Surgery for Obesity and Related Diseases 10 (2014) 1233–1234
Surgeon-at-work
How to create a diverting ileostomy in the obese Antonio Iannelli, M.D., Ph.D.a,b,c,*, Anne-Sophie Schneck, M.D.a,b,c, Jean Gugenheim, M.D., Ph.D.a,b,c b
a Centre Hospitalier Universitaire of Nice, Digestive Center, Nice, France Institut National de la Santé et de la Recherche Médicale (INSERM), U1065, Team 8, “Hepatic Complications in Obesity”, Nice, France c University of Nice-Sophia-Antipolis, Faculty of Medecine, Nice, France Received July 23, 2014; accepted July 28, 2014
Keywords:
Ileostomy; Obese
Creating a stoma in the obese patient may be particularly challenging, especially in the patient with central obesity [1]. With the recent epidemic of obesity, the magnitude of this problem is significant [2,3]. Colorectal surgery is associated with an increased risk of postoperative morbidity in the setting of obesity [4,5]. Furthermore, the increased rate of conversion from laparoscopic to open surgery reflects the technical difficulty of colorectal surgery in the obese patient [6]. Meguid et al. reported a technique to perform a terminal ileostomy [7]. However, the loop ileostomy may be virtually impossible in the case of central obesity. Herein we report a simple technique to perform a modified loop ileostomy in this situation.
space created by the lipectomy. The Roux limb is then passed through the abdominal wall up to the level of the skin without tension and sutured there with 2 interrupted sutures. The small bowel is stapled with a linear TA™ stapler, (Covidien Surgical Mansfield, MA) or TX stapler (Ethicon Surgery, Cincinnati, OH) distal to the ileo-ileostomy (Fig. 2). The main abdominal wound is closed, the staple line is removed, and the stoma sutured to the skin with interrupted sutures as usual. Ileostomy closure The Roux limb is evaluated endoscopically to determine whether the staple line has spontaneously disrupted. If this
Surgical technique The small bowel is divided with a linear stapler 40-cm proximal to the ileocecal valve. The vessels in the mesentery are identified by transillumination, the arcade is ligated close to the bowel and the mesentery divided. The distal end is anastomosed side-to-side to the proximal bowel to construct a 20-cm long Roux limb. The stoma location is identified and a circular skin incision made as usual. The subcutaneous tissue is mobilized off the fascia around the stomal aperture and removed before creating the transmuscular passage that will accommodate the Roux limb (Fig. 1). The skin flap is tacked back to the underlying fascia with multiple interrupted sutures to close the dead * Correspondence: Antonio Iannelli, M.D., Ph.D., Service de Chirurgie Digestive et Transplantation Hépatique - Hôpital Archet 2, 151 Route Saint-Antoine de Ginestière BP 3079, Nice, Cedex 3, France E-mail: [email protected]
Fig. 1. A subcutaneous lipectomy is done about the stoma to create a thinned neoabdominal wall and decrease the tension on the ileostomy.
http://dx.doi.org/10.1016/j.soard.2014.07.015 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
1234
A. Iannelli et al. / Surgery for Obesity and Related Diseases 10 (2014) 1233–1234
Fig. 2. A Roux-en-Y loop is used to facilitate the passage of the bowel through the abdominal wall aperture.
is not the case, the staple line is forced open with the endoscope. Once the staple line has been disrupted, the ileostomy is freed down to the peritoneum, where it is closed with a linear stapler and replaced into the abdomen. The wound is closed as usual. This technique was used 3 times in the setting of emergency and in 1 elective operation. Partial disruption of the staple line was found in all patients at endoscopy 4–6 months after ileostomy creation. Complete opening was then easily achieved endoscopically, and the ileostomy closed as described. Discussion The alarming worldwide increase in the prevalence of obesity has a profound effect on digestive nonbariatric surgery. Colorectal surgery in the obese may be particularly challenging with increased operative times and the need to convert to open surgery for laparoscopic procedures [3]. Indeed, performing a loop-ileostomy in the obese patient may be particularly challenging given the thickness of both the abdominal wall and the segment of bowel to bring to the level of the skin. The technical alternative may consist of performing a transverse colostomy, where the thickness of the abdominal wall is less prominent. However, the
ileostomy may remain the preferred alternative for some surgeons and is the only choice when the right colon has been removed. The rational of the present technique consists of decreasing the thickness of the abdominal wall by removal of the excess subcutaneous tissue about the stoma aperture and performing a Roux-en-Y with a 20-cm Roux limb instead of a loop ileostomy. Indeed, this is less thick and easier to pass through the stomal aperture than a loop ileostomy. The main advantages of this procedure rely in the reduction of tension on the ileostomy and the simplification of ileostomy closure that is limited to the stapling of the Roux-en-Y loop avoiding the need for an anastomosis. Although the staple line disrupts spontaneously in most if not all cases with time, if it is intact the endoscope should be advanced gently to avoid any transmural disruption. When endoscopic opening of the staple line cannot be achieved, the latter should be resected and the ileostomy closed by surgery. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Acknowledgments The authors thank MA Poumellec for the figure artwork. References [1] Beck SJ. Stoma issues in the obese patient. Clin Colon Rectal Surg 2011;24:259–62. [2] Haslam DW, James WPT. Obesity. Lancet 2005;366. (1197197 R). [3] Hawn MT, Bian J, Leeth RR, et al. Impact of obesity on resource utilization for general surgical procedures. Ann Surg 2005;241:821–6. [4] Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes after colorectal resection. Am J Surg 2000;179:275–81. [5] Balentine CJ, Wilks J, Robinson C, et al. Obesity increases wound complications in rectal cancer surgery. J Surg Res 2010;163:35–9. [6] Makino T, Shukla PJ, Rubino F, Milsom JW. The impact of obesity on perioperative outcomes after laparoscopic colorectal resection. Ann Surg 2012;255:228–36. [7] Meguid MM, McIvor A, Xenos L. Creation of a neoabdominal wall to facilitate emergency placement of a terminal ileostomy in a morbidly obese patient. Am J Surg 1997;173. (298298 W).
Surgeon-at-work
How to create a diverting ileostomy in the obese Antonio Iannelli, M.D., Ph.D.a,b,c,*, Anne-Sophie Schneck, M.D.a,b,c, Jean Gugenheim, M.D., Ph.D.a,b,c b
a Centre Hospitalier Universitaire of Nice, Digestive Center, Nice, France Institut National de la Santé et de la Recherche Médicale (INSERM), U1065, Team 8, “Hepatic Complications in Obesity”, Nice, France c University of Nice-Sophia-Antipolis, Faculty of Medecine, Nice, France Received July 23, 2014; accepted July 28, 2014
Keywords:
Ileostomy; Obese
Creating a stoma in the obese patient may be particularly challenging, especially in the patient with central obesity [1]. With the recent epidemic of obesity, the magnitude of this problem is significant [2,3]. Colorectal surgery is associated with an increased risk of postoperative morbidity in the setting of obesity [4,5]. Furthermore, the increased rate of conversion from laparoscopic to open surgery reflects the technical difficulty of colorectal surgery in the obese patient [6]. Meguid et al. reported a technique to perform a terminal ileostomy [7]. However, the loop ileostomy may be virtually impossible in the case of central obesity. Herein we report a simple technique to perform a modified loop ileostomy in this situation.
space created by the lipectomy. The Roux limb is then passed through the abdominal wall up to the level of the skin without tension and sutured there with 2 interrupted sutures. The small bowel is stapled with a linear TA™ stapler, (Covidien Surgical Mansfield, MA) or TX stapler (Ethicon Surgery, Cincinnati, OH) distal to the ileo-ileostomy (Fig. 2). The main abdominal wound is closed, the staple line is removed, and the stoma sutured to the skin with interrupted sutures as usual. Ileostomy closure The Roux limb is evaluated endoscopically to determine whether the staple line has spontaneously disrupted. If this
Surgical technique The small bowel is divided with a linear stapler 40-cm proximal to the ileocecal valve. The vessels in the mesentery are identified by transillumination, the arcade is ligated close to the bowel and the mesentery divided. The distal end is anastomosed side-to-side to the proximal bowel to construct a 20-cm long Roux limb. The stoma location is identified and a circular skin incision made as usual. The subcutaneous tissue is mobilized off the fascia around the stomal aperture and removed before creating the transmuscular passage that will accommodate the Roux limb (Fig. 1). The skin flap is tacked back to the underlying fascia with multiple interrupted sutures to close the dead * Correspondence: Antonio Iannelli, M.D., Ph.D., Service de Chirurgie Digestive et Transplantation Hépatique - Hôpital Archet 2, 151 Route Saint-Antoine de Ginestière BP 3079, Nice, Cedex 3, France E-mail: [email protected]
Fig. 1. A subcutaneous lipectomy is done about the stoma to create a thinned neoabdominal wall and decrease the tension on the ileostomy.
http://dx.doi.org/10.1016/j.soard.2014.07.015 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
1234
A. Iannelli et al. / Surgery for Obesity and Related Diseases 10 (2014) 1233–1234
Fig. 2. A Roux-en-Y loop is used to facilitate the passage of the bowel through the abdominal wall aperture.
is not the case, the staple line is forced open with the endoscope. Once the staple line has been disrupted, the ileostomy is freed down to the peritoneum, where it is closed with a linear stapler and replaced into the abdomen. The wound is closed as usual. This technique was used 3 times in the setting of emergency and in 1 elective operation. Partial disruption of the staple line was found in all patients at endoscopy 4–6 months after ileostomy creation. Complete opening was then easily achieved endoscopically, and the ileostomy closed as described. Discussion The alarming worldwide increase in the prevalence of obesity has a profound effect on digestive nonbariatric surgery. Colorectal surgery in the obese may be particularly challenging with increased operative times and the need to convert to open surgery for laparoscopic procedures [3]. Indeed, performing a loop-ileostomy in the obese patient may be particularly challenging given the thickness of both the abdominal wall and the segment of bowel to bring to the level of the skin. The technical alternative may consist of performing a transverse colostomy, where the thickness of the abdominal wall is less prominent. However, the
ileostomy may remain the preferred alternative for some surgeons and is the only choice when the right colon has been removed. The rational of the present technique consists of decreasing the thickness of the abdominal wall by removal of the excess subcutaneous tissue about the stoma aperture and performing a Roux-en-Y with a 20-cm Roux limb instead of a loop ileostomy. Indeed, this is less thick and easier to pass through the stomal aperture than a loop ileostomy. The main advantages of this procedure rely in the reduction of tension on the ileostomy and the simplification of ileostomy closure that is limited to the stapling of the Roux-en-Y loop avoiding the need for an anastomosis. Although the staple line disrupts spontaneously in most if not all cases with time, if it is intact the endoscope should be advanced gently to avoid any transmural disruption. When endoscopic opening of the staple line cannot be achieved, the latter should be resected and the ileostomy closed by surgery. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Acknowledgments The authors thank MA Poumellec for the figure artwork. References [1] Beck SJ. Stoma issues in the obese patient. Clin Colon Rectal Surg 2011;24:259–62. [2] Haslam DW, James WPT. Obesity. Lancet 2005;366. (1197197 R). [3] Hawn MT, Bian J, Leeth RR, et al. Impact of obesity on resource utilization for general surgical procedures. Ann Surg 2005;241:821–6. [4] Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes after colorectal resection. Am J Surg 2000;179:275–81. [5] Balentine CJ, Wilks J, Robinson C, et al. Obesity increases wound complications in rectal cancer surgery. J Surg Res 2010;163:35–9. [6] Makino T, Shukla PJ, Rubino F, Milsom JW. The impact of obesity on perioperative outcomes after laparoscopic colorectal resection. Ann Surg 2012;255:228–36. [7] Meguid MM, McIvor A, Xenos L. Creation of a neoabdominal wall to facilitate emergency placement of a terminal ileostomy in a morbidly obese patient. Am J Surg 1997;173. (298298 W).
