Chapter 4

Laparoscopic techniques for stoma creation

Q.A.J. Eijsbouts, C. Sietses, F.J. Berends, M.A. Cuesta

Submitted

Abstract

Background: Laparoscopic bowel surgery is considered by many to be a complex surgical procedure. Therefore a progressive learning effort is necessary to build up enough experience to perform this type of surgery. Stoma creation requires less experience in laparoscopic bowel surgery and may be considered as the ideal first step to start with. The aim of this study is to describe the surgical procedure along with the clinical experience, indications and results.

Methods: All patients who had a laparoscopically created stoma, ileostomy or colostomy have been included in this study.

Results: From January 1993 to May 1999, 28 patients (11 male and 17 female patients) with a mean age of 38 years (range 21 to 68) have been operated on. Indications for stoma were: faecal deviation during a complex recto-vaginal fistula operation or sphincter repair because of fecal incontinence; extensive perineal fistulas in patients with Crohn’s diseases, in patients with slow colonic transit and finally in palliation of unresectable rectal cancer. Mean operative time was 55 minutes (range 25 to 190 minutes). The mean hospital stay was seven days, partly dedicated to the stoma training. There were two conversions due to extensive adhesions. Four complications were observed: two immediately after operation: one torsion of the ileostomy and one misplaced loop ileostomy both necessitating reoperation and two long term complications, a retraction of an end-ileostomy and another patient with a prolaps of a loop ileostomy.

Conclusions: Laparoscopic stoma creation is the ideal first step that can be taken before starting with more difficult bowel procedures. Even if this procedure is elegant and may have enormous advantages for the patient, it is essential to visualize the bowel loop completely in order to avoid the most frequent complications such as the torsion or the misplaced stoma.

Introduction

Creation of an ileostoma or colostomy alone or in combination with other intestinal handling is a frequent surgical procedure for benign and malignant diseases in digestive surgery. During the conventional approach a laparotomy needs to be performed for finding the adequate loop of bowel followed by dissection of the loop, creation of a hole in the abdominal wall to exteriorize the bowel and maturation of the stoma. Imperative is that the bowel will be placed in a correct way without any tension and torsion in order to avoid cumbersome complications [11, 15-17]. All of these steps can be performed by laparoscopy, therefore avoiding the necessity of performing a laparotomy. That will mean increased comfort for the patient and at the same time the avoidance of all complications of laparotomy [1-7, 12-14]. This laparoscopic operation is considered as the most simple laparoscopic operation of the bowels, because of limited dissection and hardly any mesenteric handling. Nevertheless it requires a precise operative technique and visualization of the bowel in order to avoid the above mentioned operative complications. In this paper a report is made of indications for creation of an ileostomy or colostomy along with a description of the operative technique, results and complications.

Patients and methods

Patients

From January 1993 to May 1999 twenty-eight patients underwent a laparoscopic creation of a loop ileostomy (16 patients), conventional ileostomies (three patients) and sigmoid colostomy (9 patients). There were 11 male and 17 female patients with a mean age of 38 years (range 21-68).

Indications for the intervention were:

• An intestinal deviation after perianal repair (Martius plasty) for a recurrent recto-vaginal fistula in six patients (loop ileostomy);
• An intestinal deviation after sphincter reconstruction because of fecal incontinence in another six patients (loop ileostomy);
• In two patients with impalement trauma after anorectal reconstruction (loop ileostomy);
• In four patients with extensive perianal Crohn’s fistulae (two loop ileostomy and two sigmoid colostomy);
• Because of chronic obstipation in eight patients, two of them with paraplegia: three conventional ileostomies and five sigmoid colostomies), and
• In two patients with unresectable rectal cancer for palliation (sigmoid colostomy).

All the loop ileostomies were considered as temporarily stomas, the conventional ileostomies and the sigmoid colostomies as definitive stomas.

All the stoma sites were marked preoperatively and patients were supported pre and postoperatively by a stoma nurse.

Technique

Laparoscopic creation of a stoma has been performed under general anaesthesia.

Prophylactic antibiotics (Zinacef^® and metronidazol) are given and before the operation the urinary bladder has to be emptied.

End ileostoma/loop ileostomy

The monitor is placed to the right of the patient alongside the feet. The surgeon stands on the left side of the patient, the assistant on the right.

After insufflation of the abdomen, the laparoscope is introduced below the umbilicus and a second trocar of 5 mm is introduced in the left iliac fossae (Fig. 1). Here, the whole abdomen can be explored and the distal loop of the terminal ileum can be easily found and grasped in the correct direction to avoid posterior torsions. The skin and fat are excised, the fascia is opened and the chosen loop exteriorized through the previously defined site for the ileostomy (if loop ileostomy). If end ileostomy has to be created after exteriorization, the terminal ileum can be divided by means of the staplers. Afterwards, the ileostomy can be matured and followed by laparoscopic last inspection of the loop.

Loop colostomy/end sigmoid colostomy

The monitor is placed to the left of the patient alongside the feet. The surgeon stands on the right side of the patient, the assistant on the left. After insufflation of the abdomen, the laparoscope is introduced in the right hypochondrium; two trocars of 10 mm are introduced laterally to the rectus muscle on the right, one lateral of the umbilicus and the other in the right iliac fossae (Fig. 2). In this way, after the general inspection of the abdominal cavity, the sigmoid loop can be mobilized of the retroperitoneum, enough to be elevated up to the abdominal wall. The loop of the sigmoid is grasped with a Babcock clamp in order to indicate which side of the loop is proximal and distal in order to avoid torsions. Afterwards, the previously determined site for colostomy is excised and the loop exteriorized. Depending on the type of colostomy, (double or end colostomy), the loop can be divided exteriorly by means of the stapler in the case of the end colostomy reintroducing the distal part of the sigmoid into the abdomen. In this way the colostomy can be matured. Final laparoscopic inspection is done for haemostasia and to prove that the colostomy loop is the proximal one (continuity with the descended colon).

Results

The mean operative time was 55 minutes for ileostomy (range 25 to 90 minutes) and 65 for colostomy time (40 to 170 minutes). There were two conversions due to extensive adhesions (two planned ileostomies).

No peroperative complications were recorded.

The hospital stay was seven days (five to 16 days) due to the learning of the stoma care that takes place in the hospital.

There were four (14%) postoperative complications related to the procedure:

• One torsion of the ileostomy with signs of intestinal obstruction necessitating a reoperation;
• Miscreated loop ileostomy in which the long side was the efferent side. Initially treated conservatively, the patient developed an intestinal obstruction. Diagnosed as having an incarcerated parastomal hernia, the patient underwent a laparotomy with correction of the stoma;
• Superficial necrosis of a sigmoid colostomy with consecutive retraction and stenosis, necessitating correction by laparotomy;
• Prolaps of a loop ileostomy, treated by taking down of the stoma.

No mortality was recorded in this series.

Discussion

Several authors have published their experience with laparoscopic stoma creation. In this paper indications for stoma creation are according to literature [1-7, 12-14]. Possibilities are the loop and end ileostomies and the end and loop colostomies including the transverse colon and the sigmoid colon. The reported average operative time, 60 minutes and the low conversion rate are in concordance with literature [3, 7].

Oliviera et al in a series of 32 patients reported a conversion rate of 16% due to adhesions and in two patients a stoma outlet obstruction [7]. In this repport a 14% of technical complications such as torsion, wrong creation of a loop ileostomy, superficial necrosis with posterior retraction and stenosis and a prolaps of a loop ileostomy are the same results published with the creation of a stoma in a conventional way [11, 15-17].

Even if the advantages of the laparoscopic procedure are remarkable for the patients, complications are still present. Important technical conditions during the operation are good visualization, a correct identification of the loop and after exteriorization the confirmation that the exteriorized loop is correct and without torsion. All the published series concluded that the creation of the stomas is feasible, safe and effective for a variety of indications mentioned above. Laparoscopic bowel surgery is considered by many to be a complex surgical procedure. In the learning process of laparoscopic intestinal surgery [8-10], creation of stomas is considered as the initial operation to start with. Careful preparation of the patient, preoperative mark of the stoma site, instrument and position of the patient along with an adequate technique are crucial for the good outcome of the patient. After a successful start with these procedures many surgeons are motivated to learn more extensive laparoscopic intestinal procedures.

References

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