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 Table of Contents  
SURGEON AT WORK
Year : 2019  |  Volume : 52  |  Issue : 2  |  Page : 57-59

A simple technique to create spur in loop colostomy


Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission28-Sep-2018
Date of Decision11-Oct-2018
Date of Acceptance18-Nov-2018
Date of Web Publication18-Apr-2019

Correspondence Address:
Dr. Anand Pandey
Department of Pediatric Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_101_18

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  Abstract 

A colostomy is one of the most popular techniques used as a protective maneuver for a distal anastomosis and/or temporary fecal diversion loop colostomy is used mainly for fecal diversion so as to protect the distal bowel. We report a new simple technique for the creation of mucosal spur in between the proximal and distal stoma without using either a tube or skin flap. The essence of this technique is the creation of mucosal spur by placing two additional sutures in the bridge in between the proximal and distal stoma. The placement of sutures creates the spur and helps in defunctioning of distal stoma. Seventeen patients were operated by this technique over a period of 1 year. The creation of the mucosal spur was excellent. There was no requirement of a tube or skin flap in any of the patients in the follow-up. There was no problem of loss of spur over a period. This is a simple technique, which needs few additional sutures apart from the necessary sutures needed for maturation of colostomy.

Keywords: Loop colostomy, spur


How to cite this article:
Singh G, Pandey A, Rawat J, Singh S. A simple technique to create spur in loop colostomy. Formos J Surg 2019;52:57-9

How to cite this URL:
Singh G, Pandey A, Rawat J, Singh S. A simple technique to create spur in loop colostomy. Formos J Surg [serial online] 2019 [cited 2019 May 22];52:57-9. Available from: http://www.e-fjs.org/text.asp?2019/52/2/57/256529


  Introduction Top


A colostomy is one of the most popular techniques used as a protective maneuver for a distal anastomosis and/or temporary fecal diversion.[1] There are three types of colostomy-loop, double barrel, and end colostomy.[2] The indications vary according to the need. Creation of proper colostomy is very important as it leaves a lasting impact on the patient.[3] Loop colostomy is used mainly for fecal diversion so as to protect the distal bowel.

During the formation of loop colostomy, it is fixed to the muscles and skin so that it may not retract. In this process, a tube has been used, which passes through the mesentery.[4] A skin flap has also been described.[5] In addition, the use of tube or skin flap helps in forming a spur between proximal and distal stoma of the loop.[3] This may help to defunction the distal bowel.

We have created a spur in between the proximal and distal stoma without using either a tube or skin flap. Rather, it was accomplished using few additional sutures.


  Methods Top


This was a series over a period of 1 year. It included those patients who needed loop colostomy as a mode of fecal diversion. Written and informed consent was obtained from the attendants of the patients.

Technique

It is described as below:

An incision is made in the left iliac fossa. The underlying fascia is divided in the same line. The rectus muscle is exposed. A part of it may have to be divided and posterior rectus sheath is exposed. The posterior sheath is divided and peritoneal cavity is opened. We make an opening in the mesentery and an infant feeding tube (6–8 Fr) is passed through it. The loop of bowel is delivered through the skin incision ensuring that the bowel loop is under no tension, so as to compromise the vascular supply.

The loop is anchored to the muscles so as to fix the loop. Thereafter, a transverse incision is made along the length of the loop of colon through one of the tenia. This opens up the lumen. Maturation of the ostomy is performed after that using 3-0 or 4-0 polyglactin sutures. Up to this level, the technique is similar to the standard described one.

A stay suture is placed in midline to lift the cleft between proximal and distal stoma. Sutures are placed from either side of the bridge between proximal and distal stoma in a direction perpendicular to the stoma openings. These start from midline. The suture bite includes mucosa and submucosa twice and then anchored to the skin. It is then fixed at this point. This fixation causes elevation of the bridge between proximal and distal stoma with disappearance of the cleft [Figure 1], [Figure 2], [Figure 3], [Figure 4]. The feeding tube is removed at this point.
Figure 1: (a) Line diagram showing placement of sutures in the bridge between proximal and distal stoma. (b) Line diagram after tying the knots of the sutures placed

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Figure 2: Clinical picture showing colostomy. The cleft between proximal and distal stoma is visible

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Figure 3: Placement of sutures in the bridge between proximal and distal stoma

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Figure 4: The spur is clearly elevated between proximal and distal stoma. The cleft between proximal and distal stoma is now obliterated

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  Results Top


The duration of this study was 1 year. During this period, 17 colostomies were made by this technique. The diagnosis in these patients included Hirschsprung's disease (HD, 9), anorectal malformation (ARM, 6), and pelvic trauma (2). Of these, 15 were male and two female. The median age of the patients was 15 days (range 1 day to 4 years).

The creation of the mucosal spur was obvious. There was complete obliteration of the cleft between the proximal and distal stoma. In the follow-up, there was no complication as regard to the creation of the spur. There was no sutural dehiscence or loss of spur. There was no report of colostomy prolapse or retraction. The mean duration of follow-up was 7.6 months (range 3–11 months). There was no follow-up loss.


  Discussion Top


There are sporadic reports of ostomy surgery before the 1700s. Following the development of anesthesia during the mid-1800s, surgeons used diverting colostomy to manage bowel obstruction.[6] Colostomy forms an important part of the management of children with congenital and acquired disorders of the large bowel. Overall, HD and ARM are the most common indications for colostomy in children.[7]

Currently, in adults during stoma formation, the anchoring stitches to underlying muscles are not used, and the ostomy is matured after opening the lumen.[8] The situation in children is, however, different. In pediatric population, the stitches to underlying fascia transversalis and muscles are important to avoid stomal prolapse, an important complication of colostomy formation.[4]

In a standard loop colostomy, after opening the lumen, maturation of the loop is performed. This step is needed to prevent the development of serositis.[9] In a loop colostomy, the bridge between the proximal and distal stoma is sagging, which appears like a cleft between proximal and distal stoma. This creates a groove between proximal and distal stoma. It is for this junction that a spur is created by tube. Spur is also believed to defunction the distal bowel.[10]

As mentioned previously, a tube or skin flap have been used to create the spur. The disadvantage of the tube may be the difficulty in placement of colostomy bag. As regards to using the skin flap, it is an additional step in making a colostomy. Although not evaluated in this study, it may be guessed that additional maneuver will lead to consuming of additional time. The technique described by us is simple. By placing few additional sutures, a well-formed spur can be created. Apart from these sutures in the bridge, there is no other intervention. We did not have any complications in the follow-up period, suggesting that the additional sutures did not have any untoward effect on the colostomy.


  Conclusion Top


The procedure described here is simple for making a loop colostomy with an adequate spur. The follow-up results are good. Use of this technique by others may substantiate our efforts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Fonseca AZ, Uramoto E, Santos-Rosa OM, Santin S, Ribeiro M Jr. Colostomy closure: Risk factors for complications. Arq Bras Cir Dig 2017;30:231-4.  Back to cited text no. 1
    
2.
Gauderer MW. Stomas of small and large intestine. In: Coran AG, Adzick NS, Krummel TM, Laberge J, Shamberger RC, Caldmone AA, editors. Pediatric Surgery. 7th ed. Philadelphia, PA: Elsevier Saunders; 2012. p. 1235-46.  Back to cited text no. 2
    
3.
Cataldo PA. Technical tips for stoma creation in the challenging patient. Clin Colon Rectal Surg 2008;21:17-22.  Back to cited text no. 3
    
4.
Lloyd DA. Colostomy: Formation and closure. In: Spitz L, Coran AG, editors. Operative Pediatric Surgery. 6th ed. Boca Raton, FL: CPC Press, Taylor and Francis Group; 2006. p. 619-32.  Back to cited text no. 4
    
5.
Motamedi MR, Rezaei M, Kharazm P, Sharifi M, Kavyani A, Zade MZ, et al. An easy solution for the diverting loop colostomy: Our technique. Med J Islam Repub Iran 2006;20:137-40.  Back to cited text no. 5
    
6.
Doughty DB. History of ostomy surgery. J Wound Ostomy Continence Nurs 2008;35:34-8.  Back to cited text no. 6
    
7.
Ekenze SO, Agugua-Obianyo NE, Amah CC. Colostomy for large bowel anomalies in children: A case controlled study. Int J Surg 2007;5:273-7.  Back to cited text no. 7
    
8.
Whitehead A, Cataldo PA. Technical considerations in stoma creation. Clin Colon Rectal Surg 2017;30:162-71.  Back to cited text no. 8
    
9.
Glasgow SC, Fleshman JW. Colon, rectum, and anus. In: Klingensmith ME, Chen LE, Glasgow SC, Goers TA, Melby SJ, editors. The Washington Manual of Surgery. 5th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2008. p. 214-37.  Back to cited text no. 9
    
10.
Ngakane H, Luvuno FM. Technical aids in surgery. Completely defunctioning loop colostomy. S Afr J Surg 1989;27:145-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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