In every instance an interlude that may be as long as 10 weeks should be allowed between the 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 assured by contrast study using fluoroscopy.
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. Other preoperative preparation is in accordance with that outlined in Plate 65.
Spinal or general anesthesia may be used. Local anesthesia is contraindicated in the presence of infection about a wound.
The patient is placed in a comfortable supine position.
Supplementary to the routine skin preparation, a sterile gauze sponge is inserted into the colostomy opening.
Figure 2 shows the cross-sectional anatomy of the colostomy. 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.
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 the closure (Figure 5). With the index finger still in the lumen of the intestine, the operator makes an incision with scissors around the margin of the mucosal reflection (Figure 6). This incision is carried through the seromuscular layer down to the submucosa in an effort to develop separate layers for closure (Figure 6).
With its margin held taut with forceps, the mucous membrane is closed transversely to the long axis of the bowel. A continuous fine absorbable suture is used (Figure 7). Following closure of the mucosa, the previously developed seromuscular layer, which has been freed of any fat, is approximated with interrupted Halsted sutures of fine silk (Figure 8). The wound is irrigated repeatedly, and clean towels are applied around the wound. All instruments and materials are removed, gloves are changed, and the wound is closed only with clean instruments.
The closed portion of the bowel is held to one side while the adjacent fascia is divided with curved scissors. The detachment of the fascia from the bowel is facilitated by exposure of the silk sutures previously placed for fixation of the bowel at the time of colostomy (Figure 9). The peritoneal cavity is not opened in this method of closure.
The patency of the bowel is tested by the surgeon's thumb and index finger. If a small opening has been accidentally made in the peritoneum, it is carefully closed with interrupted sutures. The wound is irrigated repeatedly with warm saline. The suture line is depressed with forceps, while the margins of the overlying fascia are approximated with interrupted sutures of 00 silk (Figure 10). The subcutaneous tissue and skin are closed in layers in the routine manner (Figure 11). Some omit closure of the skin because of the possibility of infection and perform a delayed secondary closure.
Instead of attempting to incise the ring of scar tissue at the junction of mucous membrane and the serosa of the bowel, some operators prefer to divide the full thickness of the bowel adjacent to the colostomy opening. After the bowel has been freed from the surrounding tissues, the surgeon's index finger may be inserted into the colostomy to serve as a guide while the bowel is being divided with curved scissors adjacent to the margin of the presenting mucous membrane (Figure 12). It may be necessary to free the intestine from the peritoneum and open into the peritoneal cavity in order to mobilize a sufficient amount of the bowel for a satisfactory closure.
The intestinal wall is excised until the scarred edges of bowel around the colostomy opening are completely cut away, leaving normal-appearing intestinal wall to be closed. The bowel is closed transversely to the long axis of the intestine to prevent stenosis. The bowel wall is held taut with either Allis or Babcock forceps above and below the angles of the new opening. The mucous membrane of the intestine is closed on the inner side with a continuous fine absorbable suture of the Connell type. Interrupted 0000 silk sutures on a French or straight milliner's needle are preferred by many (Figure 13). Interrupted mattress sutures of 00 silk or 00 absorbable synthetic sutures are placed to invert the mucosal suture line and to approximate the seromuscular layer over it (Figure 14).
The wound is irrigated with saline. All contaminated instruments, gloves, and towels are discarded, and clean materials are used if it is necessary to open the peritoneal cavity about the margin of the bowel in order to replace the closure within the peritoneal cavity (Figure 15). The patency of the lumen of the bowel is assured by palpation between the surgeon's thumb and index finger. If possible, the omentum is tucked over the site of the closure. The peritoneum is closed with interrupted sutures of 00 absorbable synthetic suture material, followed by a routine closure of the layers of the abdominal wall (Figures 16 and 17). When gross contamination has occurred, some prefer to partially approximate the subcutaneous tissue and omit skin approximation by sutures. The wound is covered with a sterile dressing.
Parenteral fluids are administered for several days. A clear liquid diet is given for a few days, followed by a low-residue diet; a regular diet can be resumed after bowel action has started. Occasionally, a leak may occur at the closure site, but no immediate effort is made to repair the fistula because closure is frequently spontaneous. Early ambulation is encouraged.