Methods for ostomies

There are some important general principles: (1) Always try to bring an ostomy out through a separate smaller incision, and not through a laparotomy incision, unless you have to, because the wound is much more likely to become infected, and perhaps burst. (2) With all colostomies do Lord's procedure (maximal anal dilatation 22.5) before you send the patient back to the ward. This will temporarily paralyse his external sphincter, and allow his distal colon to drain more easily.

Sigmoid volvulus is the commonest cause of obstruction of the large gut in much of the developing world, so it is described elsewhere (10.10), and with it the detailed method for doing a sigmoid colostomy. Here are details of the other methods.

CLAMP, enterostomy, crushing, Lloyd Davies parallel action to take apart, one only. This is for crushing the spur of a double-barrelled colostomy.

OSTOMIES In most patients you will need to follow the general methods for intestinal obstruction in Section 10.3.

CAECOSTOMY [s7]UNDER LOCAL ANAESTHESIA INDICATIONS. (1) Penetrating injuries of the caecum. (2) An obstruction proximal to the mid transverse colon, if you feel unable to do a right hemicolectomy. (3) Obstruction anywhere in the colon, if the patient is too ill for a colostomy. (3) A minimally skilled operator faced with any large gut obstruction.

X-RAYS. Before you start, make sure exactly where the patient's caecum is. Look for its gas shadow on the X-ray. It can be suprisingly high. Percuss his abdomen to make sure.

EQUIPMENT. A large (30 Ch) Malecot or, less satisfactorily, a large de Pezzer catheter with the top of its bell cut off.

ANAESTHESIA. General or local anaesthesia (A 6.7).

METHOD. Study Figure 66-18. Then, with the greatest possible care, make a small gridiron incision at McBurney's point (12-1) well laterally over his dilated caecum[md]you can easily nick or burst it. Put packs round the wound inside his abdomen to minimize the consequences of spillage. Have suction instantly available.

Partly deflate his caecum by needle aspiration (10-9), or by decompression (after placing a purse string suture round it), so as to take the tension off it. As soon as you have done this, its walls will become thicker and more vascular.

If his caecum is mobile enough to deliver out of his abdomen, gently bring it out, assisted by Dennis Browne forceps if necessary. In practice this is seldom possible. If you succeed, drain it, and then apply the anchoring sutures described below.

If it is not mobile enough, insert several 3/0 atraumatic chromic catgut sutures from the cut edges of his peritoneum to a 6 cm ring on his caecum. Pick up its seromuscular layer only. Don't penetrate its mucosa. Leave the sutures long, hold them in haemostats and don't tie them yet. Make another 4 cm purse string circle inside this.

With suction immediately handy and the surrounding area carefully packed off, make a small nick in the centre of the purse string. Flatten the end of the catheter in a haemostat. Using a screwing movement, quickly push the haemostat and catheter through the nick in the centre of the purse string. Open the jaws of the haemostat to release the catheter, remove the haemostat, and quickly tighten the purse string to secure the catheter in place.

CAUTION ! Make sure the catheter can drain off to the side, so that it does not flood his abdomen.

Close the muscle layers of his abdominal wall with interrupted catgut, monofilament, or steel wire, but leave his skin unsutured. His wound is sure to become infected, and this will minimize it. Suture the catheter to his skin to prevent it being pulled out. Clamp it and block it with a spigot, until he returns to the ward. Then connect it to a bag or bottle. Flush it out with one or two litres of saline, which need not be sterile, at least twice a day.

DIFFICULTIES [s7]WITH A CAECOSTOMY If his CAECUM BURSTS with a puff of gas as you open it, suck vigorously. This will not be a major disaster if you have previously sutured the cut edges of his peritoneum to his caecum, and so isolated his peritoneal cavity. Deliver his burst caecum, and extend the incision if necessary. Apply a soft clamp and repair the perforation, invaginating it as you do so. Then do a standard caecostomy away from the site of the perforation. Alternatively, exteriorize his caecum. If necessary, you can sew the caecostomy tube into the tear in his burst caecum, provided it is not necrotic or gangrenous.

If, when you open his peritoneum, you find that his CAECUM IS GANGRENOUS but has not yet perforated, exteriorize it. Make a bigger wound and deliver his caecum through it. Resect it. You now have two choices; (1) You can do an end-to-side anastomosis of his ileum to his terminal colon (9-11). Or, (2) you can close his colon, exteriorize the gangrenous area, do an ileostomy and then close this 3 weeks later. Meanwhile, he will lose much fluid and many electrolytes.

If you DON'T HAVE A SUITABLE CATHETER, you can stitch the wall of his caecum to his parietal peritoneum before you open his caecum. Then apply a colostomy bag over the opening. The difficulty with this is that it tends to close spontaneously.

Fig. 9-15 A LOOP COLOSTOMY IN THE TRANSVERSE OR SIGMOID COLON. A, make these incisions for a transverse or a sigmoid colostomy. B, incise the rectus muscle for a transverse colostomy. C, incise the greater omentum and bring a loop of transverse colon through it. D, incise the mesentery. E, bring the transverse colon through the greater omentum. F, push a piece of tube or a glass rod through the hole, and suture the colon to the peritoneum. G, close the wound. H, open the colon and suture it to the edges of the skin wound. I, the completed colostomy. J, after healing of the wound. After Goligher JC, ''The Surgery of the Anus, Rectum and Colon', Figs 347 to 361. Bailli[gr]ere Tindall, with kind permission.

TRANSVERSE COLOSTOMY INDICATIONS. (1) Obstruction distal to the middle of a patient's transverse colon. (2) A penetrating injury of his transverse colon. (3) Gangrene of part of his transverse colon due to strangulation or interference with its blood supply. (4) A rectovaginal fistula prior to repair. (5) Protecting an anastomosis for sigmoid volvulus after resection.

A transverse colostomy is not difficult, and is better than a caecostomy. There are 3 types: (1) A plain loop. (2) A double- barrel colostomy. (3) A ''spectacles colostomy' as in Fig. 9-17.

METHOD. Make a right (or left) paramedian incision centered on his umbilicus. Open his peritoneum with the greatest care, as for any gut obstruction (9-2).

Try to find his transverse colon without allowing loops of his small gut to protrude from his wound. They will probably bulge into the wound, covered by omentum.

Lift his omentum upwards and forwards, so that you can see his transverse colon. Is it very distended? If it is not distended, his large gut is probably not obstructed and you will have to look for some other pathology. If it is very distended, you may need to deflate it first (10-9). Is it mobile enough to lift forward to skin level? If he is very obese, this may be difficult.

Make a 4 cm separate transverse skin incision above and to the right of the laparotomy incision, as in A Fig. 9-15. Divide his anterior rectus sheath in the same line as his skin. Cut his rectus muscle transversely. Your index and middle finger should be able to lie comfortably in the wound, but should not allow another finger to enter it.

CAUTION ! (1) Make the incision well to the right. (2) It must be high enough to avoid his umbilicus, and not so high that his transverse colon cannot reach it. (3) Make it just large enough to take the loop comfortably. (4) Make sure you have got his transverse colon and not his stomach or his sigmoid colon! The transverse colon has taenae (unlike the stomach), and is attached by a short omentum to the greater curvature of the stomach.

Choose an area of his transverse colon to the right of the midline. Trim off the omentum attached to 7 to 10 cm of its anterior surface so as to make a gap in it (C, Fig. 9-15, B, Fig. 9-19). Try to avoid tying any small vessels that may be present. Deliver a loop of his transverse colon through this gap.

Make a small window in his transverse mesocolon next to the mesenteric border of his colon (D, Fig. 9-15, C in Fig. 9-19). Do this by pushing a large blunt haemostat through it close to the wall of his gut, while you open and close its jaws. Avoid injuring the branches of his middle colic artery as you do so.

Pass a rubber catheter through the window you have made, and grasp both its ends with a haemostat (D, Fig. 9-19). Test the colon for mobility again. If it is very tense and distended, decompress it.

If you want to double-barrel it, insert a few interrupted catgut sutures between its loops, biting only its seromuscular coat as in D, Fig. 9-19.

CAUTION ! You must be able to deliver the loop of colon you have isolated through the transverse incision comfortably.

Push a second haemostat through the smaller transverse incision that is to be the site of the colostomy, and grasp the catheter you have placed round his colon. Release the first haemostat, and by pulling with one hand and pushing with the other, withdraw the loop of colon, so that it comes out through the colostomy incision and rests on his abdominal wall.

If the wound is loose enough to let you insert a finger alongside the loop of colon, there will be no risk of the lumen occluding, and the colostomy should function satisfactorily. If his colon is not loose enough, extend the incision.

Close his abdomen so as to withstand a high intra-abdominal tension, as in Section 9.8.

Pass a short piece of thick rubber tube, or a short glass rod attached to a piece of rubber tube, through the window occupied by the catheter(F, Fig. 9-15), and keep it there with two stitches anchored to his skin. Pass a few interrupted sutures between the fascia of his abdominal wall and the seromuscular layer of his gut, and between his skin and the free margin of his gut.

CAUTION ! Before you place these sutures, make sure his colon is not twisted, and that it runs transversely, as a transverse colon should.

Open his colostomy immediately. If you delay, his obstruction is not relieved. Apply a substantial dressing to the laparotomy wound. Make a 3 cm incision (as in E, Fig. 9-19) through both coats of his colon across its axis (in line with the rubber tube), or better, longitudinally along a taenia (G, and H, Fig. 9-15). It will open to form two stomata (I, Fig. 9-15). You will have to close the opening transversely to avoid obstruction: opening it longitudinally ensures a wider lumen. Suture his skin to his mucosa, as in H and I, Fig. 9-15. Push a finger down the afferent loop to make sure that it is patent[md]a gush of gas and faeces is an encouraging sign. If possible, apply a commercial colostomy bag. If not, improvise one as in Fig. 9-16.

SIGMOID COLOSTOMY INDICATIONS. (1) Wounds of the rectum. (2) Chronic obstructive rectal lesions including carcinoma. (3) Following resection for sigmoid volvulus.

CONTRAINDICATIONS. Situations in which a sigmoid colostomy wound would interfere with subsequent operations, for example the repair of a rectovaginal fistula.

METHOD. This is described under volvulus of the sigmoid colon as part of Hartmann's operation in Section 10.10 and Fig. 10-16. It also closely resembles a transverse colostomy. You can ''double-barrel' and ''spectacle' it as with a transverse colostomy, as described above, or leave a blind distal end.

Draw a line from the patient's umbilicus to his left iliac spine (A, in Fig. 9-19). Site the mid point of the incision at the junction of the medial two-thirds and the lateral one third. This is the same as McBurney's point but is in the left iliac fossa. Site the incision carefully. Choose a site for the stoma in the upper part of the mobile loop of the sigmoid colon, to prevent the colostomy prolapsing later.

Fig. 9-16 IF YOU DON'T HAVE A COLOSTOMY BAG, you can make one from an ordinary plastic bag, a tin, a piece of rubber, such as that from the inner tube of a car tyre, and a piece of string. The tin should be a small one and should fit comfortably over the patient's colostomy. A small ''Carnation milk' tin works well, provided it has no sharp edges. Make holes for the string in the side of the tin, and make sure it has no sharp edges. You can also use a pessary ring to hold the bag. If you are using disposable bags be sure to give the patient enough. A washable non-disposable bag may be more practical. He needs at least two. Make sure that he or his relatives know how to wash and use them. D, E, and F, an ostomy appliance made from a coconut and a plastic bag. A, B, and C, kindly contributed by John Tarpley.

END (TERMINAL) COLOSTOMY INDICATIONS. (1) As part of Hartmann's procedure when this is done for sigmoid volvulus or for any other reason. (2) Severe damage to the pelvirectal colon complicating surgery for PID (6.6). (3) A permanent colostomy, as after resection of a low carcinoma of the rectum.

The disadvantage with the method which follows is that it leaves a lateral space through which gut can herniate internally. The alternative, which is to lead the sigmoid colon through an extraperitoneal tunnel round the left paracolic gutter, is too difficult to be described here.

METHOD. Make an appropriate incision in the patient's abdominal wall, as in A, Fig. 9-15. Insert a crushing clamp through it and draw out the end of his gut. Before you close his abdomen, put in a few catgut sutures between the seromuscular coat of his gut, and the peritoneum of his abdominal wall. Place them so that there will be 1.5 cm of healthy gut protruding beyond the skin, then close his abdomen.

To open the colostomy, cut off the crushing clamp with a sharp scalpel. Control bleeding. Suture mucosa to skin all round with interrupted 2/0 or 3/0 monofilament.

Ideally, use the method in F, and G, Fig. 9-17. Use stitches which take a bite of: (1) his anterior rectus sheath without going through his skin, (2) the seromuscular coat of his gut about 8 mm proximal to its tip, (3) the mucosa and seromuscular coat of the tip of his gut. When you eventually tighten these sutures, you will find his colostomy will evert itself beautifully.

BYPASSES AN ILEO-TRANSVERSE COLOSTOMY takes the end of his ileum about 15 cm from his ileocaecal valve, and anastomoses it to his transverse colon, leaving the stump of his ileum, his caecum and his ascending colon in place. Use it to provide temporary relief for obstruction of his caecum or ascending colon, by ileocaecal tuberculosis (29.5) or carcinoma.

Make an end-to-side anastomosis, as in Section 9.4, Fig. 9- 11. Use the second part of the method of end-to-side anastomosis in Fig. 66-20. Close the stump of his ileum with an all-coats layer, and then invert this with Lembert sutures (one contributor leaes the stump open, it will not leak into the peritoneal cavity). Leave his right colon and the stump of his ileum in place to be joined up later.

AN ENTERO-ENTEROSTOMY. Make a side-to-side anastomosis as in Fig 9-12. This figure shows the ends of the gut resected: you usually need to leave them in continuity. Make it between adjacent loops of his small gut (for obstruction of his small gut by adhesions or tuberculous peritonitis), or between his small gut and his large gut (G, Fig. 32-15b) for obstruction of his ascending colon, usually by ileocaecal tuberculosis or carcinoma.

Fig. 9-17 MORE METHODS FOR OSTOMIES. A, the site of the incision for a spectacles colostomy. B, the spectacles incision. Remove the skin inside each loop. C, turning back the flap. D, the transverse colon exteriorized and clamped with two crushing clamps. E, the completed colostomy. F, and G, a secure method of suturing a patient's colon to his abdominal wall.

SPECTACLES COLOSTOMY INDICATIONS. A moderately defunctioning colostomy, as in preparing a child with an imperforate anus for definitive surgery later.

METHOD. Site the spectacles colostomy in his right hypochondrium, as in A, Fig. 9-17. Make a spectacles-shaped incision (B), and remove the skin inside each loop. Turn back the flap (C). Exteriorize and clamp the transverse colon with two crushing clamps (D), to make the colostomy (E).

Fig. 9-18 CLOSING A LOOP COLOSTOMY INTRAPERITONEALLY. Only do this if you cannot close it extraperitoneally, as in the next figure, which is safer. A, insert traction sutures. B, raise an ellipse of skin round the colostomy. C, dissect the ellipse of skin free from the rectus sheath. D, free the colostomy loop. E, excise a cuff of skin and evert the gut edges. F, the proximal gut edge is everted, the distal gut edge is still inverted. G, and H, closing the colostomy with Connell loop-on-mucosa stitches. I, inserting a second layer of seromuscular Lembert sutures. J, closing the muscles of the abdominal wall in one layer. After Maingot R, ''The Management of Abdominal Operations', Figs. 396 to 404. HK Lewis, with kind permission.

CLOSING A COLOSTOMY INTRAPERITONEALLY If you cannot refer him, do this 4 to 6 weeks later, when his wound is healthy and he has recovered from his original operation.

CAUTION ! (1) He will be hoping for this as soon as possible. Don't let him persuade you to do it too early. (2) It is not an easy operation, so refer him if you can.

Wash out his gut proximally, and distally through his rectum. Repeat this daily for 2 or 3 days before the operation. Some surgeons give him magnesium sulphate to help empty his proximal gut and to make sure that the next faeces he passes will be soft. Give him neomycin 500 mg 6-hourly for 2 days, then give him oral perioperative chloramphenicol and rectal metronidazole (2.9).

To minimize bleeding infiltrate the skin and subcutaneous tissues around his colostomy with a local anaesthetic solution containing adrenalin 1:200,000 (A 5.4). Wait to allow the anaesthetic to act. Or, use general anaesthesia. The infiltration is valuable in demonstrating tissue planes.

Insert traction sutures round the colostomy (A, in Fig. 9- 18). Make an elliptical incision round it (B). Use a fine knife and sharp scissors to dissect it free from the surrounding skin and fascia, and from the muscle of his abdominal wall (C). Keep a finger in the lumen to tell you when you are getting dangerously close to it.

Raise the ellipse of skin from his abdominal wall (D). Using sharp dissection, clean the sheath of his rectus muscle until you reach the edge of the opening through which his gut is passing.

If, at this stage you think you can unite the two loops of his gut extraperitoneally, do so (see below).

If this is difficult, you will have to enter his peritoneal cavity. Free the parietal peritoneum round the circumference of the opening. Divide any adhesions that may be present. Draw his colon out of the incision, and place packs over the wound. Trim away the everted edges of his gut (E). Close it transversely with Connell stitches (G, and H; see also A, Fig. 9-6). Start by placing two atraumatic sutures through all the coats of the gut where his proximal and distal colon meet. Tie the knot in the lumen, and work from each side.

Check, by pinching with your fingers, that, when you cut off the skin remnants and closed the colostomy, you left plenty of room for faeces to go through.

If there is enough room for his faeces to go through, add a second layer of interrupted Lembert inverting sutures through the seromuscular layer (I), and tuck it into his abdomen.

If there is not enough room, resect the colostomy and do a new end-to-end anastomosis.

Close his abdominal wall with interrupted sutures. Now do a Lord's procedure (maximal anal dilatation) before he goes back to the ward.

Fig. 9-19 A DOUBLE-BARRELLED COLOSTOMY. MAKING IT AND CLOSING IT EXTRAPERITONEALLY. A, the incisions. B, the site in patient's mesentery through which to pass the loop of bowel. C, the site in his mesocolon through which to pass the rubber tube. D, the loop double-barrelled and brought out through the transverse colostomy incision using a rubber tube. E, opening his colostomy (in this case transversely), and anchoring it in place with a short rubber tube. F, skin-to-mucosa sutures have been inserted all round. G, applying the crushing clamp when his colostomy is ready for closure. H, the two stomas are now one. After checking that loops have united in the depths of the wound, infiltrate around the colostomy and use the skin incision shown. I, excising the skin. J, the gut sutured and about to be returned to his abdomen with a drain. K, a cross-section of the finished colostomy.

CLOSING A COLOSTOMY EXTRAPERITONEALLY This mostly applies to a loop colostomy and a double- barrelled colostomy with a spur that can be crushed. The description that follows is for the double-barrelled colostomy in Fig. 9-19, but you can do it with the loop colostomy in Fig. 9- 15.

As soon as the patient no longer needs his colostomy, crush the spur, as in G, Fig. 9-19. When you are ready, put one finger into each lumen to check that no tissue has been caught between the loops. This should not happen if you have double-barrelled it satisfactorily. If you mistakenly crush his small gut, he will get an ileo-colic fistula. Put the crushing clamp on the spur and tighten the clamp a little. Each day, tighten it a bit more, until it falls free.

When the crushing clamp has fallen off, put your finger into the stoma. The spur should have gone, so that the contents of his gut can pass easily along his colon. Insert your index finger to check that there is a nice big opening between the two loops of colostomy. If there is, close the colostomy extraperitoneally.

Under appropriate anaesthesia (which can be local), infiltrate round his colostomy with adrenalin 1:200,000; wait 5 minutes, make an elliptical incision close to the edge of the colostomy, and prolong it along Lange's lines as shown. With a finger in the colostomy, and with Allis' forceps applied to the skin round the edge of the colostomy, dissect with a No. 11 scalpel blade, or fine scissors, in the plane between his gut and his abdominal wall. Try to avoid entering his peritoneal cavity; but if you do it is unimportant. Lift the cuff clear. Check that the spur is sufficiently deep to allow the faecal stream to pass over the top of it easily. A colostomy is rather bulky, so you may have to sweep his peritoneum away from his abdominal wall a little with your finger to make space for it.

Complete the closure in two layers in the same way as for an intraperitoneal anastomosis, first with an all-coats layer of continuous catgut, and then with a layer of interrupted inverting seromuscular Lembert sutures. The suture line may leak, so put a rubber drain down to it.

If you don't have a proper crushing clamp, either don't use this method, or use a large rubber covered straight haemostat, or Kocher's forceps. Apply them for 15 minutes the first day, half an hour on the second day, and an hour on the third day. By 5[nd]7 days you should be able to leave them on continuously, until they fall off by themselves 2[nd]4 days later. If the stoma bleeds, stop the process for a day.

CLOSING HARTMANN'S OPERATION. See Section 10.10a.

DIFFICULTIES [s7]WITH COLOSTOMIES If his COLOSTOMY ''RUNS LIKE A RIVER', this is likely to be a good sign in the early stages, because it means that his obstructed gut is emptying itself. If it happens later, give him kaolin mixture with 1 to 2 tablets of codein phosphate 3 times a day. If it happens after you have crushed the spur of a double-barrelled colostomy, you may have crushed a loop of small gut at the apex of the spur and made an ileostomy in error. Refer him to an expert immediately.

If his COLOSTOMY DOES NOT WORK at all, this is likely to be serious. Put a finger into the afferent loop to make sure that it has not become occluded. If this fails to start it, put a glycerine suppository or an enema solution into the afferent loop. If it is still not working after 3 days, he may have a proximal obstruction or ileus.

If the GUT FORMING HIS COLOSTOMY NECROSES (rare), you probably damaged its mesentery by stretching or compressing it into too small a hole. Take him back to the theatre, enlarge the opening in his abdominal wall, and make a fresh colostomy by bringing out more gut.

If his COLOSTOMY WITHDRAWS BACK INTO ITS HOLE, it will contaminate his peritoneum and cause faecal peritonitis, which may be fatal. A glass rod or rubber tube through a loop colostomy should prevent it doing this. To be even more certain, put 6 interrupted sutures between the seromuscular coat of his colon and his anterior rectus sheath (F, and G, Fig. 9-17). When it has withdrawn, you may need to operate to put it right.

If A HERNIA FORMS round his colostomy, it will probably only be a little bulge, and is unlikely to grow big. Prevent it by: (1) not making the opening for the colostomy too big, (2) stitching the seromuscular layer of the gut to the anterior layer of the fascia of his abdominal wall (F, and G. Fig. 9-17).

If his COLOSTOMY PROLAPSES, it will look just like a prolapse of his rectum. Gut spouts out, but you can usually push it back. This is quite common and embarrassing. Prevention is difficult, but the deep sutures mentioned above are some help (F, and G, Fig. 9-17). Reduce it as necessary

If he develops signs of INTESTINAL OBSTRUCTION, adhesions may be forming inside his abdomen at the site where his colostomy emerges, or from the original disease process. They are no different from the adhesions developing after any other abdominal operation. Explore him if he does not improve.