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Construction of the Intestinal Stoma with an Intraluminal Stapling Device
0022-5347 /89/1425-1279$02.00/0 Vol. 142, November
THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL AssOClATlON, INC.
Printed in US,A,
Urologists At Work CONSTRUCTION OF THE INTESTINAL STOMA WITH AN INTRALUMINAL STAPLING DEVICE JAMES F. DONOVAN, HOWARD N. WINFIELD
AND
RICHARD D. WILLIAMS
From the Department of Urology, The University of Iowa Hospitals and Clinics, and Iowa City Veterans' Administration Medical Center, Iowa City, Iowa
ABSTRACT
We have used the intraluminal circular stapler to facilitate construction of the intestinal conduit stoma. We have encountered no complications related to the stapled stoma construction technique in 8 patients. The stoma is circular, uniform in size and is fitted easily with an appliance. The circular staple line provides a watertight seal that prevents contamination of the subcutaneous tissues. The technique is rapid, reliable and reproducible. (J. Ural., 142: 1279-1281, 1989) Since the introduction of mechanical stapling devices by Hultl in 19091 and, more recently, the refinement of Russian stapling devices by Steichen and Ravitch, 2 such devices have increased in type and number of applications. The use of the intraluminal stapler in construction of loop and end colostomies, and Brooke's ileostomy has been described previously.'3' 4 We have adapted this technique to the stoma construction in urinary diversion. MATERIALS AND METHODS
At urinary diversion an appropriate length of ileum or colon is isolated to be used as the urinary conduit. The distal limb of the conduit is clamped with a purse-string device (Ethicon disposable purse-string device or V. Mueller purse-string clamp). The purse-string device stabilizes the bowel in a serrated clamp and allows one to place a circumferential pursestring suture by passing a Keith needle with swaged 2-zero nylon through each side of the clamp device. One should not dispose of the Keith needle until the purse-string device has been removed and the circumferential suture has been inspected; occasionally, a short gap may be discovered between the purse-string start and end points that will require an additional pass of the suture. Isolation of the ileal loop, the ureterointestinal anastomosis and the enteroenterostomy are performed as per the usual routine. We prefer the 1-step resection and anastomosis technique described by Barcelona, and modified by Ravitch and Steichen." This maneuver isolates the ileal conduit and reestablishes enteral continuity in 1 step. The conduit is without staples: a purse-string is positioned at the distal loop, while the proximal loop remains open to permit a Wallace type ureterointestinal anastomosis with 4-zero polydioxanone (fig. 1). No staple lines are discarded. The site of stoma construction is determined preoperatively with the assistance of a stomal therapist. A small circular disk of skin is excised and the subcutaneous fat is dissected from the surrounding skin circumferentially, thus, creating a 2 cm. skin flap that facilitates drawing the conduit into the subcutaneous space and provides skin of reasonable thickness for the stapled enterocutaneous anastomosis (fig. 1). Through the skin wound, sharp and blunt dissection exposes the anterior rectus fascia. A cruciate incision is made in the rectus sheath and Accepted for publication June 7, 1989.
blunt dissection is used to complete the transabdominal path through the middle of the rectus muscle. A purse-string suture then is placed around the circular skin wound with monofilament 2-zero suture. Once the necessary preparation of the stoma and skin has been completed, the distal ileum is brought through the transabdominal path and the circular skin wound (fig. 2). The distal ureteral stents are cut to an appropriate length and pushed back into the distal conduit to allow insertion of the staple anvil. The intraluminal circular stapler* is configured with the anvil and cartridge separated, and the anvil is inserted carefully into the distal conduit (fig. 2). Once the distal conduit has completely enveloped the anvil, the distal conduit purse-string is tightened above the staple anvil and secured to the staple spindle. The ileum-anvil assembly is passed into the subcutaneous space (fig. 3), which allows the skin purse-string to be tightened and secured above the ileum and anvil. The anvil and cartridge are approximated to stabilize the tissues before staple application (fig. 4). Certain manufacturers provide an adjustable tissue-gap function that allows the operator to vary the staple height according to the tissue thickness. This flexibility may be beneficial considering the variable thickness of the colon and small bowel. With the enterocutaneous tissues apposed the staple assembly is drawn away from the body wall to assure adequate bowel in the subcutaneous compartment and to provide for subsequent eversion of the stoma. The staple device is fired. The anvil and cartridge are separated, and the instrument is turned 180 degrees to free the tissues from the anvil and cartridge. The anvil then is removed from the stoma (fig. 5). Once the staple instrument is removed the instrument is disassembled and the resected tissue is inspected to assure the presence of 2 complete tissue rings. The site of the conduit traversing the peritoneum and transversalis fascia is exposed and the conduit is secured to the transversalis fascia with 3zero nonabsorbable suture. The ureteral stents are retrieved from the distal conduit and secured to the stoma mucosa or the adjacent skin with 3-zero absorbable suture. Finally, after closure of the abdomen a stomal appliance is fitted to the stoma to collect the urine.
* Proximate ILP21-Ethicon, EEA21-U.S. Surgical, Ethicon, Inc., Somerville, New Jersey.
1279
1280
DONOVAN, WINFIELD AND WILLIAMS
FIG. 1. Purse-string device is clamped to distal loop and purse-string suture is placed. Skin site is prepared by excision of skin disk, undermining of adjacent skin and placement of circumferential purse-string suture with 2-zero monofilament suture. Anterior rectus sheath is incised in cruciate fashion.
FIG. 2. Distal conduit is brought through anterior abdominal wall, and ureteral stents are trimmed and pushed into conduit. Anvil of intraluminal stapling device is inserted into conduit and intestinal purse-string suture is tied.
RESULTS
A
We have used the intraluminal stapler for enteral stoma construction in 8 patients followed for 3 to 14 months with no complications attributable to the stapling technique. The most significant variable in proper technique is the length of distal stoma advanced into the subcutaneous space, which must be sufficient to allow subsequent eversion. DISCUSSION
FIG. 3. Ileum-anvil assembly is passed into subcutaneous space. Skin purse-string suture is secured to staple spindle above conduit.
Urinary diversion with or without cystectomy frequently is associated with complications. Complications most commonly are at the site of ureterointestinal anastomosis or stoma construction. Complications at the stoma include parastomal infection, stoma retraction, parastomal hernia and stomal stenosis. G The use of the intraluminal stapling device for stomal construction offers 2 distinct advantages over traditional suture techniques: 1) the enterocutaneous anastomosis is watertight and effectively eliminates the possibility of continuous contamination of the subcutaneous space by urine (stapling instru-
C-i}J\TSTRUCTION OF Ir",ITESTn~JAL STOfhA VVltil"1 If\1TRALU:tvn:~F.AL 8'TAPLI}\JG DE'VICE
128L
FIG. 4. Intraluminal circular stapler cartridge and anvil are approximated, securing skin and conduit before staple application. Assembly is drawn upward to assure advancement of distal conduit into subcutaneous space and to provide eversion of stoma.
FIG. 5. Completed stoma. Conduit is secured to transversalis fascia and peritoneum at posterior rectus sheath. Stents are retrieved and secured to everted stomal mucosa.
ments with variable staple height may offer an additional advantage in allowing adjustment of staple height to accommodate different skin and bowel thickness) and 2) the enterocutaneous stoma is constructed rapidly with eversion of the stoma achieved adjusting the of distal conduit brought into the subcutaneous compartment, thus, eliminating the need for everting sutures. The stapled enterocutaneous anastomosis requires 2 purse-string sutures, each placed 2 passes of the needle through the purse-string device (compared to tying each stoma-skin suture with traditional stoma construction). The stapled stoma technique is adapted from previous reports by Chung.'· 4 Modifications of his technique include the introduction of ureteral stents and advancement of the distal conduit through the skin wound before insertion of the stapling device. The stents, trimmed to 5 cm. beyond the distal conduit, are easily integrated into this technique. The stents are pushed back into the conduit before insertion of the staple anvil into the conduit. Rather than loading the distal conduit onto the anvil without advancing the conduit through the skin site as described by Chung, the conduit is brought through the skin site and sufficient conduit is advanced to provide the desired eversion of the stoma. A stomal skin excision slightly larger
than that described is necessary but is _Ju:sunea. n1 of the greater control exerted over stomal eversion. In summary, the use of in the construction of the ilea! stoma nr,mr,,w," a safe and reliable alternative to traditional suture The can be performed and relies techniques, We complication have used this method in 8 related to the stomal construction or to the use of stapl~ devices, REFERENCES
1. Hult!, H.: II Kongress der Ungarischen Gesellschaft for Chirurgie,
Budapest, May, 1908. Pester: Med. Chir. Presse, 45: 108, 1909. 2. Steichen, F. M. and Ravitch, M. M.: Stapling in Surgery. Chicago: Year Book Medical Publishers, Inc., p. 1, 1984. 3. Chung, R S.: Loop colostomy with the intraluminal stapler (ILS). Dis. Colon Rectum, 28: 464, 1985. 4. Chung, R. S.: End colostomy and Brooke's ileostomy constructed by surgical stapler. Surg., Gynec. & Obst., 162: 63, 1986. 5. Ravitch, M. M. and Steichen, F. M.: Staplers in gastrointestinal surgery. In: Maingot's Abdominal Operations, 8th ed. Edited by S. L Schwartz and H. Ellis. Norwalk, Connecticut: AppletonCentury-Crofts, vol. 2, chapt. 61, pp. 1537-1575, 1985. 6. Svare, J., Walter, S., Kvist Kristensen, J. and Lund, F.: Ilea! conduit urinary diversion-early and late complications. Eur. UroL, 11: 83, 1985.
THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL AssOClATlON, INC.
Printed in US,A,
Urologists At Work CONSTRUCTION OF THE INTESTINAL STOMA WITH AN INTRALUMINAL STAPLING DEVICE JAMES F. DONOVAN, HOWARD N. WINFIELD
AND
RICHARD D. WILLIAMS
From the Department of Urology, The University of Iowa Hospitals and Clinics, and Iowa City Veterans' Administration Medical Center, Iowa City, Iowa
ABSTRACT
We have used the intraluminal circular stapler to facilitate construction of the intestinal conduit stoma. We have encountered no complications related to the stapled stoma construction technique in 8 patients. The stoma is circular, uniform in size and is fitted easily with an appliance. The circular staple line provides a watertight seal that prevents contamination of the subcutaneous tissues. The technique is rapid, reliable and reproducible. (J. Ural., 142: 1279-1281, 1989) Since the introduction of mechanical stapling devices by Hultl in 19091 and, more recently, the refinement of Russian stapling devices by Steichen and Ravitch, 2 such devices have increased in type and number of applications. The use of the intraluminal stapler in construction of loop and end colostomies, and Brooke's ileostomy has been described previously.'3' 4 We have adapted this technique to the stoma construction in urinary diversion. MATERIALS AND METHODS
At urinary diversion an appropriate length of ileum or colon is isolated to be used as the urinary conduit. The distal limb of the conduit is clamped with a purse-string device (Ethicon disposable purse-string device or V. Mueller purse-string clamp). The purse-string device stabilizes the bowel in a serrated clamp and allows one to place a circumferential pursestring suture by passing a Keith needle with swaged 2-zero nylon through each side of the clamp device. One should not dispose of the Keith needle until the purse-string device has been removed and the circumferential suture has been inspected; occasionally, a short gap may be discovered between the purse-string start and end points that will require an additional pass of the suture. Isolation of the ileal loop, the ureterointestinal anastomosis and the enteroenterostomy are performed as per the usual routine. We prefer the 1-step resection and anastomosis technique described by Barcelona, and modified by Ravitch and Steichen." This maneuver isolates the ileal conduit and reestablishes enteral continuity in 1 step. The conduit is without staples: a purse-string is positioned at the distal loop, while the proximal loop remains open to permit a Wallace type ureterointestinal anastomosis with 4-zero polydioxanone (fig. 1). No staple lines are discarded. The site of stoma construction is determined preoperatively with the assistance of a stomal therapist. A small circular disk of skin is excised and the subcutaneous fat is dissected from the surrounding skin circumferentially, thus, creating a 2 cm. skin flap that facilitates drawing the conduit into the subcutaneous space and provides skin of reasonable thickness for the stapled enterocutaneous anastomosis (fig. 1). Through the skin wound, sharp and blunt dissection exposes the anterior rectus fascia. A cruciate incision is made in the rectus sheath and Accepted for publication June 7, 1989.
blunt dissection is used to complete the transabdominal path through the middle of the rectus muscle. A purse-string suture then is placed around the circular skin wound with monofilament 2-zero suture. Once the necessary preparation of the stoma and skin has been completed, the distal ileum is brought through the transabdominal path and the circular skin wound (fig. 2). The distal ureteral stents are cut to an appropriate length and pushed back into the distal conduit to allow insertion of the staple anvil. The intraluminal circular stapler* is configured with the anvil and cartridge separated, and the anvil is inserted carefully into the distal conduit (fig. 2). Once the distal conduit has completely enveloped the anvil, the distal conduit purse-string is tightened above the staple anvil and secured to the staple spindle. The ileum-anvil assembly is passed into the subcutaneous space (fig. 3), which allows the skin purse-string to be tightened and secured above the ileum and anvil. The anvil and cartridge are approximated to stabilize the tissues before staple application (fig. 4). Certain manufacturers provide an adjustable tissue-gap function that allows the operator to vary the staple height according to the tissue thickness. This flexibility may be beneficial considering the variable thickness of the colon and small bowel. With the enterocutaneous tissues apposed the staple assembly is drawn away from the body wall to assure adequate bowel in the subcutaneous compartment and to provide for subsequent eversion of the stoma. The staple device is fired. The anvil and cartridge are separated, and the instrument is turned 180 degrees to free the tissues from the anvil and cartridge. The anvil then is removed from the stoma (fig. 5). Once the staple instrument is removed the instrument is disassembled and the resected tissue is inspected to assure the presence of 2 complete tissue rings. The site of the conduit traversing the peritoneum and transversalis fascia is exposed and the conduit is secured to the transversalis fascia with 3zero nonabsorbable suture. The ureteral stents are retrieved from the distal conduit and secured to the stoma mucosa or the adjacent skin with 3-zero absorbable suture. Finally, after closure of the abdomen a stomal appliance is fitted to the stoma to collect the urine.
* Proximate ILP21-Ethicon, EEA21-U.S. Surgical, Ethicon, Inc., Somerville, New Jersey.
1279
1280
DONOVAN, WINFIELD AND WILLIAMS
FIG. 1. Purse-string device is clamped to distal loop and purse-string suture is placed. Skin site is prepared by excision of skin disk, undermining of adjacent skin and placement of circumferential purse-string suture with 2-zero monofilament suture. Anterior rectus sheath is incised in cruciate fashion.
FIG. 2. Distal conduit is brought through anterior abdominal wall, and ureteral stents are trimmed and pushed into conduit. Anvil of intraluminal stapling device is inserted into conduit and intestinal purse-string suture is tied.
RESULTS
A
We have used the intraluminal stapler for enteral stoma construction in 8 patients followed for 3 to 14 months with no complications attributable to the stapling technique. The most significant variable in proper technique is the length of distal stoma advanced into the subcutaneous space, which must be sufficient to allow subsequent eversion. DISCUSSION
FIG. 3. Ileum-anvil assembly is passed into subcutaneous space. Skin purse-string suture is secured to staple spindle above conduit.
Urinary diversion with or without cystectomy frequently is associated with complications. Complications most commonly are at the site of ureterointestinal anastomosis or stoma construction. Complications at the stoma include parastomal infection, stoma retraction, parastomal hernia and stomal stenosis. G The use of the intraluminal stapling device for stomal construction offers 2 distinct advantages over traditional suture techniques: 1) the enterocutaneous anastomosis is watertight and effectively eliminates the possibility of continuous contamination of the subcutaneous space by urine (stapling instru-
C-i}J\TSTRUCTION OF Ir",ITESTn~JAL STOfhA VVltil"1 If\1TRALU:tvn:~F.AL 8'TAPLI}\JG DE'VICE
128L
FIG. 4. Intraluminal circular stapler cartridge and anvil are approximated, securing skin and conduit before staple application. Assembly is drawn upward to assure advancement of distal conduit into subcutaneous space and to provide eversion of stoma.
FIG. 5. Completed stoma. Conduit is secured to transversalis fascia and peritoneum at posterior rectus sheath. Stents are retrieved and secured to everted stomal mucosa.
ments with variable staple height may offer an additional advantage in allowing adjustment of staple height to accommodate different skin and bowel thickness) and 2) the enterocutaneous stoma is constructed rapidly with eversion of the stoma achieved adjusting the of distal conduit brought into the subcutaneous compartment, thus, eliminating the need for everting sutures. The stapled enterocutaneous anastomosis requires 2 purse-string sutures, each placed 2 passes of the needle through the purse-string device (compared to tying each stoma-skin suture with traditional stoma construction). The stapled stoma technique is adapted from previous reports by Chung.'· 4 Modifications of his technique include the introduction of ureteral stents and advancement of the distal conduit through the skin wound before insertion of the stapling device. The stents, trimmed to 5 cm. beyond the distal conduit, are easily integrated into this technique. The stents are pushed back into the conduit before insertion of the staple anvil into the conduit. Rather than loading the distal conduit onto the anvil without advancing the conduit through the skin site as described by Chung, the conduit is brought through the skin site and sufficient conduit is advanced to provide the desired eversion of the stoma. A stomal skin excision slightly larger
than that described is necessary but is _Ju:sunea. n1 of the greater control exerted over stomal eversion. In summary, the use of in the construction of the ilea! stoma nr,mr,,w," a safe and reliable alternative to traditional suture The can be performed and relies techniques, We complication have used this method in 8 related to the stomal construction or to the use of stapl~ devices, REFERENCES
1. Hult!, H.: II Kongress der Ungarischen Gesellschaft for Chirurgie,
Budapest, May, 1908. Pester: Med. Chir. Presse, 45: 108, 1909. 2. Steichen, F. M. and Ravitch, M. M.: Stapling in Surgery. Chicago: Year Book Medical Publishers, Inc., p. 1, 1984. 3. Chung, R S.: Loop colostomy with the intraluminal stapler (ILS). Dis. Colon Rectum, 28: 464, 1985. 4. Chung, R. S.: End colostomy and Brooke's ileostomy constructed by surgical stapler. Surg., Gynec. & Obst., 162: 63, 1986. 5. Ravitch, M. M. and Steichen, F. M.: Staplers in gastrointestinal surgery. In: Maingot's Abdominal Operations, 8th ed. Edited by S. L Schwartz and H. Ellis. Norwalk, Connecticut: AppletonCentury-Crofts, vol. 2, chapt. 61, pp. 1537-1575, 1985. 6. Svare, J., Walter, S., Kvist Kristensen, J. and Lund, F.: Ilea! conduit urinary diversion-early and late complications. Eur. UroL, 11: 83, 1985.