Br. J. Surg. Vol. 66 (1979) 505-506
Transcutaneous d ef unction ing colostomy FERNANDO RENAGA SYKES* SUMMARY
The technique is described for constructing an occlusive tube colostomy which requires no second operative procedure for closure. The advantages of this method are discussed and it is recommended as a superior alternative to loop colostomy OY caecostomy for defunctioning the unobstructed distal bowel.
DIVERSION of the faecal stream to defunction the distal colon presents technical problems ; the two most important are, that the diversion of the faecal stream is frequently incomplete and that a second operation is required to close the colostomy. The aim of this paper is to describe a technique which overcomes these problems. Method The part of the colon selected for the colostomy is brought out through the omentum so that the omentum shields the remaining abdominal cavity from faecal contamination. A soft Penrose drain 2-3 cm wide and 20 cm long is passed through the mesocolon near the bowel wall. Three centimetres proximal to the Penrose drain and on the antimesenteric border of the colon, preferably through a taenia coli, a longitudinal incision 2 cm long is made. A de Pezzer catheter, with the side holes enlarged, is passed into the lumen of the bowel through the incision (Fig. 1). A purse-string suture is placed around the catheter to avoid spillage. The de Pezzer catheter is invaginated into the wall of the colon by suturing the serosa over the catheter for a distance of 8-10 cm. Two skin incisions 3 cm long are made parallel to the colon at the site of the Penrose drain, each end of which is brought out through an incision. A third incision is made for the de Pezzer catheter, between those for the Penrose drain and the laparotomy wound (Fig. 2). The ends of the Penrose drain are tied over a gauze swab, ensuring that the lumen of the colon is occluded against the abdominal wall without impairing the blood supply. The tip of the de Pezzer catheter now lies free in the proximal colon with the distal end occluded by the Penrose drain. Having ascertained that the de Pezzer catheter is suitably sited, it is sutured to the abdominal wall. On completion of the transcutaneous defunctioning colostomy, the laparotomy incision is closed. Anal dilatation is a routine procedure following this operation. Postoperatively the catheter is attached to tubing, and washouts through the catheter are only performed if there is a suspicion of tube blockage. In order to remove the tube, which is left in place for a minimum of 3 weeks, one end of the Penrose drain is divided (Fig. 3) and the drain is withdrawn. The de Pezzer tube is then removed and normal gastrointestinal continuity restored without a further operative procedure. Barium enema studies performed after removal of the drain show a narrowing at the site of the colostomy: however, a repeat examination at t year shows a normal colonic lumen.
Discussion To date, 12 transcutaneous defunctioning colostomies have been performed (low rectal anastomosis, 10; traumatic faecal fistula in the sigmoid, 1 ; sigmoid myotomy, 1). The only complication in this series occurred in the first patient whose catheter was removed on day 14 after operation; this resulted in leakage along the catheter track causing an abscess. This was aggravated by the passage of the catheter through the upper end of the laparotomy wound. For
Fig. 1. The Penrose drain has been placed through the mesentery and the incision in the taenia coli of the antimesenteric border is being made. Note the enlarged opening in the tip of the de Pezzer catheter.
Fig. 2. The completed operation. The Penrose drain has been tied over a gauze swab, and the tube drain brought out through a separate incision between the Penrose drain and the abdominal wound.
Fig. 3. Removal of the transcutaneous colostomy: the Penrose drain is being divided on the skin surface in preparation for removal.
* Head of the Proctology Department, Surgical Unit, Hospital Sagrado Corazbn, Barcelona, Spain.
506
F. R. Sykes
this reason a separate incision was made in the remaining cases. The indications for this procedure are indentical to those of the usual loop colostomy, but in the presence of complete obstruction distal to the colostomy, the dangers associated with a closed loop would occur. Even in the presence of partial obstruction, this colostomy would not enable complete clearance of the faecal contents of the bowel immediately proximal to the obstruction, hence, it would not be advised in the management of obstruction. However, the place of this procedure is in those instances when complete rest of the distal colon is required, such as in the presence of a faecal fistula. For defunctioning the colon in order to protect an anastomosis it is ideal, producing a complete exclusion,
yet not requiring a second operation t o clear the colostomy. Because the faeces drain through a tube into a bag, the patient is spared the discomfort of a colostomy, which, particularly in the immediate postoperative period, is hard to manage. The emotional stress to which many patients are submitted by the appearance of a colostomy is avoided by this technique and the inevitable odour is reduced by the closed drainage technique described. The technique of transcutaneous defunctioning colostomy is proposed as an alternative t o both loop colostomy and a caecostomy, overcoming the disadvantages of both techniques and having few, if any, drawbacks of its own. Paper accepted I I October 1978.
Br. J. Surg. Vol. 66 (1979) 506
Pyloromyotomy forceps A. G . J O H N S O N A N D F. K H A N ” A NUMBER of different instruments have been devised for performing pyloromyotomy (Ramstedt’s operation) in infants (Quinby, 1966; Benson, 1969). The best known is the Dennis Browne forceps (Browne, 1951), but this is only useful at the end of the operation when the muscle has been well separated, because its tips are 3 mm apart when closed. Many surgeons
insert a small curved haemostat into the scalpel incision to separate the circular muscle fibres, but this is often too wide and is smooth on the outside and tends to slip. The new forceps (GU Manufacturing Co. Ltd, Plympton Street, London) illustrated in Fig. 1 is serrated on the outside and closes to form a sharp ‘keel’ (inset) which can be inserted into the initial scalpel incision. The curve of the blades follows the shape of the pyloric muscle in longitudinal section and the tip is blunt so as not to damage the thin fornix of the duodenal wall at the end of the incision. For the past 3 years the forceps has been found useful by more experienced surgeons as well as by registrars learning the operation for the first time.
References BENSON c. D. MUSTARD
(1969) Prepyloric and pyloric obstruction. In:
w.
T., RAVITCH M. M., SNYDER
w.
H.
et al. (ed.)
Paediatric Surgery. Chicago, Year Book, vol. 2, p. 795. BROWNE D.
(1951) The technique of Ramstedt’s operation.
Proc. R . Soc. Med. 44, 1057-1059.
w. c. (1966) Complete pyloromyotomy without duodenal perforation. Surgery 59, 627-630.
QUINBY
Paper accepted 17 January 1979.
Fig. 1. The forceps, with close-up views of the tips.
* Professorial Unit of Surgery, Charing Cross Hospital Medical School, Fulhani Palace Road, London.
Transcutaneous d ef unction ing colostomy FERNANDO RENAGA SYKES* SUMMARY
The technique is described for constructing an occlusive tube colostomy which requires no second operative procedure for closure. The advantages of this method are discussed and it is recommended as a superior alternative to loop colostomy OY caecostomy for defunctioning the unobstructed distal bowel.
DIVERSION of the faecal stream to defunction the distal colon presents technical problems ; the two most important are, that the diversion of the faecal stream is frequently incomplete and that a second operation is required to close the colostomy. The aim of this paper is to describe a technique which overcomes these problems. Method The part of the colon selected for the colostomy is brought out through the omentum so that the omentum shields the remaining abdominal cavity from faecal contamination. A soft Penrose drain 2-3 cm wide and 20 cm long is passed through the mesocolon near the bowel wall. Three centimetres proximal to the Penrose drain and on the antimesenteric border of the colon, preferably through a taenia coli, a longitudinal incision 2 cm long is made. A de Pezzer catheter, with the side holes enlarged, is passed into the lumen of the bowel through the incision (Fig. 1). A purse-string suture is placed around the catheter to avoid spillage. The de Pezzer catheter is invaginated into the wall of the colon by suturing the serosa over the catheter for a distance of 8-10 cm. Two skin incisions 3 cm long are made parallel to the colon at the site of the Penrose drain, each end of which is brought out through an incision. A third incision is made for the de Pezzer catheter, between those for the Penrose drain and the laparotomy wound (Fig. 2). The ends of the Penrose drain are tied over a gauze swab, ensuring that the lumen of the colon is occluded against the abdominal wall without impairing the blood supply. The tip of the de Pezzer catheter now lies free in the proximal colon with the distal end occluded by the Penrose drain. Having ascertained that the de Pezzer catheter is suitably sited, it is sutured to the abdominal wall. On completion of the transcutaneous defunctioning colostomy, the laparotomy incision is closed. Anal dilatation is a routine procedure following this operation. Postoperatively the catheter is attached to tubing, and washouts through the catheter are only performed if there is a suspicion of tube blockage. In order to remove the tube, which is left in place for a minimum of 3 weeks, one end of the Penrose drain is divided (Fig. 3) and the drain is withdrawn. The de Pezzer tube is then removed and normal gastrointestinal continuity restored without a further operative procedure. Barium enema studies performed after removal of the drain show a narrowing at the site of the colostomy: however, a repeat examination at t year shows a normal colonic lumen.
Discussion To date, 12 transcutaneous defunctioning colostomies have been performed (low rectal anastomosis, 10; traumatic faecal fistula in the sigmoid, 1 ; sigmoid myotomy, 1). The only complication in this series occurred in the first patient whose catheter was removed on day 14 after operation; this resulted in leakage along the catheter track causing an abscess. This was aggravated by the passage of the catheter through the upper end of the laparotomy wound. For
Fig. 1. The Penrose drain has been placed through the mesentery and the incision in the taenia coli of the antimesenteric border is being made. Note the enlarged opening in the tip of the de Pezzer catheter.
Fig. 2. The completed operation. The Penrose drain has been tied over a gauze swab, and the tube drain brought out through a separate incision between the Penrose drain and the abdominal wound.
Fig. 3. Removal of the transcutaneous colostomy: the Penrose drain is being divided on the skin surface in preparation for removal.
* Head of the Proctology Department, Surgical Unit, Hospital Sagrado Corazbn, Barcelona, Spain.
506
F. R. Sykes
this reason a separate incision was made in the remaining cases. The indications for this procedure are indentical to those of the usual loop colostomy, but in the presence of complete obstruction distal to the colostomy, the dangers associated with a closed loop would occur. Even in the presence of partial obstruction, this colostomy would not enable complete clearance of the faecal contents of the bowel immediately proximal to the obstruction, hence, it would not be advised in the management of obstruction. However, the place of this procedure is in those instances when complete rest of the distal colon is required, such as in the presence of a faecal fistula. For defunctioning the colon in order to protect an anastomosis it is ideal, producing a complete exclusion,
yet not requiring a second operation t o clear the colostomy. Because the faeces drain through a tube into a bag, the patient is spared the discomfort of a colostomy, which, particularly in the immediate postoperative period, is hard to manage. The emotional stress to which many patients are submitted by the appearance of a colostomy is avoided by this technique and the inevitable odour is reduced by the closed drainage technique described. The technique of transcutaneous defunctioning colostomy is proposed as an alternative t o both loop colostomy and a caecostomy, overcoming the disadvantages of both techniques and having few, if any, drawbacks of its own. Paper accepted I I October 1978.
Br. J. Surg. Vol. 66 (1979) 506
Pyloromyotomy forceps A. G . J O H N S O N A N D F. K H A N ” A NUMBER of different instruments have been devised for performing pyloromyotomy (Ramstedt’s operation) in infants (Quinby, 1966; Benson, 1969). The best known is the Dennis Browne forceps (Browne, 1951), but this is only useful at the end of the operation when the muscle has been well separated, because its tips are 3 mm apart when closed. Many surgeons
insert a small curved haemostat into the scalpel incision to separate the circular muscle fibres, but this is often too wide and is smooth on the outside and tends to slip. The new forceps (GU Manufacturing Co. Ltd, Plympton Street, London) illustrated in Fig. 1 is serrated on the outside and closes to form a sharp ‘keel’ (inset) which can be inserted into the initial scalpel incision. The curve of the blades follows the shape of the pyloric muscle in longitudinal section and the tip is blunt so as not to damage the thin fornix of the duodenal wall at the end of the incision. For the past 3 years the forceps has been found useful by more experienced surgeons as well as by registrars learning the operation for the first time.
References BENSON c. D. MUSTARD
(1969) Prepyloric and pyloric obstruction. In:
w.
T., RAVITCH M. M., SNYDER
w.
H.
et al. (ed.)
Paediatric Surgery. Chicago, Year Book, vol. 2, p. 795. BROWNE D.
(1951) The technique of Ramstedt’s operation.
Proc. R . Soc. Med. 44, 1057-1059.
w. c. (1966) Complete pyloromyotomy without duodenal perforation. Surgery 59, 627-630.
QUINBY
Paper accepted 17 January 1979.
Fig. 1. The forceps, with close-up views of the tips.
* Professorial Unit of Surgery, Charing Cross Hospital Medical School, Fulhani Palace Road, London.
