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Technique of Ileostomy
Technique of Ileostomy ALBERT S. LYONS, M.D., F.A.C.S.*
The patient restored to health by removal of the diseased colon and rectum will nevertheless be disabled economically, socially and psychologically unless he can take adequate care of the ileostomy. One of the reasons for the striking success of surgery in rehabilitating patients invalided by ulcerative colitis has been the gradual improvement in the technique of performing ileostomy. The evolution in the surgical construction of the ileostomy fortunately has been accompanied by corresponding advances in the design of appliances and by the development of methods of improved ileostomy management by the ileostomy associations, which are now widespread in this country and abroad. The virtually unmanageable loop ileostomy employed in the early years of the century was followed by the double-barreled stoma, and later by the single-end ileostomy. The relatively flat opening was replaced by the projecting spout, enabling the emissions to be more easily received by the appliance. The temporarily closed or intubated stoma is now left open and unmolested. The former location in the exploring incision has been changed to a separate opening, thus allowing the ileostomy to be surrounded by an intact skin surface. The exposed serosal surface, associated often with ileostomy dysfunction, is now covered by the everted wall of the ileum or by a mucosal graft. Various fixation procedures have been introduced to minimize prolapse and retraction. Further improvements will surely be developed in the future. Many men have contributed to this continual betterment. To mention some would require mentioning all. However, each center reports its own techniques but rarely those of others. The present report is a critical summary of most of the techniques now known to be in use, including my own, based on personal experience during the past 25 years with the operative treatment of ulcerative colitis and with the intimate care of patients with ileostomies performed by a variety of techniques. From the Department of Surgery of The Mount Sinai Hospital, New York, N.Y. * Associate Attending Surgeon, The Mount Sinai, Elmhurst City and Metropolitan Hospitals; Attending Surgeon, Bronx Veterans Administration and Italian Hospitals; Assistant Clinical Professor of Surgery, New York Medical College.
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One of my purposes is to provide the surgeon who performs the occasional ileostomy with a critique of the different methods, from which he can extract the details which seem to suit the exigencies of the moment. I also hope that the experienced operator will derive the stimulation that comes of matching his views with those of others. All considerations concerning the technique of colectomy, as well as preoperative and postoperative care, have been omitted. This presentation is concerned solely with the details that bear on constructing the ileostomy itself. Most often, ileostomy is the concomitant of a subtotal colectomy or a total proctocolectomy. In general, the steps of the operation have a set schedule (modified according to individual preferences): 1. 2. 3. 4. 5. 6. 7. 8.
Left-sided incision and laparotomy Transection of the ileum before or after mobilization of the colon Making the right-sided, separate, stab wound for the site of the stoma Withdrawal of the proximal ileal limb through the stab wound Fixation of mesentery and ileum to parietal peritoneum Either further mobilization of the rectum or completion of the colectomy Closure of left incision Fashioning of the stoma
When the ileostomy is performed alone, as a first stage without colectomy at the same time, it is better here, too, to bring out the ileostomy through a wound separate from the main incision. Usually, but not always, the distal limb is also exteriorized (this limb can bear a clamp temporarily). The distal limb should be a distance from the proximal limb, with adequate free skin available around the proximal stoma to permit the fitting of an appliance. CONSTRUCTING THE ILEOSTOMY
Placement of the Stoma (Fig. 1) The optimum position for the stoma differs in each person, but in everyone there should be if possible an adequate area of skin on all sides of the ileostomy for the placement and adherence of the containing appliance. A wise precaution is to fit a sham appliance and belt to the patient before the operation, allowing him to wear the apparatus for several hours or days, depending on his condition. In this way, one can learn where the stoma is best placed to permit the disk to avoid skin irregularities, scars and bony projections (such as the anterior superior spine), and to allow the belt to encircle the waist horizontally rather than to run obliquely and pull the appliance up against the undersurface of the stoma (Fig. 2). The spot finally chosen should be clearly indicated by indelible marking. Some have advocated excising the umbilicus and bringing the ileum through the opening thus created. However, patients often find that this causes a more prominent bulge by the appliance and its location in or near
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the laparotomy incision scar can pose problems in the management of an appliance. Generally speaking, if there is adequate clearance around the stoma to avoid impingement by the disk on the anterior iliac spine and the stoma is not too low for the fold in the waist, an appliance can be well fitted, even if the umbilicus, the main incision scar, or other irregularities are too close, for various adjustments and modifications are possible to makeup for these problems. INTERFERING CONTOURS TO BE AVOIDED
Waist Fold and Iliac Crest Anterior Superior Spine Scars a depressions
Figure 1. Placement of the ileostomy stoma. Structures to be considered: anterior superior spine; fold of the waist; umbilicus; scars and irregularities; main incision; costa margin.
Figure 2. Ileostomy stoma. Shape is round; length is adequate; anterior superior spine is well avoided. But, stoma is too low for waist fold so that belt will pull appliance up and against stoma.
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Stab Wound An ileostomy protruding through an incision scar is usually less manageable than one emerging through a stab wound a distance from the incision. Even if the incision does not break down, the later scarring can cause difficulties in adherence because of its thickness or irregularity. The excision of an ellipse or a wafer of skin of a size to accommodate the diameter of the ileal limb will usually result eventually in a widely patent stoma without subsequent stricture. If one retracts the skin opening too strongly while the deeper layers are being incised, actual tearing can occur, especially in patients who are in poor general nutrition and who have been receiving large doses of the corticosteroids. If the excised skin is a longitudinal ellipse with the long diameter larger than the horizontal diameter, the ultimate shape of the stoma is apt to be round, whereas if the skin opening is at first circular, the stomal measurement eventually becomes wider in the horizontal diameter, as the skin tensions tend to pull laterally and medially. The immediate skin opening should not be much larger than the diameter of the protruding ileal limb lest, in the process of everting the mucosa later, the everted portion may have to be pulled from apposition to the ileal wall. On the other hand, too small a skin opening may itself lead to future encircling stricture. An effective policy is to excise an ellipse of skin whose vertical diameter is what one estimates to be the total diameter of the ileum. If this measurement proves too small when the stoma is being fashioned by an eversion technique, the stomal opening can be tailored further to fit. I should mention that a few claim equally good results with employing a single slit in the skin instead of excising an ellipse or wafer. This has not been my experience.
Abdominal Wall Opening In general, the opening in the abdominal wall, from skin to peritoneal cavity, should be an inverted truncated cone with the base at the skin. Thus, the skin opening is largest and the peritoneal opening is smallest (Fig. 3). To achieve this, the fascia over the rectus muscle may be incised in a cruciate manner or excised in an ellipse as with the skin. I usually favor the cross incision as it seems easier to make and control. I am not sure how important the size of the fascial opening is, as long as it is not too large. It is possible that too large an opening may be a factor in herniation::).nd prolapse, but it is uncommon to find as a cause of stenosis a
~~~rF~~§~~~~~_ Skin FQsciQ -Muscle ----'1--_ _ _ _- Peritoneum
Figure 3. Diagram of abdominal wall tunnel.
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stricture of the ileal limb at the fascial level. If the skin opening is adequate and the fascial opening is a little smaller, I believe that the requirements are met. If one finds, after the skin opening is made, that the fascia presenting is the external oblique, it usually means that the stoma is going to be placed too far laterally. However, in a few patients in whom the rectus muscle is relatively narrow, the fascial opening may actually have to be in the external oblique instead of the anterior rectus sheath. The fibers of the rectus muscle are simply separated and held apart with blunt retractors. The posterior rectus sheath in this area is transversalis fascia and the peritoneum. Sometimes this combined layer is quite thick and firm. When one makes a small incisional opening here, the edges often feel rigid and sharp against the finger inserted into the peritoneal cavity. However, a late stenosis due to stricture at this level is virtually unknown, so that the opening is best made only just large enough to admit the ileal limb and its mesenteric edge. On the other hand, prolapse and herniation may sometimes be started by a peritoneal opening too large. An ingenious cutting device has been described to ream out the entire abdominal wall to create a passage through which the ileum can be brought. I have had no experience with this method. It appears to me, however, that circular openings in the peritoneum, muscle and fascia equal to an adequate skin opening are apt to be too large for the ileal limb and prone to prolapse, intussusception and herniation.
Transection of the Deum It is common sense to transect the ileum well above all visible disease. If the ileum is entirely normal down to the ileocecal valve, the transection is then possible in the terminal 2 to 4 inches. Much has been made of the need to preserve these last few inches in order to obtain good waterabsorbing function, leading to semisolid evacuations. However, I have not been able to confirm this correlation. Some patients with 10 inches of terminal ileum removed have had semisolid and even partially formed ileal emissions; others with the stomas in the terminal 2 to 4 inches have had continual liquid contents. On the other hand, evidence is available that the B12 vitamins (and perhaps other substances) have their greatest absorption in the terminal ileum. I would therefore agree that the transection should be as low down as is practicable, commensurate with using normal-appearing ileum, bring~ ing up the ileal limb without tension, and maintaining adequate blood supply to the ileal end. I would not necessarily strain for the last 4 inches. However, when one has to perform an ileostomy much over a foot above the ileocecal valve, one finds a percentage of people with large liquid evacuations which sometimes can reach proportions difficult to manage and depleting in effect. In preparing for resection of the ileum, if one severs the deeper vessels
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Figure 4. mesentery.
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Transection of the ileal
in the mesentery more distally than the planned site of transection of the bowel and then continues to clamp, cut and ligate the mesentery obliquely back toward the intestinal wall, the blood supply to the very end of the ileostomy is apt to be more secure (Fig. 4). One can then later straighten completely the end of the ileum by cutting with impunity the very terminal mesenteric vessels, and free the stomal portion from the "chordee" caused by the mesenteric attachment (Fig. 5). One can thus virtually denude the last inch of ileum without danger. When the mesenteric vessel branches are clamped and ligated, if a longer rather than a shorter stump of vessel is left beyond the vessel arcade and the ligature, there is less likelihood of puncturing a blood vessel with a suture needle when the edge of the mesentery is later fixed to the parietal peritoneum. The transection of the ileum may be made between De Martel, Payr, Kocher or other clamps. Some tie off the distal limb and leave a clamp on the proximal until after it is drawn through the stab wound. I prefer to close over the ends of both limbs with a running Parker-Kerr stitch, leaving the suture ends long. Mter complete mobilization of the colon, these long ends are used to draw the proximal limb out through the constructed stab wound. When the stoma is to be fashioned, the entire closed and crushed rim is excised.
Antiprolapse Sutures A variety of suture techniques have been advanced to prevent both prolapse and retraction. The cut edge of the mesentery is fixed to the anterior parietal peritoneum by at least several sutures. If possible, the cut edge of the mesentery is best faced either caudad or laterad. When the root of the mesentery takes a course in an obliquely cephalad direction, facing the cut edge caudad causes the mesentery to twist too much. A
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Figure 5. ileal end.
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Straightening the
cephalolateral direction may then be the only position possible. Fine silk sutures are probably more likely to maintain the fixation longer and are usually easier to manipulate. Care must be taken to avoid puncturing the vessels of the mesentery when the fixation sutures are passed. Sometimes, instead of passing the needle through the mesenteric edge, one can pick up separately the mesenteric leaves on each side of the vessels. Whenever feasible, without causing tension, the fixation sutures are continued, to close off the lumbar space lateral to the ileostomy. This maneuver makes a firm fixation, obliterates a potential opening where intestinal loops can get caught, and buries the raw cut edge of the mesentery. However, the lateral space must be completely closed for more harm than good is accomplished by leaving a small space between the remaining cut edge of mesentery and the right posterolateral parietal peritoneum. If one has to strain to effect this complete closure, it is better to leave the lateral space widely open and to fix the mesenteric edge to the parietal peritoneum for only an inch or two. Attention should be paid to the anterior parietal peritoneal opening through which the ileal limb has been brought. If this opening is too large, one can see that the bowel wall and mesentery do not fill it. This can be made smaller in various ways: by one or more peritoneal sutures in the upper angle; by suturing the peritoneal edge to the side of the mesentery (taking care to avoid puncturing a vessel) ; by sutures between the edge of the peritoneal opening and the bowel wall. Some surgeons use this layer of sutures routinely, surrounding the entire circumf~rence of the ileum and mesentery with sutures to the rim of the parietal peritoneal opening. I have used only enough stitching to bring the peritoneal edge in contact
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l;=-----Skin Fascia Muscle
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Figure 6. Fixation sutures. A, Edge of mesentery to anterior parietal peritoneum. B, Edge of peritoneal opening to wall of ileum. C, Edge of fascia to mesenteric edge.
with the bowel and mesentery (usually only two or three are needed). I have the impression that many sutures here can lead to edema. Of course, the needle must penetrate only into the seromuscular layer. Sutures entering the mucosa can lead to fistula. The fear of this has led many surgeons to eschew any sutures into the bowel wall. Some surgeons also suture the side wall of the ileum to the fascia (this is done later when the stoma is being fashioned), to obliterate further any disproportion between the emerging ileal limb and the abdominal wall opening. I have not found this necessary. If I desire to bring the fascial layer in closer proximity to the ileum, I prefer to use a suture between the mesenteric edge and the cut edge of the fascia (Fig. 6). The further employment of an "angulation" stitch attempts to change the angle of approach of the ileum toward the abdominal wall from a straight perpendicular line to a more acute angle, so that peristaltic activity will not tend to intussuscept or prolapse the ileum through the abdominal wall channel. This angulation is accomplished by suturing either the side of the mesentery or the ileal limb to the surface of the anterior parietal peritoneum. I have avoided this procedure because it can lead easily to obstructing angulation of the ileum. In one patient, intermittent partial obstructions were relieved by "de-angulating" the ileal limb. Goligher has described a method of ileostomy that brings the ileum retroperitoneally behind and around the posterior and lateral parietal peritoneum. When it reaches the anterior abdominal wall, the limb is then: brought through the muscle, fascia and skin as in all other ileostomies. This procedure is devised primarily to prevent prolapse, retraction, and internal twists of loops of bowel around the exteriorized ileal limb. I have had no experience with the operation. I cannot help but wonder, however, whether obstructions will be caused at the point where the ileum dips behind the peritoneum and where it turns to emerge anteriorly. Another means has been suggested of preventing prolapse by plicating
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the terminal foot or two of ileum in the manner advised by Noble. This method has brought its own complications and is no longer advocated by its authors.
Mucosal Eversion One of the important advances in the construction of an ileal stoma has been the concept of "maturing" the exteriorized limb by covering the serosal wall immediately with the mucosal lining. This may be accomplished either by the mucosal eversion graft technique of Crile and Turnbull or by the full-thickness eversion described by Brooke. The mucosal eversion method requires the excision of a seromuscular cylinder just proximal to the end of the ileum, so that a layer of mucosa can be turned back to cover completely the serosal surface of the projecting limb. The technique demands a little practice to enter, without annoying bleeding, the proper plane between the mucosa and the seromuscular layer, but the end result is a well shaped, projecting, relatively small ileostomy. Sometirr.es, the color of the mucosa of the denuded portion becomes so blue that one fears for its viability, but after its application to the serosal surface the color gradually returns. Actually the procedure is a sort of mucosal graft, rather than an eversion technique. The full-thickness eversion is simpler. The entire end of the bowel is turned inside out and sutured to the surrounding skin edges previously made by excising an ellipse of skin. The eversion maneuvers can be assisted by introducing an instrument into the open end of the bowel (e.g., Babcock, Allis, Ford or delta clamp) to grasp the mucosa and deeper layers. Another method is to push from the outside with a peanut sponge as the ileal edge is everted. Some surgeons proceed immediately to suture the mucosa to skin. Others prefer first to fix the turned-back edge to the serosal surface of the ileum in order to maintain the everted position. I favor the latter method because occasionally the ileostomy later slides in and out, thus losing the eversion. In addition, by fixing the everted wall, the permanent length of the spout is clearly detennined. For this fixation, three fine sutures to the ileal serosal surface are ample. Of course, the main fixation suture, as advocated by Brooke, is quite useful. This suture is passed from ileal edge to mesenteric stump, to skin edge and back to ileal end, thus bringing together skin, mesentery and end of bowel. The ileal rim is next sutured to the skin edges by interrupted fine sutures. Sometimes the sutures through the skin lead later to a scalloping effect, which can be annoying in obtaining a snug fit of appliances. If the skin side of the suture is subcuticular rather than through the epithelium, the resulting margin is smooth and straight. These sutures are placed in sufficient number to keep the ileal edge from unraveling away from the skin edge. Usually, eight sutures or less are quite adequate (to cover the eight main points of the compass).
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All stomas should be covered by mucosa by any of the techniques. Leaving the ileostomy closed by clamp or suture for later opening has no advantage and often leads to stomal dysfunction and stenosis. The same can be said of immediate intubation.
Length of Stoma Views vary on the optimum length of the stoma. In the United States, most of the members of the ileostomy clubs favor a length of Y2 to % inch. In England, a 1- to 2-inch length is preferred. Some surgeons seem to desire an even longer projection. The chief advantage of a longer spout is that it prevents the surrounding skin at the base of the stoma from being flooded with ileal contents. Also, a non-cement appliance is possible for those who cannot or do not wish to use cement. The disadvantage is that pressure effects from the appliance bag on the side of the spout can sometimes be annoying. However, no matter what the preferred length is, a flat stoma (flush with the skin) is held to be thoroughly undesirable by every group interested in evaluating this problem. In order to obtain the desired projection, enough length of ileum must be drawn out through the stab wound while the colectomy wound is still open, before the fixation sutures have been placed in the mesentery. The exteriorized limb should be approximately twice as long as the desired length because the eversion procedures used to "mature" the stoma make the ultimate spout length half as long as the ileal limb measures when it is first exteriorized. Thus for a I-inch long stoma, 2 full inches of ileum should be out of the stab wound under no pull, before the eversion or mucosal turnback is begun. Although the occasional early postoperative edema of the ileostomy later subsides and although the diameter of the stoma may gradually shrink to a smaller size, the length of the projection remains the sameunless of course mechanical prolapse or retraction occurs. Thus, if at the conclusion of the operation the surgeon finds the spout too long or too short for his purposes, he cannot rely on its later gradual withdrawal or projection (as often does happen when a colostomy is brought out without "maturing" and is left to project well beyond the skin level). The ileostomy must be constructed to the desired length at the time of operation. Skin grafted ileostomies are no longer useful or wise. They had the advantage originally of ensuring a projecting spout suitable for the then available but now archaic appliances. Before the sutures are placed to approximate the everted mucosa to the skin edges, the direction of the spout should be assessed. If possible, the ileostomy should point either straight forward or down (caudad) for stomas of an inch or less in length. The stomas pointing upward or to the side are more difficult to manage. For ileostomies longer than an inch, the direction should certainly be downward only. To correct any eccentric course, the surgeon has only to excise a sufficient rim of the caudal everted
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edge of ileum, so that when this is sewn to the skin, the stoma will be drawn to point straight downward. Different surgeons choose different suture material with equally good results for the various maneuvers in constructing an ileostomy. I do not believe that either the nature or the size of the sutures is vital to success. In general, I prefer the finer gauges throughout: silk for mesenteric and bowel fixations; plain catgut for ligation of vessels; chromic catgut for suturing ileal edge to the skin.
Skin Protection As soon as the operation is completed and the dressings of the main wound have been placed, an appliance should be cemented to the skin around the stoma. Any of the plastic, transparent, adhesive pouches are suitable. The proper-sized opening is easier to fashion if one measures the newly made ileostomy with a disposable cardboard card sold by most of the appliance manufacturers. Whatever the method employed, the pouch adheres best if the hole is slightly larger (by a VIe-inch rim) than the diameter of the stoma. I prefer to use cement in addition to the adhesive surface already on the pouch, applying the cement to both the skin and the pouch disk, waiting for it to dry, and then with the hand inside the pouch placing the hole accurately over the stoma. If this first appliance hangs obliquely to the side rather than straight down, it can be more easily emptied in the early days while the patient is more often in bed than ambulatory.
DISCUSSION
Constructing the ileostomy usually occurs near the end of the operation. Sometimes the procedure has been arduous or the patient's condition has been unstable, so that there may be pressure on the surgeon to eliminate or to gloss over some of the steps in fashioning the ileostomy, in his zeal to complete the operation and terminate the anesthesia. However, the surgeon will do well to keep in mind that to the patient the ileostomy-not the colectomy-is the operation. Upon the patient's adjustment to the new structure depends much of his future social and economic activity. Therefore, a carefully performed ileostomy is the first essential of the triad in proper ileostomy management: a well constructed stoma; psychologic adjustment; an adequate appliance. Although a properly formed stoma is highly important, it must not be assumed that a surgically correct result means automatically a well managed ileostomy. The person with a perfectly constructed stoma may nevertheless be subject to skin macerations, to difficulties in gaining secure adherence of an appliance, and to inability to accept the ileostomy. Conversely, even a poorly formed stoma can sometimes be managed well by
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an enthusiastic ileostomist, together with a patient surgeon and the ministrations of another ileostomist.
Ileostomy Clubs One of the most important forces in extending the usefulness of colectomy and ileostomy in rehabilitating patients with ulcerative colitis has been the "ileostomy club principle." Extraordinary stimulus to psychologic adjustment, priceless information, and immeasurable aids in managing appliances have been afforded patients, doctors and nursing personnel by the ileostomy clubs. The first such organization was established in New York almost 15 years ago, * but there are now over 50 in the United States and over 15 in foreign countries. Most of these organizations are also affiliated with each other through a United Ostomy Association.t Every surgeon who has performed an ileostomy or has a patient with ileostomy in his care will help his patient remarkably by referring him to the nearest club. Before operation, a doubtful, fearful prospect is often transformed into a cheerful, eager anticipant by a member of the visiting committee of an ileostomy society. After operation, depression and revulsion are sometimes dramatically altered to hope and acceptance. Indeed, the indications for surgery, the technique of ileostomy construction, and the methods of stomal care have all been definitively affected by the activities of the ileostomy associations. It is the members of these organizations who in the end actually determine the value of any particular technique of ileostomy.
REFERENCES 1. Bacon, H. E.: Ulcerative Colitis. Philadelphia, J. B. Lippincott Co., 1958. 2. Bargen, J. A., Brown, P. W. and Rankin, J. W.: Indications for and technique of ileostomy in chronic ulcerative colitis. Surg. Gynec. & Obst. 55: 196, 1932. 3. Brooke, B. N.: Management of ileostomy including its complications. Lancet 2: 102, 1952. 4. Brown, J. Y.: The Lane operation. Tr. South. Surg. & Gynec. A. 24: 137,1911. 5. Cattell, R. B.: The surgical treatment of ulcerative colitis. Lahey Clinic Bull. 1: 2, 1938. 6. Coffey, R. C.: The two stage operation in abdominal surgery. Tr. West. Surg. A. 26: 159, 1916. 7. Crile, G., Jr. and Turnbull, R. B.: The mechanism and prevention of ileostomy dysfunction. Ann. Surg. 140: 459, 1954. 8. Dennis, C.: Ileostomy and colectomy in chronic ulcerative colitis. Surgery 18: 435, 1945. 9. Flannery, M. G.: Creation, care and complications of ileostomy. Ann. Surg. 151: 970, 1960. 10. Fleming, J. P. and Lin-Min Ou Yang: The ileostomized patient. Dis. Colon & Rectum 7: 147 (March-April) 1964.
* The first reported ileostomy club was called "QT" (after the surgical wards at The Mount Sinai Hospital). t The United Ostomy Association publishes a quarterly bulletin which includes a listing of all the clubs.
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11. Garlock, J. H.: Surgical treatment of intractable ulcerative colitis. Ann. Surg. 113: 1, 1941. 12. Garlock, J. H. and Kirschner, P. A.: Prevention of ileostomy dysfunction. Surgery 40: 678, 1956. 13. Goligher, J. C.: Extraperitoneal colostomy or ileostomy. Brit. J. Surg. 46: 97.1958. 14. Goligher, J. C.: Ileostomy reconstruction. Brit. J. Surg. 50: 259, 1962. 15. Jones, T. E.: The surgical treatment of ulcerative colitis. J.A.M.A. 111: 2076,1938. 16. Logan, A. H.: Chronic ulcerative colitis, a review of 117 cases. Northwest Med. 18: 1, 1919. 17. Lenneberg, E.: QT Boston: An ileostomy group. New England J. Med. 251: 1008, 1954. 18. Lyons, A. S.: An ileostomy club. J.A.M.A. 150: 812,1952. 19. Lyons, A. S., Robinson, B., Schreiber, G. and Turell, R.: Rehabilitation of patients with ileostomy or colostomy. Mod. Med. 22: 115 (Feb. 15) 1954. 20. Lyons, A. S.: Ileostomy-management and complications. S. CLIN. NORTH AMERICA 35: 1411 (Oct.) 1955. 21. Lyons, A. S. and Turell, R.: Operative correction of intestinal stomal difficulties. Am. J. Surg. 101: 55, 1961. 22. Rankin, F. W.: Total colectomy-its indication and technic. Tr. Am. S. A. 49: 263, 1931. 23. Ravitch, M. M. and Mandelbaum, I.: Evolution of the surgical approach to the therapy of idiopathic chronic ulcerative colitis. S. CLIN. NORTH AMERICA 35: 1401 (Oct.) 1955. 24. Stone, H. B.: The surgical treatment of chronic ulcerative colitis. Ann. Surg. 77: 293, 1923. 25. Valiente, M. A.: Ileostomy; refinements in technique. J. Internat. ColI. Surgeons 26: 15, 1956. 26. Warren, R. and McKittrick, L. S.: Ileostomy for ulcerative colitis: Technique, complications, and management. Surg. Gynec. & Obst. 93: 555, 1951. 7 East 80th Street New York, N. Y. 10021
The patient restored to health by removal of the diseased colon and rectum will nevertheless be disabled economically, socially and psychologically unless he can take adequate care of the ileostomy. One of the reasons for the striking success of surgery in rehabilitating patients invalided by ulcerative colitis has been the gradual improvement in the technique of performing ileostomy. The evolution in the surgical construction of the ileostomy fortunately has been accompanied by corresponding advances in the design of appliances and by the development of methods of improved ileostomy management by the ileostomy associations, which are now widespread in this country and abroad. The virtually unmanageable loop ileostomy employed in the early years of the century was followed by the double-barreled stoma, and later by the single-end ileostomy. The relatively flat opening was replaced by the projecting spout, enabling the emissions to be more easily received by the appliance. The temporarily closed or intubated stoma is now left open and unmolested. The former location in the exploring incision has been changed to a separate opening, thus allowing the ileostomy to be surrounded by an intact skin surface. The exposed serosal surface, associated often with ileostomy dysfunction, is now covered by the everted wall of the ileum or by a mucosal graft. Various fixation procedures have been introduced to minimize prolapse and retraction. Further improvements will surely be developed in the future. Many men have contributed to this continual betterment. To mention some would require mentioning all. However, each center reports its own techniques but rarely those of others. The present report is a critical summary of most of the techniques now known to be in use, including my own, based on personal experience during the past 25 years with the operative treatment of ulcerative colitis and with the intimate care of patients with ileostomies performed by a variety of techniques. From the Department of Surgery of The Mount Sinai Hospital, New York, N.Y. * Associate Attending Surgeon, The Mount Sinai, Elmhurst City and Metropolitan Hospitals; Attending Surgeon, Bronx Veterans Administration and Italian Hospitals; Assistant Clinical Professor of Surgery, New York Medical College.
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One of my purposes is to provide the surgeon who performs the occasional ileostomy with a critique of the different methods, from which he can extract the details which seem to suit the exigencies of the moment. I also hope that the experienced operator will derive the stimulation that comes of matching his views with those of others. All considerations concerning the technique of colectomy, as well as preoperative and postoperative care, have been omitted. This presentation is concerned solely with the details that bear on constructing the ileostomy itself. Most often, ileostomy is the concomitant of a subtotal colectomy or a total proctocolectomy. In general, the steps of the operation have a set schedule (modified according to individual preferences): 1. 2. 3. 4. 5. 6. 7. 8.
Left-sided incision and laparotomy Transection of the ileum before or after mobilization of the colon Making the right-sided, separate, stab wound for the site of the stoma Withdrawal of the proximal ileal limb through the stab wound Fixation of mesentery and ileum to parietal peritoneum Either further mobilization of the rectum or completion of the colectomy Closure of left incision Fashioning of the stoma
When the ileostomy is performed alone, as a first stage without colectomy at the same time, it is better here, too, to bring out the ileostomy through a wound separate from the main incision. Usually, but not always, the distal limb is also exteriorized (this limb can bear a clamp temporarily). The distal limb should be a distance from the proximal limb, with adequate free skin available around the proximal stoma to permit the fitting of an appliance. CONSTRUCTING THE ILEOSTOMY
Placement of the Stoma (Fig. 1) The optimum position for the stoma differs in each person, but in everyone there should be if possible an adequate area of skin on all sides of the ileostomy for the placement and adherence of the containing appliance. A wise precaution is to fit a sham appliance and belt to the patient before the operation, allowing him to wear the apparatus for several hours or days, depending on his condition. In this way, one can learn where the stoma is best placed to permit the disk to avoid skin irregularities, scars and bony projections (such as the anterior superior spine), and to allow the belt to encircle the waist horizontally rather than to run obliquely and pull the appliance up against the undersurface of the stoma (Fig. 2). The spot finally chosen should be clearly indicated by indelible marking. Some have advocated excising the umbilicus and bringing the ileum through the opening thus created. However, patients often find that this causes a more prominent bulge by the appliance and its location in or near
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the laparotomy incision scar can pose problems in the management of an appliance. Generally speaking, if there is adequate clearance around the stoma to avoid impingement by the disk on the anterior iliac spine and the stoma is not too low for the fold in the waist, an appliance can be well fitted, even if the umbilicus, the main incision scar, or other irregularities are too close, for various adjustments and modifications are possible to makeup for these problems. INTERFERING CONTOURS TO BE AVOIDED
Waist Fold and Iliac Crest Anterior Superior Spine Scars a depressions
Figure 1. Placement of the ileostomy stoma. Structures to be considered: anterior superior spine; fold of the waist; umbilicus; scars and irregularities; main incision; costa margin.
Figure 2. Ileostomy stoma. Shape is round; length is adequate; anterior superior spine is well avoided. But, stoma is too low for waist fold so that belt will pull appliance up and against stoma.
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Stab Wound An ileostomy protruding through an incision scar is usually less manageable than one emerging through a stab wound a distance from the incision. Even if the incision does not break down, the later scarring can cause difficulties in adherence because of its thickness or irregularity. The excision of an ellipse or a wafer of skin of a size to accommodate the diameter of the ileal limb will usually result eventually in a widely patent stoma without subsequent stricture. If one retracts the skin opening too strongly while the deeper layers are being incised, actual tearing can occur, especially in patients who are in poor general nutrition and who have been receiving large doses of the corticosteroids. If the excised skin is a longitudinal ellipse with the long diameter larger than the horizontal diameter, the ultimate shape of the stoma is apt to be round, whereas if the skin opening is at first circular, the stomal measurement eventually becomes wider in the horizontal diameter, as the skin tensions tend to pull laterally and medially. The immediate skin opening should not be much larger than the diameter of the protruding ileal limb lest, in the process of everting the mucosa later, the everted portion may have to be pulled from apposition to the ileal wall. On the other hand, too small a skin opening may itself lead to future encircling stricture. An effective policy is to excise an ellipse of skin whose vertical diameter is what one estimates to be the total diameter of the ileum. If this measurement proves too small when the stoma is being fashioned by an eversion technique, the stomal opening can be tailored further to fit. I should mention that a few claim equally good results with employing a single slit in the skin instead of excising an ellipse or wafer. This has not been my experience.
Abdominal Wall Opening In general, the opening in the abdominal wall, from skin to peritoneal cavity, should be an inverted truncated cone with the base at the skin. Thus, the skin opening is largest and the peritoneal opening is smallest (Fig. 3). To achieve this, the fascia over the rectus muscle may be incised in a cruciate manner or excised in an ellipse as with the skin. I usually favor the cross incision as it seems easier to make and control. I am not sure how important the size of the fascial opening is, as long as it is not too large. It is possible that too large an opening may be a factor in herniation::).nd prolapse, but it is uncommon to find as a cause of stenosis a
~~~rF~~§~~~~~_ Skin FQsciQ -Muscle ----'1--_ _ _ _- Peritoneum
Figure 3. Diagram of abdominal wall tunnel.
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stricture of the ileal limb at the fascial level. If the skin opening is adequate and the fascial opening is a little smaller, I believe that the requirements are met. If one finds, after the skin opening is made, that the fascia presenting is the external oblique, it usually means that the stoma is going to be placed too far laterally. However, in a few patients in whom the rectus muscle is relatively narrow, the fascial opening may actually have to be in the external oblique instead of the anterior rectus sheath. The fibers of the rectus muscle are simply separated and held apart with blunt retractors. The posterior rectus sheath in this area is transversalis fascia and the peritoneum. Sometimes this combined layer is quite thick and firm. When one makes a small incisional opening here, the edges often feel rigid and sharp against the finger inserted into the peritoneal cavity. However, a late stenosis due to stricture at this level is virtually unknown, so that the opening is best made only just large enough to admit the ileal limb and its mesenteric edge. On the other hand, prolapse and herniation may sometimes be started by a peritoneal opening too large. An ingenious cutting device has been described to ream out the entire abdominal wall to create a passage through which the ileum can be brought. I have had no experience with this method. It appears to me, however, that circular openings in the peritoneum, muscle and fascia equal to an adequate skin opening are apt to be too large for the ileal limb and prone to prolapse, intussusception and herniation.
Transection of the Deum It is common sense to transect the ileum well above all visible disease. If the ileum is entirely normal down to the ileocecal valve, the transection is then possible in the terminal 2 to 4 inches. Much has been made of the need to preserve these last few inches in order to obtain good waterabsorbing function, leading to semisolid evacuations. However, I have not been able to confirm this correlation. Some patients with 10 inches of terminal ileum removed have had semisolid and even partially formed ileal emissions; others with the stomas in the terminal 2 to 4 inches have had continual liquid contents. On the other hand, evidence is available that the B12 vitamins (and perhaps other substances) have their greatest absorption in the terminal ileum. I would therefore agree that the transection should be as low down as is practicable, commensurate with using normal-appearing ileum, bring~ ing up the ileal limb without tension, and maintaining adequate blood supply to the ileal end. I would not necessarily strain for the last 4 inches. However, when one has to perform an ileostomy much over a foot above the ileocecal valve, one finds a percentage of people with large liquid evacuations which sometimes can reach proportions difficult to manage and depleting in effect. In preparing for resection of the ileum, if one severs the deeper vessels
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Figure 4. mesentery.
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Transection of the ileal
in the mesentery more distally than the planned site of transection of the bowel and then continues to clamp, cut and ligate the mesentery obliquely back toward the intestinal wall, the blood supply to the very end of the ileostomy is apt to be more secure (Fig. 4). One can then later straighten completely the end of the ileum by cutting with impunity the very terminal mesenteric vessels, and free the stomal portion from the "chordee" caused by the mesenteric attachment (Fig. 5). One can thus virtually denude the last inch of ileum without danger. When the mesenteric vessel branches are clamped and ligated, if a longer rather than a shorter stump of vessel is left beyond the vessel arcade and the ligature, there is less likelihood of puncturing a blood vessel with a suture needle when the edge of the mesentery is later fixed to the parietal peritoneum. The transection of the ileum may be made between De Martel, Payr, Kocher or other clamps. Some tie off the distal limb and leave a clamp on the proximal until after it is drawn through the stab wound. I prefer to close over the ends of both limbs with a running Parker-Kerr stitch, leaving the suture ends long. Mter complete mobilization of the colon, these long ends are used to draw the proximal limb out through the constructed stab wound. When the stoma is to be fashioned, the entire closed and crushed rim is excised.
Antiprolapse Sutures A variety of suture techniques have been advanced to prevent both prolapse and retraction. The cut edge of the mesentery is fixed to the anterior parietal peritoneum by at least several sutures. If possible, the cut edge of the mesentery is best faced either caudad or laterad. When the root of the mesentery takes a course in an obliquely cephalad direction, facing the cut edge caudad causes the mesentery to twist too much. A
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Figure 5. ileal end.
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Straightening the
cephalolateral direction may then be the only position possible. Fine silk sutures are probably more likely to maintain the fixation longer and are usually easier to manipulate. Care must be taken to avoid puncturing the vessels of the mesentery when the fixation sutures are passed. Sometimes, instead of passing the needle through the mesenteric edge, one can pick up separately the mesenteric leaves on each side of the vessels. Whenever feasible, without causing tension, the fixation sutures are continued, to close off the lumbar space lateral to the ileostomy. This maneuver makes a firm fixation, obliterates a potential opening where intestinal loops can get caught, and buries the raw cut edge of the mesentery. However, the lateral space must be completely closed for more harm than good is accomplished by leaving a small space between the remaining cut edge of mesentery and the right posterolateral parietal peritoneum. If one has to strain to effect this complete closure, it is better to leave the lateral space widely open and to fix the mesenteric edge to the parietal peritoneum for only an inch or two. Attention should be paid to the anterior parietal peritoneal opening through which the ileal limb has been brought. If this opening is too large, one can see that the bowel wall and mesentery do not fill it. This can be made smaller in various ways: by one or more peritoneal sutures in the upper angle; by suturing the peritoneal edge to the side of the mesentery (taking care to avoid puncturing a vessel) ; by sutures between the edge of the peritoneal opening and the bowel wall. Some surgeons use this layer of sutures routinely, surrounding the entire circumf~rence of the ileum and mesentery with sutures to the rim of the parietal peritoneal opening. I have used only enough stitching to bring the peritoneal edge in contact
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l;=-----Skin Fascia Muscle
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Figure 6. Fixation sutures. A, Edge of mesentery to anterior parietal peritoneum. B, Edge of peritoneal opening to wall of ileum. C, Edge of fascia to mesenteric edge.
with the bowel and mesentery (usually only two or three are needed). I have the impression that many sutures here can lead to edema. Of course, the needle must penetrate only into the seromuscular layer. Sutures entering the mucosa can lead to fistula. The fear of this has led many surgeons to eschew any sutures into the bowel wall. Some surgeons also suture the side wall of the ileum to the fascia (this is done later when the stoma is being fashioned), to obliterate further any disproportion between the emerging ileal limb and the abdominal wall opening. I have not found this necessary. If I desire to bring the fascial layer in closer proximity to the ileum, I prefer to use a suture between the mesenteric edge and the cut edge of the fascia (Fig. 6). The further employment of an "angulation" stitch attempts to change the angle of approach of the ileum toward the abdominal wall from a straight perpendicular line to a more acute angle, so that peristaltic activity will not tend to intussuscept or prolapse the ileum through the abdominal wall channel. This angulation is accomplished by suturing either the side of the mesentery or the ileal limb to the surface of the anterior parietal peritoneum. I have avoided this procedure because it can lead easily to obstructing angulation of the ileum. In one patient, intermittent partial obstructions were relieved by "de-angulating" the ileal limb. Goligher has described a method of ileostomy that brings the ileum retroperitoneally behind and around the posterior and lateral parietal peritoneum. When it reaches the anterior abdominal wall, the limb is then: brought through the muscle, fascia and skin as in all other ileostomies. This procedure is devised primarily to prevent prolapse, retraction, and internal twists of loops of bowel around the exteriorized ileal limb. I have had no experience with the operation. I cannot help but wonder, however, whether obstructions will be caused at the point where the ileum dips behind the peritoneum and where it turns to emerge anteriorly. Another means has been suggested of preventing prolapse by plicating
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the terminal foot or two of ileum in the manner advised by Noble. This method has brought its own complications and is no longer advocated by its authors.
Mucosal Eversion One of the important advances in the construction of an ileal stoma has been the concept of "maturing" the exteriorized limb by covering the serosal wall immediately with the mucosal lining. This may be accomplished either by the mucosal eversion graft technique of Crile and Turnbull or by the full-thickness eversion described by Brooke. The mucosal eversion method requires the excision of a seromuscular cylinder just proximal to the end of the ileum, so that a layer of mucosa can be turned back to cover completely the serosal surface of the projecting limb. The technique demands a little practice to enter, without annoying bleeding, the proper plane between the mucosa and the seromuscular layer, but the end result is a well shaped, projecting, relatively small ileostomy. Sometirr.es, the color of the mucosa of the denuded portion becomes so blue that one fears for its viability, but after its application to the serosal surface the color gradually returns. Actually the procedure is a sort of mucosal graft, rather than an eversion technique. The full-thickness eversion is simpler. The entire end of the bowel is turned inside out and sutured to the surrounding skin edges previously made by excising an ellipse of skin. The eversion maneuvers can be assisted by introducing an instrument into the open end of the bowel (e.g., Babcock, Allis, Ford or delta clamp) to grasp the mucosa and deeper layers. Another method is to push from the outside with a peanut sponge as the ileal edge is everted. Some surgeons proceed immediately to suture the mucosa to skin. Others prefer first to fix the turned-back edge to the serosal surface of the ileum in order to maintain the everted position. I favor the latter method because occasionally the ileostomy later slides in and out, thus losing the eversion. In addition, by fixing the everted wall, the permanent length of the spout is clearly detennined. For this fixation, three fine sutures to the ileal serosal surface are ample. Of course, the main fixation suture, as advocated by Brooke, is quite useful. This suture is passed from ileal edge to mesenteric stump, to skin edge and back to ileal end, thus bringing together skin, mesentery and end of bowel. The ileal rim is next sutured to the skin edges by interrupted fine sutures. Sometimes the sutures through the skin lead later to a scalloping effect, which can be annoying in obtaining a snug fit of appliances. If the skin side of the suture is subcuticular rather than through the epithelium, the resulting margin is smooth and straight. These sutures are placed in sufficient number to keep the ileal edge from unraveling away from the skin edge. Usually, eight sutures or less are quite adequate (to cover the eight main points of the compass).
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All stomas should be covered by mucosa by any of the techniques. Leaving the ileostomy closed by clamp or suture for later opening has no advantage and often leads to stomal dysfunction and stenosis. The same can be said of immediate intubation.
Length of Stoma Views vary on the optimum length of the stoma. In the United States, most of the members of the ileostomy clubs favor a length of Y2 to % inch. In England, a 1- to 2-inch length is preferred. Some surgeons seem to desire an even longer projection. The chief advantage of a longer spout is that it prevents the surrounding skin at the base of the stoma from being flooded with ileal contents. Also, a non-cement appliance is possible for those who cannot or do not wish to use cement. The disadvantage is that pressure effects from the appliance bag on the side of the spout can sometimes be annoying. However, no matter what the preferred length is, a flat stoma (flush with the skin) is held to be thoroughly undesirable by every group interested in evaluating this problem. In order to obtain the desired projection, enough length of ileum must be drawn out through the stab wound while the colectomy wound is still open, before the fixation sutures have been placed in the mesentery. The exteriorized limb should be approximately twice as long as the desired length because the eversion procedures used to "mature" the stoma make the ultimate spout length half as long as the ileal limb measures when it is first exteriorized. Thus for a I-inch long stoma, 2 full inches of ileum should be out of the stab wound under no pull, before the eversion or mucosal turnback is begun. Although the occasional early postoperative edema of the ileostomy later subsides and although the diameter of the stoma may gradually shrink to a smaller size, the length of the projection remains the sameunless of course mechanical prolapse or retraction occurs. Thus, if at the conclusion of the operation the surgeon finds the spout too long or too short for his purposes, he cannot rely on its later gradual withdrawal or projection (as often does happen when a colostomy is brought out without "maturing" and is left to project well beyond the skin level). The ileostomy must be constructed to the desired length at the time of operation. Skin grafted ileostomies are no longer useful or wise. They had the advantage originally of ensuring a projecting spout suitable for the then available but now archaic appliances. Before the sutures are placed to approximate the everted mucosa to the skin edges, the direction of the spout should be assessed. If possible, the ileostomy should point either straight forward or down (caudad) for stomas of an inch or less in length. The stomas pointing upward or to the side are more difficult to manage. For ileostomies longer than an inch, the direction should certainly be downward only. To correct any eccentric course, the surgeon has only to excise a sufficient rim of the caudal everted
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edge of ileum, so that when this is sewn to the skin, the stoma will be drawn to point straight downward. Different surgeons choose different suture material with equally good results for the various maneuvers in constructing an ileostomy. I do not believe that either the nature or the size of the sutures is vital to success. In general, I prefer the finer gauges throughout: silk for mesenteric and bowel fixations; plain catgut for ligation of vessels; chromic catgut for suturing ileal edge to the skin.
Skin Protection As soon as the operation is completed and the dressings of the main wound have been placed, an appliance should be cemented to the skin around the stoma. Any of the plastic, transparent, adhesive pouches are suitable. The proper-sized opening is easier to fashion if one measures the newly made ileostomy with a disposable cardboard card sold by most of the appliance manufacturers. Whatever the method employed, the pouch adheres best if the hole is slightly larger (by a VIe-inch rim) than the diameter of the stoma. I prefer to use cement in addition to the adhesive surface already on the pouch, applying the cement to both the skin and the pouch disk, waiting for it to dry, and then with the hand inside the pouch placing the hole accurately over the stoma. If this first appliance hangs obliquely to the side rather than straight down, it can be more easily emptied in the early days while the patient is more often in bed than ambulatory.
DISCUSSION
Constructing the ileostomy usually occurs near the end of the operation. Sometimes the procedure has been arduous or the patient's condition has been unstable, so that there may be pressure on the surgeon to eliminate or to gloss over some of the steps in fashioning the ileostomy, in his zeal to complete the operation and terminate the anesthesia. However, the surgeon will do well to keep in mind that to the patient the ileostomy-not the colectomy-is the operation. Upon the patient's adjustment to the new structure depends much of his future social and economic activity. Therefore, a carefully performed ileostomy is the first essential of the triad in proper ileostomy management: a well constructed stoma; psychologic adjustment; an adequate appliance. Although a properly formed stoma is highly important, it must not be assumed that a surgically correct result means automatically a well managed ileostomy. The person with a perfectly constructed stoma may nevertheless be subject to skin macerations, to difficulties in gaining secure adherence of an appliance, and to inability to accept the ileostomy. Conversely, even a poorly formed stoma can sometimes be managed well by
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an enthusiastic ileostomist, together with a patient surgeon and the ministrations of another ileostomist.
Ileostomy Clubs One of the most important forces in extending the usefulness of colectomy and ileostomy in rehabilitating patients with ulcerative colitis has been the "ileostomy club principle." Extraordinary stimulus to psychologic adjustment, priceless information, and immeasurable aids in managing appliances have been afforded patients, doctors and nursing personnel by the ileostomy clubs. The first such organization was established in New York almost 15 years ago, * but there are now over 50 in the United States and over 15 in foreign countries. Most of these organizations are also affiliated with each other through a United Ostomy Association.t Every surgeon who has performed an ileostomy or has a patient with ileostomy in his care will help his patient remarkably by referring him to the nearest club. Before operation, a doubtful, fearful prospect is often transformed into a cheerful, eager anticipant by a member of the visiting committee of an ileostomy society. After operation, depression and revulsion are sometimes dramatically altered to hope and acceptance. Indeed, the indications for surgery, the technique of ileostomy construction, and the methods of stomal care have all been definitively affected by the activities of the ileostomy associations. It is the members of these organizations who in the end actually determine the value of any particular technique of ileostomy.
REFERENCES 1. Bacon, H. E.: Ulcerative Colitis. Philadelphia, J. B. Lippincott Co., 1958. 2. Bargen, J. A., Brown, P. W. and Rankin, J. W.: Indications for and technique of ileostomy in chronic ulcerative colitis. Surg. Gynec. & Obst. 55: 196, 1932. 3. Brooke, B. N.: Management of ileostomy including its complications. Lancet 2: 102, 1952. 4. Brown, J. Y.: The Lane operation. Tr. South. Surg. & Gynec. A. 24: 137,1911. 5. Cattell, R. B.: The surgical treatment of ulcerative colitis. Lahey Clinic Bull. 1: 2, 1938. 6. Coffey, R. C.: The two stage operation in abdominal surgery. Tr. West. Surg. A. 26: 159, 1916. 7. Crile, G., Jr. and Turnbull, R. B.: The mechanism and prevention of ileostomy dysfunction. Ann. Surg. 140: 459, 1954. 8. Dennis, C.: Ileostomy and colectomy in chronic ulcerative colitis. Surgery 18: 435, 1945. 9. Flannery, M. G.: Creation, care and complications of ileostomy. Ann. Surg. 151: 970, 1960. 10. Fleming, J. P. and Lin-Min Ou Yang: The ileostomized patient. Dis. Colon & Rectum 7: 147 (March-April) 1964.
* The first reported ileostomy club was called "QT" (after the surgical wards at The Mount Sinai Hospital). t The United Ostomy Association publishes a quarterly bulletin which includes a listing of all the clubs.
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11. Garlock, J. H.: Surgical treatment of intractable ulcerative colitis. Ann. Surg. 113: 1, 1941. 12. Garlock, J. H. and Kirschner, P. A.: Prevention of ileostomy dysfunction. Surgery 40: 678, 1956. 13. Goligher, J. C.: Extraperitoneal colostomy or ileostomy. Brit. J. Surg. 46: 97.1958. 14. Goligher, J. C.: Ileostomy reconstruction. Brit. J. Surg. 50: 259, 1962. 15. Jones, T. E.: The surgical treatment of ulcerative colitis. J.A.M.A. 111: 2076,1938. 16. Logan, A. H.: Chronic ulcerative colitis, a review of 117 cases. Northwest Med. 18: 1, 1919. 17. Lenneberg, E.: QT Boston: An ileostomy group. New England J. Med. 251: 1008, 1954. 18. Lyons, A. S.: An ileostomy club. J.A.M.A. 150: 812,1952. 19. Lyons, A. S., Robinson, B., Schreiber, G. and Turell, R.: Rehabilitation of patients with ileostomy or colostomy. Mod. Med. 22: 115 (Feb. 15) 1954. 20. Lyons, A. S.: Ileostomy-management and complications. S. CLIN. NORTH AMERICA 35: 1411 (Oct.) 1955. 21. Lyons, A. S. and Turell, R.: Operative correction of intestinal stomal difficulties. Am. J. Surg. 101: 55, 1961. 22. Rankin, F. W.: Total colectomy-its indication and technic. Tr. Am. S. A. 49: 263, 1931. 23. Ravitch, M. M. and Mandelbaum, I.: Evolution of the surgical approach to the therapy of idiopathic chronic ulcerative colitis. S. CLIN. NORTH AMERICA 35: 1401 (Oct.) 1955. 24. Stone, H. B.: The surgical treatment of chronic ulcerative colitis. Ann. Surg. 77: 293, 1923. 25. Valiente, M. A.: Ileostomy; refinements in technique. J. Internat. ColI. Surgeons 26: 15, 1956. 26. Warren, R. and McKittrick, L. S.: Ileostomy for ulcerative colitis: Technique, complications, and management. Surg. Gynec. & Obst. 93: 555, 1951. 7 East 80th Street New York, N. Y. 10021