Loop Ileostomy

Tery Joseph
 INDICATION
• A distal loop ileostomy is most commonly
used for temporary diversion of the
gastrointestinal contents to protect a
colonic anastomosis.
• The loop ileostomy has replaced the
traditional right transverse colon loop
colostomy in many circumstances, as this
loop is easier to construct and close.
PRE-OPERATIVE PREPARATION
• Most patients undergoing emergency or complex
operations on the colon are counseled by the
surgeon about the potential need for an ostomy. If
available, an enterostomal therapist should
visit the patient prior to surgery. The potential
ostomy site should be marked with indelible ink
• An ostomy is best placed near the
lateral
edge of the rectus muscle and sheath. It
may be placed either above or below the umbilicus.
Th e position chosen must take into consideration
the span of the ostomy gasket, such that it has a
smooth, wide surface for adherence.
PRE-OPERATIVE PREPARATION
• The costal margin, indentation of
the umbilicus, uneven scars, and
skin folds will not allow secure
placement of the ostomy gasket. In
general, the belt line should be avoided,
and the patient should both stand and sit
with an appliance in place during this
marking.
PRE-OPERATIVE PREPARATION
• The patient should be reassured about his
or her ongoing care with the enterostomal
therapist.
• If an enterostomal therapist is unavailable,
the surgeon should make every effort to
educate the patient using these written
and pictorial aids.
 DETAILS OF PROCEDURE
• The anesthesia,
position, and
abdominal incision and
exposure are
determined by the
colon operation being
performed.When
markings are made
preoperatively, they
should be scratched
gently into the skin with
an “X” prior to skin
preparation.
 DETAILS OF PROCEDURE
• A 3-cm circle of skin is excised and the
dissection is carried down through the
subcutaneous fat to the anterior fascia of
the rectus muscle. A two finger–sized
opening is made through the fascia. Some
prefer a single slit, while others make a
cruciate incision.
 DETAILS OF PROCEDURE
• The rectus muscle is spread or
retracted medially. Care should be
taken not to injure the epigastric
vessels that run deeply in the center of
this muscle. Another two finger–sized
opening is made through the posterior
sheath and peritoneum.
 DETAILS OF PROCEDURE
• An appropriate segment of terminal ileum,
usually about 1 ft or so proximal to the
ileocecal valve, is selected. This section of
small bowel must have sufficient
mobility to reach through the abdominal
wall without stretch or tension.
 DETAILS OF PROCEDURE
• A blunt Kelly hemostat is used
to create a mesenteric
opening just beneath the wall
of the ileum. A segment of
umbilical tape or a soft rubber
Penrose drain is drawn through
the opening
• The opening in the abdominal
wall is checked again for
size relative to the thickness of
the ileal loop and its mesentery.
In general, a two finger sized
opening is adequate. Th e tape
and the ileal loop are brought
through the abdominal wall
using gentle traction with a
rocking motion
 DETAILS OF PROCEDURE
• The loop is oriented in a vertical manner
with the active proximal limb and its
marking suture placed at the cephalad or 12
o’clock position. The loop ileostomy should
protrude about 5 cm above
• The caudal or inactive side of the loop is
opened transversely for two-thirds of
its diameter in a position
 DETAILS OF PROCEDURE
• The distal inactive stoma is
matured first by placing fine
absorbable sutures that tranverse
the entire thickness of the ileal
bowel wall
• Three or four sutures are
required for full eversion of the
stoma
• the proximal active stoma is
everted. This maneuver is
assisted by using the rounded,
blunt end of the scalpel handle.
The handle tip applies
countertraction as the free
mucosal edge is brought down to
the skin with forceps or a similar
grasping instrument
 DETAILS OF PROCEDURE
• The viability of the stoma is rechecked
and the intra-abdominal portion of the loop
is examined.