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Appendectomy Using
the Linear Dissecting

Transverse Loop

End Sigmoid Colostomy With Hartmann's Pouch

Closure of a Loop

Anterior Resection
of the Colon With Low
Anastomosis Using
the Gambee Suture

Low Anastomosis
of Colon to Rectum
Using the End-to-End
Surgical Stapler

Anterior Resection
of the Colon With
Low Anastomosis via
the Strasbourg-Baker

End Sigmoid Colostomy
With Hartmann's Pouch

End sigmoid colostomy with a Hartmann's pouch is the procedure of choice when permanent fecal diversion is required. In some clinics, the distal portion of the rectosigmoid colon is exteriorized as a mucous fistula in lieu of a Hartmann's pouch. The need for this in colonic problems related to gynecologic oncology is rare.

Physiologic Change. In this operation, the fecal stream is diverted from the rectum and anus. Compared with transverse colostomy, end sigmoid colostomy gives additional length to the colon for absorption of fecal fluid. Therefore, the stool is similar to that passed per anum. End sigmoid colostomy offers an opportunity for colostomy regulation that is generally not available in transverse colostomies. A single stoma improves the fit of the colostomy bag and reduces skin excoriation.

Points of Caution. An adequate incision is needed to identify, mobilize, and open the mesentery of the sigmoid colon. The incision should be selected to fit the needs of the individual patient, ensuring proper placement of the colostomy stoma. The stoma should not be placed in the patient's waistline, where clothing will interfere with it, and should never be placed on the underside of a large abdominal panniculus in obese patients. Several sutures placed from the serosal surface of the bowel to the peritoneum will reduce herniation and prolapse of the colon through the stoma.


The patient is placed in the supine position. The abdomen is opened through a left paramedian or midline incision. The sigmoid colon is identified, mobilized, and elevated. The site for transection of the bowel is made on consideration of the pathologic diagnosis. The mesentery is opened for approximately 8 cm. Often, the superior hemorrhoidal branch of the inferior mesenteric artery must be clamped and divided, but the inferior mesenteric artery itself is generally preserved. The gastrointestional anastomosis (GIA) autosuture stapler is placed across the colon and activated.

With the GIA stapler, the proximal end of the distal segment of the colon (Hartmann's pouch) is adequately closed. No further surgery to this segment is needed.

The appropriate site for the colostomy stoma has been marked on the patient's abdomen with indelible ink prior to surgery. An Allis clamp is placed on the skin at this site and elevated.

While the skin is held on traction, a knife is used to remove a disc of skin and subcutaneous tissue of appropriate diameter.

The skin disc has been removed.

The subcutaneous fat is elevated with an Allis clamp.

With the fat elevated, a knife is used to remove the remaining fatty tissue, exposing the rectus fascia.

The rectus fascia is exposed.

The rectus fascia is elevated with an Allis clamp. A knife is used to remove a disc of rectus fascia 4 cm diameter.

A large Kelly clamp is inserted through the peritoneum, bluntly penetrating the fibers of the rectus muscle. This incision is expanded with the Kelly clamp and fingers until two fingers (4 cm) traverse the defect from the skin to peritoneum without difficulty.

A Babcock clamp is inserted through the abdominal wall defect. The distal segment of the descending colon is grasped.

This distal segment of the descending colon is pulled through the defect for a distance of approximately 7 cm. Excess fatty tissue on the mesenteric side of the colon is clamped and tied up to but not exceeding 3 cm.

The excess fatty tissue is removed. The blood supply of the colon is such that up to 5 cm of colon can be nourished from the point of ligation of vessels in the mesentery. Colon in excess of this amount may become ischemic and necrose.

The stapled end of the proximal colon is elevated with a forceps and resected with curved Mayo scissors.

A "rosebud" stitch is utilized to evert the colon onto the skin, thereby elevating it off the skin edge by 1 1/2 cm. Elevating the stoma protects the skin from fecal spillage. The stitch is started on the surface of the skin 1 cm from the edge, goes through the epidermis and dermis, is passed through the serosa and muscularis of the bowel wall, and then transverses the edge of the bowel.

When tied, the stoma is inverted and raised off the level of the skin.

The mesentery of the large bowel is sutured or stapled to the peritoneum to prevent internal hernia.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
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