumatized normal colon. Occasionally, the colostomy partially or completely closes itself after the obstruction has been removed, which permits the fecal current to return to its normal route through the site of the anastomosis. Closure should be delayed until the edema and induration of the bowel about the colostomy opening have subsided and the intestine has resumed a normal appearance. The patency of any anastomosis of the intestine distal to the colostomy should be ensured by contrast material study using fluoroscopy or endoscopy.

A stapled anastomosis also may be created to close a loop colostomy (see Chapter 59).

PREOPERATIVE PREPARATION

The patient is placed on a low-residue diet with oral antibiotics before operation, and the intestines are emptied as completely as possible. During the 24 hours preceding operation, repeated irrigations in both directions through the colostomy opening are done to empty the colon.

ANESTHESIA

Spinal or general anesthesia may be used.

POSITION

The patient is placed in a comfortable supine position.

OPERATIVE PREPARATION

Supplementary to routine skin preparation, a sterile gauze sponge may be inserted into the colostomy opening. Sterile drapes are applied according to the surgeon's specifications. Then a time-out is performed.

INCISION AND EXPOSURE

While a piece of gauze is held in the lumen of the intestine, an oval incision is made through the skin and subcutaneous tissue about the colostomy (FIGURE 1). This incision may include the original scar, or alternatively, an elliptical incision may be made that includes the entire scar and colostomy. FIGURE 2 shows the cross-sectional anatomy of the colostomy.

DETAILS OF THE PROCEDURE

The operator's index finger is inserted into the colostomy to act as a guide to prevent incision through the intestinal wall or opening into the peritoneal cavity as the skin and subcutaneous tissue are divided by blunt and sharp dissection (FIGURES 3 and 4).

In the case of a colostomy that has been functioning for some time, the ring of scar tissue at the junction of mucous membrane and skin must be excised before proceeding with closure (FIGURE 5). With the index finger still ...