Annals of the Royal College of Surgeons of England (1991) vol. 73, 305-306
The trephine colostomy: a permanent left iliac fossa end colostomy without recourse to laparotomy Asha Senapati
PhD FRCS Senior Surgical Registrar
Robin K S Phillips
MS FRCS
Consultant Surgeon
St Mark's Hospital, London
Key words: Colostomy; Fistula-in-ano; Incontinence; Constipation
An operative technique for performing a permanent end sigmoid colostomy without recourse to laparotomy is presented. The results from 16 patients have shown a very low morbidity. The technique was unsuccessful in three patients, each needing a formal laparotomy.
An end sigmoid colostomy may be necessary in a variety of conditions. Examples include idiopathic faecal incontinence not improved by postanal repair, obstructive defaecation complicated by pudendal neuropathy, and complex high fistula-in-ano. Traditionally, the operation is performed at laparotomy, but avoidance of a laparotomy significantly reduces postoperative discomfort and accelerates recovery. We present a technique for performing an end sigmoid colostomy without recourse to laparotomy.
Operative technique A full bowel preparation is given, the proposed stoma site is marked and the patient is warned of the possible need for a laparotomy. Under general anaesthesia the patient is placed in the Lloyd-Davies position so as to allow access for intraoperative rigid sigmoidoscopy. A left iliac fossa trephine that will admit two fingers is performed through the belly of the rectus abdominis muscle and the peritoneum opened. Two Langenbeck retractors are introduced, one inferiorly and the other at right-angles to it on Correspondence to: Mr R K S Phillips, St Mark's Hospital, City Road, London EC1V 2PS
the left-hand side, and the wound is pulled inferiorly and to the left while at the same time lifting the abdominal wall forward off the abdominal contents. Using a pair of Babcock's forceps, the sigmoid colon is grasped and introduced into the wound. Sometimes, when the sigmoid mesentery is long and the colon is free, this can be easy; at other times with a short mesentery or some peritoneal adhesions, lateral mobilisation with scissors may be necessary. The sigmoid colon must be distinguished from the transverse colon (appendices epiploicae, no omentum, site and left lateral peritoneal attachment), and the orientation of the sigmoid loop must also be established in case it is twisted. The orientation can be checked by running the index finger down to the root of the sigmoid mesocolon or by seeing the peritoneal white line on the left-hand side. Additional confirmation can be obtained by intraoperative sigmoidoscopy and by the abdominal operator observing the direction from which insufflated air enters the sigmoid colon (successful in 14 cases). Alternatively, a sigmoid colon enterotomy is made at the proposed site of the colostomy and through which a catheter is passed after one lumen of the bowel is occluded. Saline is run down the catheter and observed sigmoidoscopically to appear in the rectum (successful in two cases). If available, a flexible sigmoidoscope may be passed rectally and the sigmoid loop directed under the trephine. The final check on the sigmoid colon orientation is achieved at the end of the procedure by passing a finger into the colostomy where it should pass upwards towards the splenic flexure of the colon. When the orientation has been confirmed, the colon is divided and closed and the distal end is returned into the abdomen. The proximal end is sutured in the usual way as an end colostomy. There is a tendency for the superior
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lip of the end colostomy to be prominent unless it is trimmed.
Results Between 1988 and 1990, eight men and eight women with a mean age of 49 years (range 27-73 years) underwent this procedure under the care of one surgeon. The indications for the procedure were: fistula-in-ano 5; constipation 5; incontinence 5; anal pain 1. An uneventful postoperative recovery occurred in 12 patients (75%). Complications occurred in four patients: acute retention of urine in one, late retraction of the stoma in two, and failure of the method in one because the sigmoid colon position and orientation could not be assessed satisfactorily without a laparotomy. The two patients with retracted stomas later needed a laparotomy. Both had stomas that appeared satisfactory when they were lying down, but when they sat up, or were standing, retraction was immediately apparent and caused problems with the adherence of their appliances. At laparotomy both patients were found to have omental bands tethering the underside of their stomas to the posterior abdominal wall. After division of these bands the stomas were satisfactory. The median postoperative stay was 11 days but in some cases the operation was used as part of the management of other conditions which led to an increased length of stay in hospital.
Discussion The left iliac fossa trephine end colostomy has been a success. Patients have minimal postoperative pain, are fully mobile immediately and there is no delay before normal alimentation is restored. Neither pain nor a neighbouring incision have hindered stoma care training. The potential pitfalls of the procedure are: inadvertently performing a transverse rather than a sigmoid colostomy; disorientation leading to closure of the proximal bowel and construction of a mucous fistula; and inadequate length in the sigmoid mesentery leading to retraction. On some occasions it may be necessary to proceed to a
laparotomy, either at the same time or later, but the majority of patients are spared this. When indicated, closure of a trephine colostomy presents no particular problem as the distal colon is attached by its mesentery to the proximal colon and is therefore easy to locate. Some authors have recommended that the lateral space should be closed in order to prevent obstruction (1). Considerable experience at this hospital with loop ileostomies, where the lateral space is not closed, has led us to question the importance of lateral space closure. Certainly there have been no problems from leaving the lateral space open in this series of patients. An alternative would be to perform a loop transverse colostomy or a loop sigmoid colostomy and some might even argue in favour of a loop ileostomy. In general, the site in the left iliac fossa is much to be preferred to the right upper quadrant, and loop stomas are generally believed less satisfactory both for stoma care and for their ability to defunction when compared with end stomas (2,3). In addition, when a stoma is intended to be permanent (as was the case in 11 of our patients) an end stoma is indicated. Retraction of the stoma can occur in up to 13% of patients with a colostomy performed by a conventional technique (4), and is thought to be caused by a tight mesentery. In our two cases, however, the retraction was caused by an omental band. We believe the trephine colostomy to be the procedure of choice when needing to construct an end sigmoid
colostomy.
References I Goligher JC. Surgery of the Anus, Rectum and Colon, 4th edition. London: Bailliere Tindall, 1980:610. 2 Winkler MJ, Volpe PA. Loop transverse colostomy-the case against. Dis Colon Rectum 1982;25:321-6. 3 Fontes B, Fontes W, Utiyama EM, Birolini D. The efficacy of loop colostomy for complete faecal diversion. Dis Colon Rectum 1988;31:298-302. 4 Herbert JC. A simple method for preventing retraction of an end colostomy. Dis Colon Rectum 1988;31:328-9.
Received 20 February 1991
The trephine colostomy: a permanent left iliac fossa end colostomy without recourse to laparotomy Asha Senapati
PhD FRCS Senior Surgical Registrar
Robin K S Phillips
MS FRCS
Consultant Surgeon
St Mark's Hospital, London
Key words: Colostomy; Fistula-in-ano; Incontinence; Constipation
An operative technique for performing a permanent end sigmoid colostomy without recourse to laparotomy is presented. The results from 16 patients have shown a very low morbidity. The technique was unsuccessful in three patients, each needing a formal laparotomy.
An end sigmoid colostomy may be necessary in a variety of conditions. Examples include idiopathic faecal incontinence not improved by postanal repair, obstructive defaecation complicated by pudendal neuropathy, and complex high fistula-in-ano. Traditionally, the operation is performed at laparotomy, but avoidance of a laparotomy significantly reduces postoperative discomfort and accelerates recovery. We present a technique for performing an end sigmoid colostomy without recourse to laparotomy.
Operative technique A full bowel preparation is given, the proposed stoma site is marked and the patient is warned of the possible need for a laparotomy. Under general anaesthesia the patient is placed in the Lloyd-Davies position so as to allow access for intraoperative rigid sigmoidoscopy. A left iliac fossa trephine that will admit two fingers is performed through the belly of the rectus abdominis muscle and the peritoneum opened. Two Langenbeck retractors are introduced, one inferiorly and the other at right-angles to it on Correspondence to: Mr R K S Phillips, St Mark's Hospital, City Road, London EC1V 2PS
the left-hand side, and the wound is pulled inferiorly and to the left while at the same time lifting the abdominal wall forward off the abdominal contents. Using a pair of Babcock's forceps, the sigmoid colon is grasped and introduced into the wound. Sometimes, when the sigmoid mesentery is long and the colon is free, this can be easy; at other times with a short mesentery or some peritoneal adhesions, lateral mobilisation with scissors may be necessary. The sigmoid colon must be distinguished from the transverse colon (appendices epiploicae, no omentum, site and left lateral peritoneal attachment), and the orientation of the sigmoid loop must also be established in case it is twisted. The orientation can be checked by running the index finger down to the root of the sigmoid mesocolon or by seeing the peritoneal white line on the left-hand side. Additional confirmation can be obtained by intraoperative sigmoidoscopy and by the abdominal operator observing the direction from which insufflated air enters the sigmoid colon (successful in 14 cases). Alternatively, a sigmoid colon enterotomy is made at the proposed site of the colostomy and through which a catheter is passed after one lumen of the bowel is occluded. Saline is run down the catheter and observed sigmoidoscopically to appear in the rectum (successful in two cases). If available, a flexible sigmoidoscope may be passed rectally and the sigmoid loop directed under the trephine. The final check on the sigmoid colon orientation is achieved at the end of the procedure by passing a finger into the colostomy where it should pass upwards towards the splenic flexure of the colon. When the orientation has been confirmed, the colon is divided and closed and the distal end is returned into the abdomen. The proximal end is sutured in the usual way as an end colostomy. There is a tendency for the superior
306
A Senapati and R K S Phillips
lip of the end colostomy to be prominent unless it is trimmed.
Results Between 1988 and 1990, eight men and eight women with a mean age of 49 years (range 27-73 years) underwent this procedure under the care of one surgeon. The indications for the procedure were: fistula-in-ano 5; constipation 5; incontinence 5; anal pain 1. An uneventful postoperative recovery occurred in 12 patients (75%). Complications occurred in four patients: acute retention of urine in one, late retraction of the stoma in two, and failure of the method in one because the sigmoid colon position and orientation could not be assessed satisfactorily without a laparotomy. The two patients with retracted stomas later needed a laparotomy. Both had stomas that appeared satisfactory when they were lying down, but when they sat up, or were standing, retraction was immediately apparent and caused problems with the adherence of their appliances. At laparotomy both patients were found to have omental bands tethering the underside of their stomas to the posterior abdominal wall. After division of these bands the stomas were satisfactory. The median postoperative stay was 11 days but in some cases the operation was used as part of the management of other conditions which led to an increased length of stay in hospital.
Discussion The left iliac fossa trephine end colostomy has been a success. Patients have minimal postoperative pain, are fully mobile immediately and there is no delay before normal alimentation is restored. Neither pain nor a neighbouring incision have hindered stoma care training. The potential pitfalls of the procedure are: inadvertently performing a transverse rather than a sigmoid colostomy; disorientation leading to closure of the proximal bowel and construction of a mucous fistula; and inadequate length in the sigmoid mesentery leading to retraction. On some occasions it may be necessary to proceed to a
laparotomy, either at the same time or later, but the majority of patients are spared this. When indicated, closure of a trephine colostomy presents no particular problem as the distal colon is attached by its mesentery to the proximal colon and is therefore easy to locate. Some authors have recommended that the lateral space should be closed in order to prevent obstruction (1). Considerable experience at this hospital with loop ileostomies, where the lateral space is not closed, has led us to question the importance of lateral space closure. Certainly there have been no problems from leaving the lateral space open in this series of patients. An alternative would be to perform a loop transverse colostomy or a loop sigmoid colostomy and some might even argue in favour of a loop ileostomy. In general, the site in the left iliac fossa is much to be preferred to the right upper quadrant, and loop stomas are generally believed less satisfactory both for stoma care and for their ability to defunction when compared with end stomas (2,3). In addition, when a stoma is intended to be permanent (as was the case in 11 of our patients) an end stoma is indicated. Retraction of the stoma can occur in up to 13% of patients with a colostomy performed by a conventional technique (4), and is thought to be caused by a tight mesentery. In our two cases, however, the retraction was caused by an omental band. We believe the trephine colostomy to be the procedure of choice when needing to construct an end sigmoid
colostomy.
References I Goligher JC. Surgery of the Anus, Rectum and Colon, 4th edition. London: Bailliere Tindall, 1980:610. 2 Winkler MJ, Volpe PA. Loop transverse colostomy-the case against. Dis Colon Rectum 1982;25:321-6. 3 Fontes B, Fontes W, Utiyama EM, Birolini D. The efficacy of loop colostomy for complete faecal diversion. Dis Colon Rectum 1988;31:298-302. 4 Herbert JC. A simple method for preventing retraction of an end colostomy. Dis Colon Rectum 1988;31:328-9.
Received 20 February 1991
