COLOSTOMY Surgical techniques of a loop colostomy are categorized as follows:

Open Laparoscopic Trephine or colonoscopy assisted.

Images depicting loop colostomy can be seen below. Construction of loop colostomy.

Open Surgical Technique

1. Preoperatively, the location of the stoma site is marked. 2. A standard midline incision is made. The colon is mobilized from its attachments sharply. The adjacent flexure may be mobilized, if needed, for the colon to reach the abdominal wall. 3. After adequate mobilization of the colon, a 4-5 cm transverse incision is then made in the right or left upper quadrant over the rectus muscle where the stoma was preoperatively marked. 4. The incision is then dissected down to the level of the fascia, which is then divided in the same fashion. 5. The rectus muscle is then exposed after retracting the fascia. 6. The lateral edge of the rectus muscle may need to be divided with electrocautery. The posterior rectus sheath is then exposed and divided to enter the peritoneal cavity. 7. A mesenteric window is constructed between the marginal artery and the mesenteric border of the bowel to avoid compromise. The loop of bowel is delivered through the transverse skin incision and no tension on the loop of bowel delivered should exist. Care should be taken that the fascial opening is wide enough to accommodate the bowel and one finger. 8. A skin bridge may be used to provide additional support to the posterior wall of the colon. 9. The midline abdominal wound is closed prior to maturing the stoma. 10. A transverse (semi lunar) incision is made along the length of the loop of colon. The incision should be long enough that the posterior wall of the colon is visualized. 11. The loop colostomy is then matured so that the proximal and distal limbs are separated. Full-thickness sutures are placed from the bowel wall to the dermis using 3-0 Vicryl sutures. The stoma is then fitted with an ostomy appliance. 12. If a bridge was used, it can be removed in 4-5 days. If concerns of poor healing exist, the bridge can be left longer.

Laparoscopic Loop Colostomy

No standard technique for performing a laparoscopic colostomy exists, but the principles are similar.

Laparoscopic approach to colostomy construction has been described, starting in the early 1990s,[1, 2] and modifications of the initially described technique have been described. The laparoscopic approach has certain advantages over the open approach that have been well described in laparoscopic surgery. The construction of the stoma is performed as described above. 1. A supraumbilical 5 mm trochar site is inserted under direct vision; through that trochar site, the authors establish pneumoperitoneum. The authors proceed with 2 more 5 mm trochar sites, one supraumbilical and one on the right lower quadrant, if a loop sigmoid colostomy is planned. The authors almost never perform transverse loop colostomies. 2. The bowel is mobilized with the goal of having adequate length to reach (without tension) the abdominal wall at site of the premarked stoma. 3. Advantages include minimized possible post operative ileus. Oral intake starts on postoperative day 1. 4. Smaller incisions, which are often distant from the stoma site, minimizing wound complications and also helping with fitting of ostomy appliances.

Colonoscopy-Assisted Trephine Loop Colostomy

Colostomy can be fashioned using colonoscopic assistance, as follows: 1. 2. 3. 4. 5. For a standard sigmoid colostomy, the patient is positioned in the lithotomy position. Complete bowel preparation is preferred. The stoma site is marked preoperatively in the standard fashion. A flexible sigmoidoscope or an adult colonoscope can be used for identification of the distal limb of the colon to be used for the colostomy. The stoma site is prepared in the same fashion as in open and laparoscopic approach, as described above. The distal limb of the colon is identified by endoscopic illumination or by insufflations of air endoscopically. The colon is then eviscerated out gently through the skin incision. A skin bridge may be used to prevent it from retracting back into the abdomen. The loop colostomy is matured using the same technique as described in the open and laparoscopic approach as above.

6. 7. 8.

The advantages of trephine colostomy over open colostomy include the following:

It can be performed under local anesthesia. It has shorter operative times. It requires decreased use of narcotic pain medications postoperatively.

Limitations include the following:

Increased problems with retraction of the stoma probably due to inadequate mobilization of the mesentery. Limited visualization, especially in patients with extensive adhesions

Laparoscopic Assisted Trephine Loop Colostomy

The techniques for the Laparoscopic assisted Trephine loop colostomies have not been standardized. It can be performed using the gasless laparoscopic approach or with the use of pneumoperitoneum. 1. The colonoscope or a sigmoidoscope can be used as described above to identify the distal limb of the colon. 2. A single incision is made in the premarked stoma site. 3. A camera is used to aid with visualization and mobilization of the segment of bowel. Abdominal wall retraction is obtained with using standard body wall retractors. 4. The distal limb is identified with endoscopic guidance and brought out through the skin incision and the colostomy is matured as described above.

Summary
Overall the surgical techniques available for constructing a loop colostomy have evolved greatly over the last decade. It is important to emphasize although a relatively simple procedure it is considered temporary with the goal to be reversed at a later date.