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Ileostomy prolapse repair utilizing bidirectional myotomy and a meshed split-thickness skin graft
MODERN OPERATIVE TECHNIQUES
lleostomy Prolapse Repair Utilizing Bidirectional Myotomy And a Meshed Split-Thickness Skin Graft
Norman Sohn, MD, New York, New York Norman Schulman, MD, New York, New York Michael A. Weinstein, MD, New York, New York Richard D. Robbins, MD, New York, New York
Operative Technique
Ileostomy prolapse can be an uncommon but frustrating problem for both the physician and the patient. Many different surgical techniques for correction have been recommended but recurrences are common. In their classic treatise on stoma surgery, Turnbull and Weakley [1] reported on the efficacy of the split-thickness, skin-grafted ileostomy as an operation to correct ileostomy prolapse. This operation has been modified by the addition of a bidirectional myotomy and meshing of the split-thickness skin graft. These latter two steps enhance the possibility of successful skin grafting. The skin graft, probably by providing a nondistensible segment of bowel, prevents prolapse.
A circumstomal incision was made, freeing the stoma and terminal ileum down to the peritoneal cavity. Approximately 8 inches of ileum was mobilized through this incision. Horizontal and longitudinal myotomies of the terminal 2 inches of ileum were then performed (Figure 1, left). A meshed split-thickness skin graft, 0.012 inch in diameter expanded 1 to 3 with a meshing device, was sutured circumstomally to the ileal serosa as well as to the skin (Figure 1, right). A bolus dressing was used around the stoma for 5 days. A large Foley catheter was placed in the stoma to collect effluent. At present, the stoma is of normal size. The patient changes his appliance every 3 to 5 days. There has been no recurrence of the prolapse in the 3 years since the operation was performed.
Case Report
Comments
A male patient underwent a total abdominal colectomy and ileostomy at the age of 19 years in 1960. In 1965, a small bowel obstruction required laparotomy, at which time a volvulus of the ileum was reduced and the mesentery of the ileum adjacent to the ileostomy was sutured to the parietal peritoneum. In 1966 a small bowel obstruction again developed which required laparotomy with construction of a new ileostomy at the same site as the original one. In 1970, ileostomy prolapse occurred and was treated by resection of the terminal 12 inches of the ileum. The prolapse recurred within 3 months. In 1975 the patient again underwent resection of the ileostomy with construction of a new stoma at the new site and fixation of the small bowel mesentery to the anterior abdominal wall. Within 3 months the prolapse recurred. When first seen, the patient had a severe ileostomy prolapse as well as peristomal skin excoriation. The prolapse measured 12 inches and filled the patient’s ileostomy appliance.
The fact that so many operations have been described to correct ileostomy prolapse attests to the inefficiency of any single procedure. The splitthickness skin graft, which was first introduced by Dragstedt et al [Z] in the 1930s and gradually became replaced by the Brook ileostomy, was noted to produce a rather rigid stoma. It was also noted that prolapsed ileostomies were not present in this type of stoma. This was the basis for Turnbull and Weakley’s [I] recommendation that this operation be utilized for ileostomy prolapse. Turnbull and Weakley report that stenosis of the ileostomy was a common occurrence of this operation. They thought that this complication could easily be managed by small incisions performed on an ambulatory basis. The addition of the bidirectional myotomy is thought to impair peristaltic activity in the stoma and thereby reduce motion and enhance the possibility of a successful take of the graft. Likewise, the meshing of the skin graft also enhances the possibility of the graft taking. We have not seen any prolapses in this patient nor in the three additional patients
From the Departmentof Surgery, Lenox Hill Hospital, New York, New York. Requests for reprints should be addressed to Norman Sob, MD, 475 East 72 Street, New York, New York 10021.
Volume 145, June 1993
807
Lygidakis
F@as 1. Lelt, the Ibum with Mtbecthsl myotomk Rmt, the meshed splitthtcknessgraft In place.
who have been subsequently treated in this fashion. Perhaps the meshing of the skin graft or bidirectional myotomy is responsible for this observation, or there may be other factors which we have not yet defined. This operation is also attractive because the need for a formal laparotomy with its attendant risk is avoided.
The operation is simple, safe, and effective, and provides a new dimension for the correction of a heretofore difficult and frustrating problem. A total of four patients have been similarly managed successfully with no recurrences in 1 to 4 years of follow-up.
Summary
References
The correction of an ileostomy prolapse by a modification of the technique of skin-grafted ileostomy as originally introduced by Dragstedt and emphasized by Turnbull and Weakley is reported.
1. Turnbull RB, Weakley FL. Atlas of intestinal stomas. St. Louis: CV Mosby, 1967:97. 2. Dragstedt LR, Dack GM, Kirsner JB. Chronic ulcerative colitis. A summary of evidence implicating bacterium necrophorum as an etiologic agent. Ann Surg 1941; 114:653-62.
808
The Amwkan
Journal of Surgery
lleostomy Prolapse Repair Utilizing Bidirectional Myotomy And a Meshed Split-Thickness Skin Graft
Norman Sohn, MD, New York, New York Norman Schulman, MD, New York, New York Michael A. Weinstein, MD, New York, New York Richard D. Robbins, MD, New York, New York
Operative Technique
Ileostomy prolapse can be an uncommon but frustrating problem for both the physician and the patient. Many different surgical techniques for correction have been recommended but recurrences are common. In their classic treatise on stoma surgery, Turnbull and Weakley [1] reported on the efficacy of the split-thickness, skin-grafted ileostomy as an operation to correct ileostomy prolapse. This operation has been modified by the addition of a bidirectional myotomy and meshing of the split-thickness skin graft. These latter two steps enhance the possibility of successful skin grafting. The skin graft, probably by providing a nondistensible segment of bowel, prevents prolapse.
A circumstomal incision was made, freeing the stoma and terminal ileum down to the peritoneal cavity. Approximately 8 inches of ileum was mobilized through this incision. Horizontal and longitudinal myotomies of the terminal 2 inches of ileum were then performed (Figure 1, left). A meshed split-thickness skin graft, 0.012 inch in diameter expanded 1 to 3 with a meshing device, was sutured circumstomally to the ileal serosa as well as to the skin (Figure 1, right). A bolus dressing was used around the stoma for 5 days. A large Foley catheter was placed in the stoma to collect effluent. At present, the stoma is of normal size. The patient changes his appliance every 3 to 5 days. There has been no recurrence of the prolapse in the 3 years since the operation was performed.
Case Report
Comments
A male patient underwent a total abdominal colectomy and ileostomy at the age of 19 years in 1960. In 1965, a small bowel obstruction required laparotomy, at which time a volvulus of the ileum was reduced and the mesentery of the ileum adjacent to the ileostomy was sutured to the parietal peritoneum. In 1966 a small bowel obstruction again developed which required laparotomy with construction of a new ileostomy at the same site as the original one. In 1970, ileostomy prolapse occurred and was treated by resection of the terminal 12 inches of the ileum. The prolapse recurred within 3 months. In 1975 the patient again underwent resection of the ileostomy with construction of a new stoma at the new site and fixation of the small bowel mesentery to the anterior abdominal wall. Within 3 months the prolapse recurred. When first seen, the patient had a severe ileostomy prolapse as well as peristomal skin excoriation. The prolapse measured 12 inches and filled the patient’s ileostomy appliance.
The fact that so many operations have been described to correct ileostomy prolapse attests to the inefficiency of any single procedure. The splitthickness skin graft, which was first introduced by Dragstedt et al [Z] in the 1930s and gradually became replaced by the Brook ileostomy, was noted to produce a rather rigid stoma. It was also noted that prolapsed ileostomies were not present in this type of stoma. This was the basis for Turnbull and Weakley’s [I] recommendation that this operation be utilized for ileostomy prolapse. Turnbull and Weakley report that stenosis of the ileostomy was a common occurrence of this operation. They thought that this complication could easily be managed by small incisions performed on an ambulatory basis. The addition of the bidirectional myotomy is thought to impair peristaltic activity in the stoma and thereby reduce motion and enhance the possibility of a successful take of the graft. Likewise, the meshing of the skin graft also enhances the possibility of the graft taking. We have not seen any prolapses in this patient nor in the three additional patients
From the Departmentof Surgery, Lenox Hill Hospital, New York, New York. Requests for reprints should be addressed to Norman Sob, MD, 475 East 72 Street, New York, New York 10021.
Volume 145, June 1993
807
Lygidakis
F@as 1. Lelt, the Ibum with Mtbecthsl myotomk Rmt, the meshed splitthtcknessgraft In place.
who have been subsequently treated in this fashion. Perhaps the meshing of the skin graft or bidirectional myotomy is responsible for this observation, or there may be other factors which we have not yet defined. This operation is also attractive because the need for a formal laparotomy with its attendant risk is avoided.
The operation is simple, safe, and effective, and provides a new dimension for the correction of a heretofore difficult and frustrating problem. A total of four patients have been similarly managed successfully with no recurrences in 1 to 4 years of follow-up.
Summary
References
The correction of an ileostomy prolapse by a modification of the technique of skin-grafted ileostomy as originally introduced by Dragstedt and emphasized by Turnbull and Weakley is reported.
1. Turnbull RB, Weakley FL. Atlas of intestinal stomas. St. Louis: CV Mosby, 1967:97. 2. Dragstedt LR, Dack GM, Kirsner JB. Chronic ulcerative colitis. A summary of evidence implicating bacterium necrophorum as an etiologic agent. Ann Surg 1941; 114:653-62.
808
The Amwkan
Journal of Surgery