Extraperitoneal Colostomy Research Articles

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a laparoscopic retractor

Although extraperitoneal colostomy is often performed to prevent postoperative parastomal hernia formation following an open abdominoperineal resection of lower rectal cancer, it has not been widely employed laparoscopically because of the difficulty associated with the extraperitoneal route. This paper describes a laparoscopic extraperitoneal sigmoid colostomy using the Endo Retract™ Maxi instrument. This surgical technique is easy, and helps to prevent the development of parastomal hernias.

Laparoscopic extraperitoneal colostomy in elective abdominoperineal resection for cancer: a single surgeon experience

Parastomal herniation of end colostomies can be chronically debilitating for patients and a difficult problem to treat. To prevent parastomal hernia (PSH) formation an extraperitoneal colostomy (EPC) approach has been developed in open colorectal surgery and some studies have suggested a potential advantage to this approach. Here we describe our technique of laparoscopic extraperitoneal stoma formation and present our experience to date. We performed a retrospective analysis of consecutive patients undergoing a laparoscopic abdominoperineal resection between March 1999 and March 2011. We performed the EPC technique as follows: under laparoscopic guidance, a smooth tip instrument was used to gently separate the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel running from the skin incision to the left flank of the abdominal cavity to join the previously dissected paracolic gutter. The colon was exteriorized and the position was checked to ensure the absence of torsion or kinking. Twenty-two patients underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. Colostomy was constructed extraperitoneally (EPC) or transperitoneally (TPC) in 12 and 10 patients respectively. There were five complications requiring operative intervention: two stomal necrosis and one surgical site infection in the TPC group and two small bowel occlusions in the EPC group. Four patients from the TPC group developed PSH at 24, 36, 48 and 72 months respectively while there were no cases of PSH in the EPC group. Extraperitoneal laparoscopic colostomy showed a potential reduction of PSH in our series of patients.

Clinical Evaluation of Extraperitoneal Colostomy without Damaging the Muscle Layer of the Abdominal Wall

This study investigated whether extraperitoneal colostomy without damaging the muscle layer of the abdominal wall is an improved surgical procedure compared with conventional sigmoid colostomy in patients undergoing abdominoperineal resection. Patients with rectal cancer undergoing abdominoperineal resection were selected and randomly divided into two groups: the study group received extraperitoneal colostomy without damaging the muscle layer of the abdominal wall and the control group received conventional colostomy. Clinical data from both groups were analysed. A total of 128 patients were included: 66 received extraperitoneal colostomy without damaging the muscle layer of the abdominal wall and 62 received conventional colostomy. Significant differences between the two groups were found in relation to colostomy operating time, defaecation sensation, bowel control and overall stoma-related complications. Duration of postoperative hospital stay was also significantly different between the study groups. Extraperitoneal colostomy without damaging the muscle layer of the abdominal wall was found to be an improved procedure compared with conventional sigmoid colostomy in abdominoperineal resection, and may reduce colostomy-related complications, shorten operating time and postoperative hospital stay, and potentially improve patients' quality of life.

Prevention of parastomal hernia by intraperitoneal onlay mesh reinforcement at the time of stoma formation

Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of this study is to assess the safety and prophylactic effect of intraperitoneal onlay mesh (IPOM) reinforcement of the abdominal wall at the time of primary stoma formation to prevent PSH occurrence. This multicentre prospective study concerned 20 patients operated for low rectal carcinoma between 2008 and 2010. Those patients had an elective and potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round composite mesh centred on the stoma site and covering the lateralised colon. There were 8 men and 12 women with a median age of 69years (range: 44-88) and a body mass index of 27 (range: 21-35). The major outcomes analysed in the study were operative time, complications related to mesh and PSH occurrence. Patients were evaluated 1month after surgery and then every 6months with physical examination and computed tomography scan (CT-scan). For PSH, we used the classification of Moreno-Matias. Surgery was performed by laparoscopy in 17 patients and by laparotomy in 3; 12 had an extraperitoneal colostomy, and 8 had a transperitoneal colostomy. The median size of the mesh was 15cm (range: 12-15). The median operative time was 225min (range: 175-300), and specific time for mesh placement was 15min (range: 12-30). One month after surgery, one patient presented with a mild stoma stenosis that was treated successfully by dilatation. With a median follow-up of 24months (range: 6-42), no other complication potentially related to the use of the mesh was recorded and no mesh had to be removed. On clinical examination, one patient (1/20=5%) had a stoma bulge that appeared a few months after surgery, but was not associated with symptoms. CT-scan evaluation confirmed that all the patients with a normal clinical examination had no PSH and revealed that the patient with the stoma bulge had a stoma loop hernia (type 1a hernia). This patient was followed up for 36months, no clinical or radiological aggravation of the stoma loop hernia was observed, and he remained totally asymptomatic. With 95% of excellent results, IPOM reinforcement at the time of end colostomy formation in selected patients is a very promising procedure. A drawback of this technique is the possibility of developing a stoma loop hernia due to sliding of the exiting colon between the covering mesh and the abdominal wall. However, this risk is low, and no adverse clinical consequence for the patient was noted in our series.

Extraperitoneal vs. intraperitoneal route for permanent colostomy: a meta-analysis of 1,071 patients

Parastomal hernia is a common complication after colostomy construction. Whether an extraperitoneal route for colostomy creation can reduce the risk of parastomal hernia remains controversial. A meta-analysis was performed to evaluate the value of extraperitoneal route in the prevention of parastomal hernia and other postoperative complications related to colostomy. A literature search of Medline, Embase, Ovid, and Cochrane databases from the years 1966 to 2010 was performed. Studies comparing extraperitoneal colostomy with intraperitoneal colostomy were identified. Extraperitoneal colostomy was performed to prevent colostomy-related complications. Data on the following outcomes were sought: incidence of postoperative colostomy complications including parastomal hernia, prolapse, and bowel obstruction. Seven retrospective studies with a combined total of 1,071 patients (250 extraperitoneal colostomy and 821 intraperitoneal colostomy) were identified. There was a significantly lower rate of parastomal hernia (odds ratio, 0.41; 95% confidence interval, 0.23-0.73, p = 0.002) in the extraperitoneal colostomy group. However, the occurrences of bowel obstruction and prolapse were not significantly different between the two groups. A limitation of the study lies on the meta-analysis of observational studies. Extraperitoneal colostomy is associated with a lower rate of postoperative parastomal hernia as compared to intraperitoneal colostomy. Prospective randomized controlled trial is warranted to further determine the role of extraperitoneal route in the prevention of parastomal hernia.

Circular Stapler-Assisted Extraperitoneal Colostomy

Aims: To report and evaluate the clinical value of circular stapler-assisted extraperitoneal colostomy. Methods: We performed circular stapler-assisted extraperitoneal colostomy following Miles’ operation in 22 patients over a 2-year period from March 2007 to March 2009. The efficiency and safety of the operation were evaluated. Results: The length of surgery was 15 ± 5 min, and all the colostomies were successfully completed during the first procedure. No complications such as anastomotic infections, hemorrhage, necrosis, or invagination occurred after surgery. No scar contraction, stoma stenoses, intestinal obstructions, or parastomal hernias were found during the follow-up period of 24–72 months. All the colostomies functioned well. Conclusion: Circular stapler-assisted extraperitoneal colostomy can be a safe and effective procedure to improve the outcome of surgery for rectal cancer. This is one of the few studies attempting stapled colostomy, and at present the technique appears promising but warrants a longer follow-up period and additional study, in particular a prospective trial including a control group.

Invited comment to the letter by K. Bielecki “Recurrent ileostomy prolapse: is it a solved problem?”

Regarding the difficult clinical problem that Dr. Bielecki has proposed, this is a complicated situation [1]. The first thought that came to mind is the fact that the only thing we can do to prevent stomal prolapse is to do an extraperitoneal ileostomy. This was proposed by Professor Goligher many years ago [2], and I think that it is the only thing a surgeon can do to prevent a prolapse. It is not a very difficult procedure; it is just a matter of making an extra peritoneal tunnel and bringing the ileostomy up through the tunnel and then bringing it out through the abdominal wall. I think this may have solved the problem for this patient; however, we have not been in the habit of making an extraperitoneal colostomy or ileostomy. You cannot build an extraperitoneal stoma routinely on every patient, and this patient had Crohn’s disease and may have had a much thickened bowel to deal with, which may have not been appropriate to place in an extraperitoneal tunnel. The other question has to do with the fact that if you do get recurrence of the terminal ileum, and it is in an extraperitoneal tunnel, it may be even more difficult to deal with if recurrent Crohn’s disease does occur. Regarding the Nobel’s plication, this is an operation we rarely do any longer; however, I think the way Dr. Bielecki managed it was the best thing to do in this situation.

The application of circular stapler in extraperitoneal colostomy

To evaluate the clinical and application value of circular stapler in extraperitoneal colostomy. Retrospective analysis was made to 22 cases that experienced extraperitoneal colostomy with circular stapler from Match 2008 to March 2009 in the department of colon and anal surgery of the first hospital of Jilin University. The length of surgery was (15 +/- 5) min when circular stapler- assisted extraperitoneal colostomy was used, and all of the colostomies were successfully completed during the first procedure. No complications occurred after surgery, such as stoma bleeding, necrosis, infection, retraction, stenosis, intestinal obstruction and hernia beside the stoma etc. Colostomy size of the uniform, beautiful shape formation. Although there were three cases requiring hemostasis due to anastomotic bleeding that occurred during the operation. About 3 months later, staples of the stoma fell off by themselves. All patients were followed up for 6 to 24 months after operation, form and function of colostomy are well. The popularization of the application of circular stapler in extraperitoneal colostomy is important and worthwhile for its obvious advantages such as simple operation, good stoma appearance and reduced complications.

The complications of synchronous combined excision for adenocarcinoma of the rectum at St Mark's Hospital.

The complications of synchronous combined excision of the rectum for adenocarcinoma in 227 patients were analysed. Urinary retention with infection occurred in 78 patients (34-4 per cent) and was the commonest complication. There was a significant correlation between tumours involving the anterior quadrants of the rectum and urinary complications. Primary suture of the perineal wound with closed drainage was associated with a higher incidence of complications than open drainage. The cumulative risk of a paracolostomy hernia in the sixth postoperative year was approximately 33 per cent. Extraperitoneal colostomy gave some protection against paracolostomy herniation.

Historical landmarks in operations on the colon—surgeons courageous

Purpose The nearly 300-year history of surgery of the colon is replete with creative daring among surgeons who conquered the challenges of operating on this highly contaminated organ, housed in the sacrosanct peritoneal cavity. Methods Alexis Littre’s suggestion in 1710 that a colostomy may be successful in treating an infant with imperforate anus began an evolutionary process of extraperitoneal colostomy for obstructing carcinomas, and then, an intraperitoneal approach, which enhanced surgical evaluation of the tumor and optimal placement of the stoma. Reybard’s introduction of sigmoid resection in 1823, followed by post-Lister contributions of Mickulicz, Paul, Murphy, Miles, Hartmann, and other 19th- and early 20th-century surgeons, paved the way for current successes in colon surgery. Results The morbidity and mortality, which still accompanies surgery on the colon, often results from a failure of today’s surgeon to apply those principles so meticulously documented by colon and rectum surgery historians. Conclusions The individual, who performs a Miles abdominoperineal resection, a Hartmann procedure, or any other of the classic operations on the colon, gains much by studying the original philosophy and technique of these pioneers in the field.

Delayed colostomy closure using the extraperitoneal method

Diverting temporary colostomy is usually closed within three months using an extraperitoneal technique. A study on loop colostomy closure protocol was carried out in 20 patients, in a period of 8 years, to restore the colonic transit at least three months after the stoma formation. The extraperitoneal technique was used. The colostomy closure was followed by complications in 7 cases (35%), of which only two were due to anastomotic dehiscence (10%). The presence of associated diseases increased morbidity. The delayed extraperitoneal colostomy did not carry a high postoperative complication rate. To achieve good results an accurate surgical technique is important.

Management of Stomal Complications

Creation of an intestinal stoma, be it temporary or permanent, requires good judgement and surgical skill. For the patient the stoma is of constant concern, and a well constructed intestinal stoma can reduce the patient's physical and psychological stress. Peristomal skin irritation should alert a search for surgical complications. Collaboration with an enterostomal therapist is strongly advised. The probability of revision of an ileostomy during the first 10 years reaches 0.44 in patients with ulcerative colitis (UC) and 0.75 in patients with Crohn's disease (CD). The most frequently seen complication are stenosis and sliding retraction. Stomal fistulas are seen more frequently in patients with CD than those with UC. Most ileostomy complications can be treated locally, without a laparotomy. The sigmoid colostomy, a stoma of the elderly, is also frequently complicated by stenosis, particularly after postoperative infection and separation at the mucocutaneous junction. Peristomal herniation is extremely common, and some degree of herniation is almost inevitable. There are no randomized studies to determine the best way to construct a colostomy. Bringing the bowel through the rectus muscle is probably superior to lateral to the muscle. Extraperitoneal colostomy does not provide any advantage over the intraperitoneal route. A colostomy stenosis is best managed locally. Infectious complications and hernias require laparotomy and resiting of the stoma.

Experiences with extraperitoneal colostomy and ileostomy.

A technique for extraperitoneal colostomy and ileostomy has been used by one of the authors since 1952. The technique is described and the results reviewed.