COLOSTOMY

Solomon Bogale (MD)

April 19 / 2010
 It is important for the practitioner at the district hospital to
be capable of performing a colostomy

Indications
 perforated diverticulitis
 perforated sigmoid carcinoma
 iatrogenic colon perforation following colonoscopy
 obstructing unresectable rectal cancer
 rectal injury
 Sigmoid volvulus
 Left colon injury etc…

Preoperative management
Patient Evaluation
Patient Resustation
Patient or family counciling
Drug’s administration
 TYPE OF COLOSTOMY
I. Loop colostomy
II. Double- barrelled colostomy
III.Hartmann diverting colostomy
Procedure (Hartmann)
Step 1.
 The abdomen should be cleansed and draped to expose the
area from the pubic symphysis to the nipples. A lower
vertical midline incision is made. For obese patients, the
incision may need to be extended cephalad. Explore the
abdomen and evaluate the pathology. If purulent fluid is
present, obtain aerobic and anaerobic cultures.
Cont.
Step 2.
 Place a self-retaining retractor such as a Balfour or Omni
retractor.
Step 3.
 Place moist laparotomy pads across the small intestine and
pack in the upper abdomen.
Step 4.
 Incise the peritoneal reflection of the sigmoid colon above
and below the site of obstruction or perforation and mobilize
the sigmoid to the extent possible.
 Attempt to identify the left ureter. If the inflammation is
severe, maintain a close plane of dissection along the
mesenteric border of the sigmoid colon to avoid injuring
the ureter, particularly for benign disease.
 If inflammation or soiling is not severe, attempt to perform a
lymphadenectomy for suspected malignancies. For benign
disease, there should be no attempt to include the mesentery

or lymph nodes with the resection.

 How is the loop ?
Viable / non viable gut
Intestine Viable Non viable
Colour light Dark

Peritoneum Shiny Dull, lustreless

Intestinal muscle Firm Flabby

Reaction to pinch Contracts Doesn’t contract

Mesenteric vessels Pulsating Not pulsating

Step 5.
 Identify proximal and distal sites of the sigmoid for resection.

The bowel should be as healthy as possible at the resection

sites. For unusually severe inflammation or extensive tumor,
it may be safest to divide the sigmoid colon
 proximal to the site of pathology and leave the pathology in
place but diverted until a subsequent operation is performed.
Cont.
Step 6.
 Divide the bowel in both locations using an automated
stapling device.

Step 7.
 Clamp, ligate, and divide the mesenteric vessels with 2-0 silk
suture.

Step 8.
 Remove the specimen. Irrigate the abdominal cavity with
several liters of warm saline. Inspect for hemostasis.

Step 9.
 The distal sigmoid colon may be loosely tacked to the sacral
promontory or psoas muscle to prevent retraction and
facilitate subsequent colostomy reversal providing that
adequate length remains after the resection.
 A long polypropylene suture attached to the Hartmann pouch
will also facilitate future identification.
Cont.
Step 10.
 Excise a circular piece of skin at the preoperatively marked
stomal site.
~ This should be approximately 2 cm in diameter.
~ Make a cruciate incision in the anterior rectus sheath.
~ Do not divide the muscle. Incise the peritoneum.
These incisions should allow passage of two fingers.

Step 11.
 Bring the proximal sigmoid colon out through the stomal
incision.
~ The colon should lie freely at the surface of the skin
without tension.
If this is not possible, mobilize the descending colon
prior to closing the abdominal fascia.
Cont.
Step 12.
 Place a closed suction drain in the pelvis if an abscess was
present.
~ Close the abdominal fascia with a running #2 nylon
suture with interrupted 0 polypropylene figure-of-eight
sutures.
~ The skin should be loosely approximated and packed
with moist gauze in the presence of a perforation.
Otherwise, the skin may be closed with staples.
Dress the abdominal incision.

Step 13.
 Excise the staple line on the proximal colon. Sew the edges

of the colostomy to the skin with 3-0 Vicryl suture,

approximating the dermis to full-thickness purchases of the
 Colostomy : Transverse Loop
Indications
 presence of obstruction of the distal (left) colon or rectum
where primary resection and anastomosis of the obstructing
lesion is unsafe or impossible.
 To protect a low anastomosis of the rectum.

Procedure

Step 1.
 The patient is positioned supine and general anesthesia used

to allow for adequate exploration.

~ Draping exposes the area from xiphoid to umbilicus and
just lateral to rectus sheath edges.
Cont.
Step 2.
 A midline incision can be made or a transverse incision over
the right rectus muscle. If the colostomy is intended to be
permanent:-
~ placement of the stoma in the left transverse colon
through a midline or left rectus incision may help to
prevent subsequent prolapse.
The incision in any case must be large enough to permit
safe manipulation and delivery of the dilated colon segment.

Step 3.
 The dilated transverse colon is identified by following the
omentum down to its colonic attachment and the omentum
and dilated segment of colon are delivered through the
abdominal wall up into the operative field.
Cont.

Step 4.
 The omentum is separated from the colon over a short
distance by sharp or cautery dissection through the
avascular plane and the omentum then transected
at right angles to the colon between clamps, allowing it to
remain attached to the colon but fall back into the peritoneal

cavity out of the way.

Step 5.
 If the colon is extremely tense or difficult to handle, it is
possible to decompress it with an aspirating needle and
close the opening with a suture, incorporating the hole into
the site of the eventual colostomy.
 Step 6.
 A short segment on the mesenteric

border of the colon is cleared to

allow passage of a small Penrose
drain. The Penrose is then used as

a handle to pull up the colon

segment. Transverse loop
colostomy. Supporting rod
It is important to bring enough
colon out of the abdominal cavityloop.
to eliminate tension once the
bridge has been placed under the
Step 7.
 The fascia is closed with 0 absorbable suture loosely enough
to allow for easy passage of a finger between the colon and
the fascia. A few of the epiploic fat attachments and/or the
colon serosa are tacked to the fascia with Vicryl suture to
prevent herniation.
Cont.

Step 8.
 The subcutaneous layer is closed with 3-0 absorbable suture
and the skin with 3-0 simple sutures.
~ The skin closure should extend close to the colon but be
loose enough to allow passage of a finger around the edge
of the wound next to the colon.

Step 9.
 The Penrose drain is withdrawn while simultaneously
replacing it with a supporting rod or bridge. The rod is
fastened to the skin with nylon suture.
The exact nature of fixation to the skin will vary between
different devices.
Cont.

Step 10.
 The colon loop is opened along one of the tenia colae for
approximately one-third of its length, incorporating any
previous decompression site.

 The edges of the opened bowel are everted and gently

approximated to the dermis, except at the point where the
rod or bridge passes behind the loop, or the opening may
be left alone to evert over time.

Step 11.
 An opening is fashioned in the ostomy disc just large enough
to fit around the ostomy flush against the surface, and the
disc is placed on the skin.
 COLOSTOMY – DOUBLE BARRELLED

 The simplest and the fastest for you, the safest and the less
traumatic for the patient, is a sigmoid resection with
exteriorization through a double-barrelled colostomy.

Carry out a left pararectal incision about 6 cm long (refer to

laparotomy lecture), with its centre a bit higher than midway

between the umbilicus and the left iliac spine.

If the sigmoid loop is not deflated enough to pass through
the lateral incision, suck it out through a hole closed by a
purse-string suture. Bring it out taking care not to twist it
(use a triangular forceps) and let it hang on the left flank of
the patient. Close the midline incision.

The resection is performed outside the

abdomen. !!
Cont.
 Dividing the mesocolon may not be that easy because of
infiltration by fibrosis, so we recommend first dividing one
segment of the sigmoid loop (the lower one) between two
strong straight forceps or intestinal clamps.

“Caution” ! Take care not to divide the colon and the

mesocolon close to the skin but at least
five (5) cms away from the skin level to avoid
retraction of the divided tissues into the abdomen.

 Divide the mesocolon step by step about intestinal resection.

Tie the vascular pedicles before dividing them since they are
large and tend to retract. Finally divide the second segment
 of the sigmoid loop between two forceps.
Once the colon is removed, manage each colonic segment by

taking out the forceps, applying diathermy or ligating the

 Colostomy Closure
Indications
Colostomy closure is indicated when the underlying condition

which required the colostomy allows it and there is adequate

distal colon and rectum to safely reestablish gastrointestinal
continuity.
~ Colostomy closure is typically performed around 12
weeks after creation of the stoma after the inflammation
that may have been associated with colostomy
placement has resolved.
Cont.

Procedure
Step 1.
 An adequate abdominal incision is made for exposure. For
closure of a loop colostomy, this can be a horizontal or
vertical elliptical incision around the stoma.
 When the two ends of the bowel are separated, a midline
incision or reopening of the previous laparotomy incision is
often required. When closing an end colostomy, the stoma is
typically oversewn before prepping the abdomen to minimize
spillage.

Step 2.
 The stoma is separated from surrounding skin, subcutaneous

tissue, and fascia until it is possible to pass a finger into the

peritoneal cavity circumferentially around the stoma.
Cont.
Step 3.
 The proximal and distal colon are mobilized as much as
necessary to allow the bowel to be reanastomosed without
tension.

Step 4.
 The colon is anastomosed in a tension-free manner using
sutures or stapling instruments. In a divided colostomy, the
bowel ends should be resected back to healthy tissue prior to

anastomosis. Either a one-layer or two-layer sutured

anastomosis can be performed.

 If the anastomosis is stapled, the two ends of bowel are

closed with a linear stapler and then a functional end-to-side

anastomosis performed.
Cont.
 When closing a loop colostomy, it may be possible to preserve
the bridge of tissue connecting the two limbs and close the
remainder of the circumference of the bowel.
 However, this must be done in a way that does not
compromise the lumen, and it may be necessary to resect back

to fresh ends to effect an adequate anastomosis.

Step 5.
 The site of the stoma is typically left open and packed to heal
by secondary intention. If a separate abdominal incision has
been made, it can be closed in layers including skin if
contamination has been minimal.
Closing a colostomy may be difficult and
should be performed electively by a
specialist surgeon

Colostomy closure should not be

performed earlier than 3 months.