JOURNAL READING

COLOSTOMY CLOSURE:
HOW TO AVOID COMPLICATION
Bischoff A. Levitt MA. Lawal TA. Pena A.
Pediatr Surg Int. Aug 16TH 2010

ADVISOR : DANIEL A., MD SURGEON

PRESENTER : Novia Rahayu T (2008-61-007)

Andi Rizki (2008-61-059)
Michael Praditya (2008-61-155)
Lenny Syahnita (2009-61-334)
INTRODUCTION
 Colostomy
• an incision (cut) into the colon (large intestine) to
create an artificial opening or "stoma" to the
exterior of the abdomen. This opening serves as a
substitute anus through which the intestines can
eliminate waste products until the colon can heal
or other corrective surgery can be done
(Texas Pediatric Surgical Assc)

• Colostomy is an operation frequently performed

in pediatric surgery.
 Indication

Anorectal Malformation

Colostomy

Hirschprung Disease
• Colostomy can cause morbidity and mortality

• Causes in pediatric population:

– Anastomotic dehiscence 0 -12,5 %
– Wound infection 0,4 – 45 %
– Other:
• Bleeding
• Anastomotic stricture
• death
• Important role:
– Preoperative
– Intraoperative
– postoperative
• Achieving Low morbidity rate
METHOD
• Retrospektif
• Data from:
– 649 patient
– Medical record
– 1982-2010
• Perioperatif protocol
 Perioperative Protocol
1. Admission on the day before surgery
2. Clear liquids by mouth
3. Repeated proximal stoma irrigations with
saline solution, 24 h prior to the operation
4. Administration of IV antibiotics during
anesthesia induction and continued for 48 h
5. Meticulous surgical technique
 Meticulous surgical technique
• Packing of the proximal
stoma
• Plastic drape to immobilize
the surgical field
• Multiple silk sutures in
mucocutaneous junction
• Careful hemostasis,
emphasis in avoiding
contamination,
• Cleaning the edge of the
stomas to allow
anastomosis
 Meticulous surgical technique (2)

• A two-layer, end-to-
end anastomosis
with separated
long-term 6-0
absorbable sutures
 Meticulous surgical technique (3)
• Generous irrigation of
the peritoneal cavity
and subsequent layers
with saline solution
• Closure in layers to
avoid dead space
• Avoidance of
hematomas
• Wound coverage with
collodium
RESULT
 Of 649 Colostomy closure:

Original disease
Anorectal malformation 583
Hirschprung’s disease 53
Others: 13
-Malignancy 4
-Teratoma 3
-Ulcerative colitis 2
-Pelvic trauma 2
-Vaginal atresia 1
-Giant seminal vesicle 1
Type of Colostomy
stoma 480
Loop 137
Hartman 32
 1,5% (10 pts) had complication

Complication
Intestinal obstruction 6
Incisional hernia 4

-No anastomosis dehiscence

-No wound infection
-No episode of bleeding
-No anastomosis stricture

No mortality
DISCUSSION
 COLOSTOMY
• A routine procedure, frequently performed
• Elective procedure
– Assumed easy, reproducible, minimal morbidity
• May still be source of complications, incl
death

• Author share routines & surgical technique

they use during colostomy closure procedure
 SURGERY PREPARATION
– Irrigation of proximal stoma
– Clear fluids by mouth
Contribution not clear

• Prophylactic antibiotic
– Erythromycin by mouth : frequent vomiting
– Ampicillin, gentamicin, clindamycin
– Ampicillin, gentamicin, flagyl
– Cephalosporin, flagyl
 OPERATIVE ROUTINES
PACKING OF STOMA
• Prepare skin with Betadine & Alcohol
• Pack proximal stoma with gauze + Betadine
• Operative field immobilized with plastic drape
Very important in reduction of contamination
COAGULATE & CUT
• Use coagulation to coagulate!
• Use cutting current to cut!
*excessive burning may leave damaged tissue 
bacterial proliferation
• Hemostasis
BOWEL ANASTOMOSIS
• One-layer anastomosis
• Two-layer anastomosis

• Several articles: both are as good

• Author’s observation: leakage or dehiscence
occurred in one-layer anastomosis

• Profuse irrigation of peritoneal cavity is also

important
ABDOMINAL WALL CLOSURE
• Single-layer with running suture
– Fashionable, quick, and easy
– Produce more pain, cosmetically undesirable, more
prone to evisceration
• Single-layer with interrupted stitches
– Used in secondary operation in wound dehiscence
– Safer closure (lower tension of skin edges), better
cosmetic scar
• Each layer closed separately
(ABDOMINAL WALL CLOSURE)
• Incisional hernia
– lack of wound layer closure
– The need to pay attention to all steps & details of
operation

• NGT is unnecessary in clean operation

• SIZE DISCREPANCY
• Greater discrepancy demands more technical
procedure
– End-to-end anastomosis or
– End-to-side anastomosis (if dicrepancy >4:1)
• The bigger size discrepancy, the longer waiting
time with the colostomy open
• End-to-side anastomosis with window-type of
stoma
– Case of as much as 10:1 discrepancy (e.g: colonic
atresia with distal microcolon)
– Window-type of stoma created 5-10 cm proximal
to anastomosis
CONCLUSION
• Based on Author’s opinion and experience
• Colostomy closure can be performed with
minimal mortality & morbidity
• Providing meticulous technique
THANK YOU