Laparoscopy-assisted stoma closure

Comparative assessment of fully laparoscopic Duhamel-Z with minimal rectorectal dissection vs. laparoscopy-assisted Duhamel-Z with blunt manual rectorectal dissection for total colonic aganglionosis

Aims

Early postoperative outcome (EPO) was compared between fully laparoscopic Duhamel-Z (F-Dz) and laparoscopy-assisted Duhamel-Z (A-Dz) anastomoses performed for total colonic aganglionosis (TCA).

Methods

EPO was assessed quarterly for the first year after F-Dz/A-Dz using a continence evaluation score (CES) based on stool frequency (motions/day) and stool consistency (0 = liquid, 1 = soft, 2 = formed), presence of anal erosion (0 = severe, 1 = moderate, 2 = mild), and incidence of enterocolitis.Surgical technique involved taking the ileostomy down, dissecting the colon laparoscopically, and preparing the pull-through ileum through the stoma wound. In F-Dz (n = 3), a working port (SILS trocar) was inserted, and laparoscopic retrorectal dissection with forceps used to create a retrorectal tunnel from the peritoneal reflection extending downward as narrow as possible along the posterior wall of the rectum to prevent lateral nerve injury and preserve vascularity. After completing the tunnel, the ileum was pulled-through from an incision on the anorectal line and a Z-shaped ileorectal side-to-side anastomosis performed without a blind pouch. In A-Dz (n = 11), the retrorectal pull-through route was created through a Pfannenstiel incision using blunt manual (finger) dissection along the anterior surface of the sacrum.

Results

Subject backgrounds were similar. Mean quarterly data were: frequency (F-Dz: 4.67, 4.67, 4.67, 3.33) vs. (A-Dz: 7.27, 7.09, 6.18, 5.36) p < .05; consistency (F-Dz: 0.33, 0.67, 0.67, 0.67) vs. (A-Dz: 0.27, 0.45, 0.70, 0.73) p = ns; anal erosion (F-Dz: 0.33, 0.33, 0.33, 0.67) vs. (A-Dz: 0.18, 0.36, 0.45, 0.64) p = ns; and enterocolitis (F-Dz: 1 episode in 1/3 cases or 33.3%) vs. (A-Dz: 7 episodes in 6/11 cases or 54.5%) p = ns.

Conclusions

Overall, EPO after F-Dz was better than after A-Dz.

A comparison of surgical site infections in children after stoma reversal between purse-string and linear closure

BACKGROUND

To reduce the surgical site infections (SSI), the purse-string closure technique has been widely performed and has also been recommended in adult stoma reversal. However, for children, some debate still exists. This study aims to compare the SSI rates in children between the purse-string and the linear for the skin closure of stoma reversal.

METHODS

The data were collected from pediatric patients, who had undergone either purse-string or linear closure for elective surgery of stoma reversal from two university hospitals between January 2016 and December 2019.

RESULTS

The purse-string and linear closure had been performed on 31 and 45 patients, respectively. At 30 days after surgery, three patients in the purse-string closure group had developed SSI compared to 14 patients in the linear closure group (9.7 vs. 31.1%, p = 0.028). Furthermore, there had been no significant difference in the overall post-operative complications. In multivariate analysis, the SSI had been significantly lower in patients with purse-string closure (OR 0.21, 95% CI 0.05-0.86, p = 0.029).

CONCLUSION

By employing the purse-string closure technique for skin closure of stoma reversal, there had been a significantly lower SSI rate compared to linear closure with no difference in the length of hospital stay.

Abdominal wall closure after a stomal reversal procedure

The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.

Factors affected by surgical technique when treating total colonic aganglionosis: laparoscopy-assisted versus open surgery

INTRODUCTION

We compared laparoscopy-assisted Duhamel (Lap-D) with open surgery (Duhamel or Soave = D/S) for treating total colonic aganglionosis (TCA) in children to establish what factors may affect outcome.

METHODS

Fourteen TCA cases treated between 1990 and 2010 were reviewed. Open D/S (O-D/S) through a vertical midline abdominal incision was routine from 1990 to 2005, whereupon Lap-D became routine. Lap-D involves laparoscopic colon resection, ileostomy take-down, and ileum pull-through through an additional Pfannenstiel incision. We compared pre-operative nutrition, operating time, intraoperative blood loss, duration until oral challenge, postoperative analgesic usage, incidence of enterocolitis, early complications that arose within 30 days of surgery, and late complications, and wound cosmesis 1 year postoperatively (Grade-1: unacceptable, Grade-2: passable, Grade-3: excellent).

RESULTS

Six had O-D/S (2D, 4S) and eight had Lap-D. Differences in patient demographics, mean ages/weights at surgery, average length of the aganglionic segment from the terminal ileum, operating time, and time taken for oral challenge were all not significant, full feeding took longer in O-D/S (6.7 vs. 5.9 days). Preoperative central vein intravenous hyperalimentation was required for one case in O-D/S and two cases in Lap-D. These three required hospitalization for at least 30 days postoperatively and parenteral nutrition after discharge. Although there were no intraoperative complications in either group, there was one case of transient ileus in O-D/S that resolved conservatively. Cosmesis was significantly better in Lap-D (O-D/S = 1.2; Lap-D = 2.1; p < 0.05).

CONCLUSIONS

Cosmesis was the only factor that was significantly different between Lap-D and O-D/S; all other factors were similar.

Laparoscopic loop ileostomy reversal: reducing morbidity while improving functional outcomes

The main advantage of a laparoscopic loop ileostomy reversal was found to be visualization of adhesions for lysis and mobilization of the stoma and small bowel.

Introduction:

Loop ileostomy reduces the morbidity associated with pelvic sepsis. However, its reversal carries a 10% to 30% complication rate. We present our technique for laparoscopic ileostomy closure.

Methods:

We conducted a retrospective chart review of subjects undergoing laparoscopic-assisted loop ileostomy closure between 2006 and 2009. Operating time, length of hospital stay, return of bowel function, and complication rates were assessed.

Results:

There were 24 (13 males) patients. Average age was 63 with a BMI of 25.9. Eighteen (75%) had a planned loop ileostomy, and 6 (25%) were emergent. Average time to reversal was 135 days. Average length of surgery was 79 minutes (range, 48 to 186), average stay was 4 days and return to bowel function was 3.6 days. We had no wound infections. Our complication rate was 29% (n=7), and reoperation rate was 12.5% (n=3). Only 1 major complication occurred, an anastomotic dehiscence.

Conclusion:

A thorough, well-visualized lysis of adhesions and mobilization of the stoma and surrounding small bowel is the main advantage of our approach. We had no wound infections and no reoperation for bowel obstruction, which we feel is a direct advantage of our technique. Our complication rate and surgical time are comparable to those of the open technique.

Colostomy closure: how to avoid complications

PURPOSE

Colostomy is an operation frequently performed in pediatric surgery. Despite its benefits, it can produce significant morbidity. In a previous publication we presented our experience with the errors and complications that occurred during cases of colostomy creation. We now have focused in the morbidity related to the colostomy closure. The technical details that might have contributed to the minimal morbidity we experienced are described.

METHODS

The medical records of 649 patients who underwent colostomy closure over a 28-year period were retrospectively reviewed looking for complications following these procedures. Our perioperative protocol for colostomy closure consisted in: clear fluids by mouth and repeated proximal stoma irrigations 24 h prior to the operation. Administration of IV antibiotics during anesthesia induction and continued for 48 h. Meticulous surgical technique that included: packing of the proximal stoma, plastic drape to immobilize the surgical field, careful hemostasis, emphasis in avoiding contamination, cleaning the edge of the stomas to allow a good 2-layer, end-to-end anastomosis with separated long-term absorbable sutures, generous irrigation of the peritoneal cavity and subsequent layers with saline solution, closure by layers to avoid dead space, and avoidance of hematomas. No drains and no nasogastric tubes were used. Oral fluids were started the day after surgery and patients were discharged 48-72 h after the operation.

RESULTS

The original diagnoses of the patients were: anorectal malformation (583), Hirschsprung's disease (53), and others (13). 10 patients (1.5%) had complications: 6 had intestinal obstruction (5 due to small bowel adhesions, 1 had temporary delay of the function of the anastomosis due to a severe size discrepancy between proximal and distal stoma with a distal microcolon) and 4 incisional hernias. There were no anastomotic dehiscences or wound infection. There was no bleeding, no anastomotic stricture and no mortality.

CONCLUSION

Based on this experience we believe that colostomy closure can be performed with minimal morbidity provided a meticulous technique is observed.

Loss of intestine during stoma closure: an experimental model comparing laparoscopic and conventional techniques

PURPOSE

This study compared laparoscopy-assisted stoma closure (Lap) with conventional closure (Co) to assess loss of intestine.

METHODS

Ileostomies (loop L; single S) were performed 5 cm proximal to the ileocecal junction through a right lower quadrant incision in forty 11-week-old Lewis rats (L = 20, S = 20). Stoma closure was performed 60 days later using laparoscopy (Lap) or conventional closure (Co) in 10 rats each, to give 4 groups, Lap-L, Lap-S, Co-L, and Co-S. End-to-end anastomosis was performed through the stoma site in all rats. Bowel resected from the skin to the anastomosis was termed resected unusable bowel (RUB) and measured blindly. Laparotomy was performed 30 days later to assess the status of the anastomosis and complications.

RESULTS

Average RUB with Lap was significantly shorter; Lap-L (17.8 mm) versus Co-L (23.8 mm), P = 0.002, and Lap-S (10.6 mm) versus Co-S (13.8 mm), P = 0.001. During Co, accidental full-thickness injury to underlying bowel during stoma take-down occurred in 3 Co-L and 2 Co-S rats. All Lap rats were uncomplicated. Average times taken until end of stoma take-down were 6.1 min for Lap-L (3.2 min for trocar insertion, 2.8 min for stoma take-down), 5.6 min for Lap-S (2.8 and 2.7 min), 6.3 min for Co-L (from first incision to stoma take-down), and 5.1 min for Co-S (P = NS). At laparotomy there was no evidence of complications such as wound infection, incisional hernia or anastomotic stenosis in any rat.

CONCLUSIONS

Our results suggest that laparoscopy-assisted stoma closure is safe and quick, and results in less loss of intestine during stoma closure.

Outcome of stoma closure in children: a comparison of laparoscopy-assisted and conventional open techniques

Laparoscopy-assisted stoma closure (LASC; n = 28) and conventional open closure (CSC; n = 24) were compared by assessing outcome in 52 consecutive cases of stoma closure (SC) in children.

Laparoscopic-assisted colostomy in children

INTRODUCTION

Colostomy morbidity has been reported to be as high as 50%. Laparoscopic-assisted colostomy (LAC) is associated with decreased colostomy complication. LAC is recommended for stoma formation in adults but has not been previously reported in children. In this paper, we report on our initial experience with LAC in children.

MATERIALS AND METHODS

Using a two- to four-port (3.5-mm) technique, LAC was performed in a female with an imperforate anus and 2 male patients with complicated Hirschsprung's disease (HD), respectively. Data collected included operative time, time to recover bowel function, and morbidity. Close follow-up was done until stoma closure.

RESULTS

The operative time was 144 minutes in the HD patients (including concomitant laparoscopic biopsies and a leveling colostomy) and 40 minutes in the imperforate anus patient. Median time to passage of both flatus and stool was 40 hours (range, 24-48). Time to commence feeds postop was 40 hours (range, 24-48). The median time of follow-up was 3 months (range, 2-9) until the stoma was taken down. No complications have occurred to date.

CONCLUSIONS

LAC is safe and easily performed in neonates and infants. It facilitates accurate stoma placement and orientation. It allows additional bowel mobilization, especially in HD. In accordance with the adult experience, LAC seems to obviate stoma-related complications. Encouraged by our initial low morbidity rate, a prospective evaluation of this technique is planned.