- Email: [email protected]
Loop ileostomy: Modification of technique
Surgical Technique
Loop ileostomy: Modification of technique Introduction: A loop ileostomy is a suitable procedure for faecal diversion. A number of technical improvements and advancement in stoma management have made its creation a suitable alternative to a loop colostomy. We describe an alternative technique for securing a loop ileostomy and perform a retrospective review of this technique. Patients & Method: 40 patients who had a loop ileostomy performed as part of an abdominal procedure were reviewed. The loop of ileum was secured to the stoma site with a novel ‘suture bridge’ technique. Results: 32 patients had the stoma formed to protect a distal anastomosis, 6 to palliate bowel obstruction, 1 to control faecal incontinence and another for colonic Crohn’s disease. There were no incidences of paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. In 27 patients this was performed by excising the muco-cutaneous edge and anterior closure. Three patients had their stomas resected and an endto-end bowel anastomoses. Following closure there were two complications in separate patients – self-limiting paralytic ileus and small bowel obstruction at the site of the stomal closure that required a second operation. There were no incidences of anastomotic leaks or bleeding in patients who had their ileostomy closed. No mortalities were attributed to either stoma formation or closure. Conclusion: We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results.
J. W. Nunoo-Mensah1 A. Chatterjee1 D. Khanwalkar2 D. G. Nasmyth1 1 Department of General Surgery, Furness General Hospital, Barrow-in-Furness, Cumbria, UK 2 Department of General Surgery, Burnley General Hospital, Burnley, UK
Correspondence to: J. W. Nunoo-Mensah, 50 Sheffield Road Godley, SK14 2PR Email: [email protected]
1.
2.
Keywords: diverting, loop, ileostomy Surg J R Coll Surg Edinb Irel., 2 October 2004, 287-291
INTRODUCTION Diverting loop ileostomies were originally described in 1940 for the treatment of acute ulcerative colitis.1 Subsequently, this procedure was abandoned because of the liability of the stoma to retract, prolapse and the lack of suitable fitting appliances.1 The current reemergence of this procedure was dictated by the need for faecal diversion following low anterior resections, ileoanal pouch anastomoses, rectosigmoid resections with primary anastomosis in acute diverticulitis and in severe perianal Crohn’s disease. Since 1940, a number of technical improvements and advancement in stoma management have occurred making this procedure a suitable alternative to a loop colostomy. These include rotating the loop clockwise so that the proximal limb is located inferiorly in order to obtain a dependent proximal limb, the use of a rubber sling to thread the stoma through the defect in the abdominal wall and everting the stoma by rolling the afferent limb over an upturned Langenbeck retractor rather than using a Babcock, which may traumatise the bowel.2,3,4 © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
Although supporting evidence is limited, most surgeons use a bridge (either plastic or glass rod) to prevent retraction of the loop ileostomy stoma. Other surgeons anchor the loop ileostomy to the rectus fascia with interrupted sutures or to the parietal peritoneum. A few surgeons neither use rods nor anchor sutures to support the stoma.5 We describe an alternative technique for securing a loop ileostomy and document a retrospective review of this technique.
3.
4.
5.
METHODS AND MATERIALS Between January 1996 and December 2001, 40 6. patients had a loop ileostomy performed after colorectal resection and bowel anastomoses for malignant and non-malignant conditions. All the loop ileostomies were formed in the right lower quadrant of the abdomen at a point 7. defined preoperatively by a stoma therapist. A circular disc of skin 2cm in diameter was excised and a cruciate defect created in the rectus sheet. After splitting the rectus muscle, 8. the posterior rectus sheath and the peritoneum were incised. The defect in the abdominal wall was dilated to admit the tip of two fingers. A
REFERENCES Williams NS, Nasmyth DG, Jones D, Smith AH. De-functioning stomas: a prospective controlled trial comparing loop ileostomy with loop transverse colostomy. Br J Surg 1986; 73(7): 56670. Turnbull RB. The surgical approach to the treatment of inflammatory bowel disease: a personal view of techniques and prognosis. In: Kirsner JB, Shorter RG, editors. Inflammatory Bowel Disease. Philadelphia: Lea & Febiger; 1975. Senapati A, Nicholls RJ. Formation of a loop stoma Br J Surg 1991;78(1): 23. Thomas DJ, Abercrombie GF. Simple technique for everting a spout ileostomy Br J Urol 1992; 70(4): 45455. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT. Techniques and complications of ileostomy takedown. Am J Surg 1999; 177(6): 463-66. Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM. Loop ileostomy for temporary faecal diversion. Am J Surg 1994: 167(5): 519-22. Grobler SP, Hosie KB, Keighly MRB. Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992; 79(1): 903-6. Fasth S, Hulten L, Palselius I. Loop ileostomy - an attractive alternative to a temporary transverse colostomy. Acta Chir Scand 1980; 146(3):203-7.
The Royal Colleges of Surgeons of Edinburgh and Ireland
287
suitable section of the small bowel was chosen and a small pair of artery forceps was used to create a mesenteric defect adjacent to the bowel wall. A rubber sling was passed thought the defect and the small bowel delivered through the defect in the abdominal wall. The loop of small bowel was secured to the subcutaneous margin of the defect by securing a minimum of four lengths of 3/0 Maxon (monofilament polyglyconate synthetic absorbable) sutures to create a ‘suture bridge’ (See Figures 1-3). This was loosely ligated to prevent narrowing of the stoma. The distal end of the loop was marked with a single 3/0 Maxon ligature. After the laparotomy wound was closed, the wall of the efferent limb was then everted, providing a stoma of 2-3cm. The small bowel was then sutured to the skin with interrupted 3/0 Monocril (monofilament polioglecaprone 25 absorbable) sutures. At no time were these sutures, including the ‘suture bridge’, removed. Of those ileostomies that were closed, either the muco-cutaneous margins were excised and the anterior defect closed or the stomas resected and an end-to-end anastomosis performed with interrupted sero-muscular 3/0 Monocril.
colonic Crohn’s disease (Table 2). There were no records of a paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. Closure was performed after a mean of 15 weeks (range 6-127 weeks). This was performed in 27 patients by excising the mucocutaneous edge and anterior closure. Three patients had their stoma resected and an end-to-end bowel anastomosis carried out. Eight patients who had a loop ileostomy created to palliate distal pathology did not have their stoma closed. One patient who had a low anterior resection and a loop ileostomy formed to protect the anastomosis died post-operatively from a myocardial infarct. In another patient, the stoma was not reversed because of concern about the adequacy of anal sphincter function. Following closure of their ileostomies, one patient had a paralytic ileus, which resolved spontaneously and another developed small bowel obstruction at the site of the stomal closure. In this latter case, a laporatomy was performed, the anterior wall closure was resected and a side-
Figure 1: Insertion of subcutaneous stitch and passage through defect in mesentery.
RESULTS Over the study period, 40 patients (17 females and 23 males with a mean age 63 years and range 26-90 years) had a diversionary loop ileostomy carried out. Thirty two patients had the stoma formed to protect a distal anastomosis (Table 1). In six of the remaining patients the stoma was formed to palliate bowel obstruction, one to control faecal incontinence and another for 288
The Royal Colleges of Surgeons of Edinburgh and Ireland
to-side anastomosis performed. There was no incidence of an anastomotic leak or haemorrhage in patients who had their ileostomy closed. No mortality was attributed to either stoma formation or closure of the loop ileostomies. TECHNIQUE: ‘SUTURE BRIDGE’ FORMATION • A small defect is created in the small bowel mesentery of © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
Figure 2: Suture to opposite site of stoma opening and repeat (x4) of the process.
the selected small bowel loop. A 3/0 Monocril suture is then secured to the subcutaneous tissue at the margin of the stoma defect
TABLE 1. PATIENTS WHO HAD LARGE BOWEL RESECTION AND A DIVERSIONARY LOOP ILEOSTOMY FORMED TO PROTECT A DISTAL ANATOMOSIS
• With the aid of an artery forceps, the needle of the suture is passed through the small bowel mesenteric defect. This process is simple if the tip of the needle is held with the tip of the artery forceps. The suture is then secured to subcutaneous tissue of the opposite side of the stoma defect
Procedure Anterior resection
27
• The needle and suture is then passed through the small bowel mesenteric defect to the original site of the first stoma. After four such passes the stitch is tied to the free length of stitch of the first subcutaneous knot. It is important not to overtighten this final knot as this may narrow the skin defect in the abdominal wall
Proctectomy and ileo-anal pouch anastomosis
2
Sigmoid colectomy
1
• Final result after the suture bridge has been formed. The loop of bowel is now ready to be opened to form the stoma
Reversal of Hartmann’s
1
Resuture of an anastomotic leak following a right hemicolectomy
1
DISCUSSION There have been several reports debating the advantages and disadvantages of using diversionary stomas after colorectal bowel resection and anastomosis. A prospective controlled study comparing loop ileostomies with transverse colostomies recommended the former in patients who require a © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
No of patients
The Royal Colleges of Surgeons of Edinburgh and Ireland
289
Figure 3: Suture bridge completed with at least four sutures traversing mesenteric opening.
defunctioning stoma.1 Advocates of temporary faecal diversion argue that a loop ileostomy decreases the incidence and severity of sepsis following a leak from an anastomosis.6 On the other hand, a loop ileostomy may carry its own complications. For this reason, some surgeons have argued for its omission under suitable conditions.7 There are a large number of reports on the complications of construction and closure of a loop ileostomy. These complications include retraction or prolapse of the loop ileostomy, high output fluid losses, transient oedema of the stoma which may be associated with obstructive symptoms, stomal necrosis, leak from the anastomosis following closure of the ileostomy, small bowel obstruction at the site of ileostomy closure, peristomal dermatitis and local wound abscesses.1,8 Complications directly related to the technique employed to secure the stoma have rarely been mentioned. If the ileal loop is sutured to the rectus sheet to reduce the risk of stoma prolapse or retraction, there is risk of developing a peristomal fistula. The use of a rod to support the mesentery will prevent
290
The Royal Colleges of Surgeons of Edinburgh and Ireland
retraction of the stoma but, as this is usually removed after 58 days, delayed retraction of the stoma may still be possible. A rod may also cause discomfort to the patient if it is secured to the skin with sutures. The use of a rod sutured to the skin also prevents the application of a stoma bag flush with the mucocutaneous junction resulting in faecal leakage onto the abdominal wall and subsequent dermatitis. If the rod is not secured and the stoma bag plate placed beneath the rod, this may result in disruption of the mucocutanoeus junction if the stoma bag is accidentally pulled. Although Phang et al (1997), in a review of 288 patients reported no cases of retraction of the stoma in their series of loop ileostomy without a supporting rod or anchoring sutures, not all surgeons share their experience or confidence.5 We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results. Although one may postulate that the ‘suture bridge’ could erode through the bowel wall this did not occur in our series. This is unlikely if the stoma has been formed without undue tension on the ‘suture © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
TABLE 2. PATIENTS WHO HAD A DIVERSIONARY LOOP ILEOSTOMY AS PART OF A PALLIATIVE PROCEDURE
Procedure
No of patients
Large bowel obstruction (trephine loop ileostomy formed for suspected splenic flexure obstructive lesion. Postmortem showed ischaemic/infarcted colonic disease)
1
Large bowel obstruction secondary to disseminated ovarian carcinoma
1
Large bowel obstruction due to large irresectable pelvic rectal tumour
1
Colonic Crohn’s disease
1
Faecal incontinence
1
RECRUITING NOW
Trephine loop ileostomy for inoperable colonic carcinoma
2
Trephine loop ileostomy for recurrent rectal carcinoma
1
bridge’. We suggest that this technique may also be employed in the formation of a loop colostomy. ACKNOWLEDGEMENT Thanks to Heather Pratt and Barbara Teague in the Clinical Audit Department at Furness General Hospital for their assistance in collecting and analysing the data. Copyright 2 September 2004
© 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH
EXAMINERS FOR THE RCSEd PANEL FOR THE INTERCOLLEGIATE MEMBERSHIP OF THE ROYAL COLLEGE OF SURGEONS OF GREAT BRITAIN AND IRELAND SURGEON EXAMINERS AND EXAMINERS IN BASIC SCIENCES Applications are invited from Surgeons, Anatomists, Physiologists and Pathologists to examine in the oral, clinical and communications skills components of the Intercollegiate MRCS Examination. (Basic Sciences Examiners are not required to examine at the clinical examination) For full eligibility criteria, person specification and application form please visit our website at: http://www.rcsed.ac.uk/content/ careers/exams Or contact the Information Section on Tel: 0131 668 9222 or e-mail: [email protected]
The Royal Colleges of Surgeons of Edinburgh and Ireland
291
Loop ileostomy: Modification of technique Introduction: A loop ileostomy is a suitable procedure for faecal diversion. A number of technical improvements and advancement in stoma management have made its creation a suitable alternative to a loop colostomy. We describe an alternative technique for securing a loop ileostomy and perform a retrospective review of this technique. Patients & Method: 40 patients who had a loop ileostomy performed as part of an abdominal procedure were reviewed. The loop of ileum was secured to the stoma site with a novel ‘suture bridge’ technique. Results: 32 patients had the stoma formed to protect a distal anastomosis, 6 to palliate bowel obstruction, 1 to control faecal incontinence and another for colonic Crohn’s disease. There were no incidences of paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. In 27 patients this was performed by excising the muco-cutaneous edge and anterior closure. Three patients had their stomas resected and an endto-end bowel anastomoses. Following closure there were two complications in separate patients – self-limiting paralytic ileus and small bowel obstruction at the site of the stomal closure that required a second operation. There were no incidences of anastomotic leaks or bleeding in patients who had their ileostomy closed. No mortalities were attributed to either stoma formation or closure. Conclusion: We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results.
J. W. Nunoo-Mensah1 A. Chatterjee1 D. Khanwalkar2 D. G. Nasmyth1 1 Department of General Surgery, Furness General Hospital, Barrow-in-Furness, Cumbria, UK 2 Department of General Surgery, Burnley General Hospital, Burnley, UK
Correspondence to: J. W. Nunoo-Mensah, 50 Sheffield Road Godley, SK14 2PR Email: [email protected]
1.
2.
Keywords: diverting, loop, ileostomy Surg J R Coll Surg Edinb Irel., 2 October 2004, 287-291
INTRODUCTION Diverting loop ileostomies were originally described in 1940 for the treatment of acute ulcerative colitis.1 Subsequently, this procedure was abandoned because of the liability of the stoma to retract, prolapse and the lack of suitable fitting appliances.1 The current reemergence of this procedure was dictated by the need for faecal diversion following low anterior resections, ileoanal pouch anastomoses, rectosigmoid resections with primary anastomosis in acute diverticulitis and in severe perianal Crohn’s disease. Since 1940, a number of technical improvements and advancement in stoma management have occurred making this procedure a suitable alternative to a loop colostomy. These include rotating the loop clockwise so that the proximal limb is located inferiorly in order to obtain a dependent proximal limb, the use of a rubber sling to thread the stoma through the defect in the abdominal wall and everting the stoma by rolling the afferent limb over an upturned Langenbeck retractor rather than using a Babcock, which may traumatise the bowel.2,3,4 © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
Although supporting evidence is limited, most surgeons use a bridge (either plastic or glass rod) to prevent retraction of the loop ileostomy stoma. Other surgeons anchor the loop ileostomy to the rectus fascia with interrupted sutures or to the parietal peritoneum. A few surgeons neither use rods nor anchor sutures to support the stoma.5 We describe an alternative technique for securing a loop ileostomy and document a retrospective review of this technique.
3.
4.
5.
METHODS AND MATERIALS Between January 1996 and December 2001, 40 6. patients had a loop ileostomy performed after colorectal resection and bowel anastomoses for malignant and non-malignant conditions. All the loop ileostomies were formed in the right lower quadrant of the abdomen at a point 7. defined preoperatively by a stoma therapist. A circular disc of skin 2cm in diameter was excised and a cruciate defect created in the rectus sheet. After splitting the rectus muscle, 8. the posterior rectus sheath and the peritoneum were incised. The defect in the abdominal wall was dilated to admit the tip of two fingers. A
REFERENCES Williams NS, Nasmyth DG, Jones D, Smith AH. De-functioning stomas: a prospective controlled trial comparing loop ileostomy with loop transverse colostomy. Br J Surg 1986; 73(7): 56670. Turnbull RB. The surgical approach to the treatment of inflammatory bowel disease: a personal view of techniques and prognosis. In: Kirsner JB, Shorter RG, editors. Inflammatory Bowel Disease. Philadelphia: Lea & Febiger; 1975. Senapati A, Nicholls RJ. Formation of a loop stoma Br J Surg 1991;78(1): 23. Thomas DJ, Abercrombie GF. Simple technique for everting a spout ileostomy Br J Urol 1992; 70(4): 45455. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT. Techniques and complications of ileostomy takedown. Am J Surg 1999; 177(6): 463-66. Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM. Loop ileostomy for temporary faecal diversion. Am J Surg 1994: 167(5): 519-22. Grobler SP, Hosie KB, Keighly MRB. Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992; 79(1): 903-6. Fasth S, Hulten L, Palselius I. Loop ileostomy - an attractive alternative to a temporary transverse colostomy. Acta Chir Scand 1980; 146(3):203-7.
The Royal Colleges of Surgeons of Edinburgh and Ireland
287
suitable section of the small bowel was chosen and a small pair of artery forceps was used to create a mesenteric defect adjacent to the bowel wall. A rubber sling was passed thought the defect and the small bowel delivered through the defect in the abdominal wall. The loop of small bowel was secured to the subcutaneous margin of the defect by securing a minimum of four lengths of 3/0 Maxon (monofilament polyglyconate synthetic absorbable) sutures to create a ‘suture bridge’ (See Figures 1-3). This was loosely ligated to prevent narrowing of the stoma. The distal end of the loop was marked with a single 3/0 Maxon ligature. After the laparotomy wound was closed, the wall of the efferent limb was then everted, providing a stoma of 2-3cm. The small bowel was then sutured to the skin with interrupted 3/0 Monocril (monofilament polioglecaprone 25 absorbable) sutures. At no time were these sutures, including the ‘suture bridge’, removed. Of those ileostomies that were closed, either the muco-cutaneous margins were excised and the anterior defect closed or the stomas resected and an end-to-end anastomosis performed with interrupted sero-muscular 3/0 Monocril.
colonic Crohn’s disease (Table 2). There were no records of a paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. Closure was performed after a mean of 15 weeks (range 6-127 weeks). This was performed in 27 patients by excising the mucocutaneous edge and anterior closure. Three patients had their stoma resected and an end-to-end bowel anastomosis carried out. Eight patients who had a loop ileostomy created to palliate distal pathology did not have their stoma closed. One patient who had a low anterior resection and a loop ileostomy formed to protect the anastomosis died post-operatively from a myocardial infarct. In another patient, the stoma was not reversed because of concern about the adequacy of anal sphincter function. Following closure of their ileostomies, one patient had a paralytic ileus, which resolved spontaneously and another developed small bowel obstruction at the site of the stomal closure. In this latter case, a laporatomy was performed, the anterior wall closure was resected and a side-
Figure 1: Insertion of subcutaneous stitch and passage through defect in mesentery.
RESULTS Over the study period, 40 patients (17 females and 23 males with a mean age 63 years and range 26-90 years) had a diversionary loop ileostomy carried out. Thirty two patients had the stoma formed to protect a distal anastomosis (Table 1). In six of the remaining patients the stoma was formed to palliate bowel obstruction, one to control faecal incontinence and another for 288
The Royal Colleges of Surgeons of Edinburgh and Ireland
to-side anastomosis performed. There was no incidence of an anastomotic leak or haemorrhage in patients who had their ileostomy closed. No mortality was attributed to either stoma formation or closure of the loop ileostomies. TECHNIQUE: ‘SUTURE BRIDGE’ FORMATION • A small defect is created in the small bowel mesentery of © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
Figure 2: Suture to opposite site of stoma opening and repeat (x4) of the process.
the selected small bowel loop. A 3/0 Monocril suture is then secured to the subcutaneous tissue at the margin of the stoma defect
TABLE 1. PATIENTS WHO HAD LARGE BOWEL RESECTION AND A DIVERSIONARY LOOP ILEOSTOMY FORMED TO PROTECT A DISTAL ANATOMOSIS
• With the aid of an artery forceps, the needle of the suture is passed through the small bowel mesenteric defect. This process is simple if the tip of the needle is held with the tip of the artery forceps. The suture is then secured to subcutaneous tissue of the opposite side of the stoma defect
Procedure Anterior resection
27
• The needle and suture is then passed through the small bowel mesenteric defect to the original site of the first stoma. After four such passes the stitch is tied to the free length of stitch of the first subcutaneous knot. It is important not to overtighten this final knot as this may narrow the skin defect in the abdominal wall
Proctectomy and ileo-anal pouch anastomosis
2
Sigmoid colectomy
1
• Final result after the suture bridge has been formed. The loop of bowel is now ready to be opened to form the stoma
Reversal of Hartmann’s
1
Resuture of an anastomotic leak following a right hemicolectomy
1
DISCUSSION There have been several reports debating the advantages and disadvantages of using diversionary stomas after colorectal bowel resection and anastomosis. A prospective controlled study comparing loop ileostomies with transverse colostomies recommended the former in patients who require a © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
No of patients
The Royal Colleges of Surgeons of Edinburgh and Ireland
289
Figure 3: Suture bridge completed with at least four sutures traversing mesenteric opening.
defunctioning stoma.1 Advocates of temporary faecal diversion argue that a loop ileostomy decreases the incidence and severity of sepsis following a leak from an anastomosis.6 On the other hand, a loop ileostomy may carry its own complications. For this reason, some surgeons have argued for its omission under suitable conditions.7 There are a large number of reports on the complications of construction and closure of a loop ileostomy. These complications include retraction or prolapse of the loop ileostomy, high output fluid losses, transient oedema of the stoma which may be associated with obstructive symptoms, stomal necrosis, leak from the anastomosis following closure of the ileostomy, small bowel obstruction at the site of ileostomy closure, peristomal dermatitis and local wound abscesses.1,8 Complications directly related to the technique employed to secure the stoma have rarely been mentioned. If the ileal loop is sutured to the rectus sheet to reduce the risk of stoma prolapse or retraction, there is risk of developing a peristomal fistula. The use of a rod to support the mesentery will prevent
290
The Royal Colleges of Surgeons of Edinburgh and Ireland
retraction of the stoma but, as this is usually removed after 58 days, delayed retraction of the stoma may still be possible. A rod may also cause discomfort to the patient if it is secured to the skin with sutures. The use of a rod sutured to the skin also prevents the application of a stoma bag flush with the mucocutaneous junction resulting in faecal leakage onto the abdominal wall and subsequent dermatitis. If the rod is not secured and the stoma bag plate placed beneath the rod, this may result in disruption of the mucocutanoeus junction if the stoma bag is accidentally pulled. Although Phang et al (1997), in a review of 288 patients reported no cases of retraction of the stoma in their series of loop ileostomy without a supporting rod or anchoring sutures, not all surgeons share their experience or confidence.5 We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results. Although one may postulate that the ‘suture bridge’ could erode through the bowel wall this did not occur in our series. This is unlikely if the stoma has been formed without undue tension on the ‘suture © 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
TABLE 2. PATIENTS WHO HAD A DIVERSIONARY LOOP ILEOSTOMY AS PART OF A PALLIATIVE PROCEDURE
Procedure
No of patients
Large bowel obstruction (trephine loop ileostomy formed for suspected splenic flexure obstructive lesion. Postmortem showed ischaemic/infarcted colonic disease)
1
Large bowel obstruction secondary to disseminated ovarian carcinoma
1
Large bowel obstruction due to large irresectable pelvic rectal tumour
1
Colonic Crohn’s disease
1
Faecal incontinence
1
RECRUITING NOW
Trephine loop ileostomy for inoperable colonic carcinoma
2
Trephine loop ileostomy for recurrent rectal carcinoma
1
bridge’. We suggest that this technique may also be employed in the formation of a loop colostomy. ACKNOWLEDGEMENT Thanks to Heather Pratt and Barbara Teague in the Clinical Audit Department at Furness General Hospital for their assistance in collecting and analysing the data. Copyright 2 September 2004
© 2004 Surg J R Coll Surg Edinb Irel 2: 5; 249-311
THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH
EXAMINERS FOR THE RCSEd PANEL FOR THE INTERCOLLEGIATE MEMBERSHIP OF THE ROYAL COLLEGE OF SURGEONS OF GREAT BRITAIN AND IRELAND SURGEON EXAMINERS AND EXAMINERS IN BASIC SCIENCES Applications are invited from Surgeons, Anatomists, Physiologists and Pathologists to examine in the oral, clinical and communications skills components of the Intercollegiate MRCS Examination. (Basic Sciences Examiners are not required to examine at the clinical examination) For full eligibility criteria, person specification and application form please visit our website at: http://www.rcsed.ac.uk/content/ careers/exams Or contact the Information Section on Tel: 0131 668 9222 or e-mail: [email protected]
The Royal Colleges of Surgeons of Edinburgh and Ireland
291