Editing Closure of loop ileostomy


== '''Indications''' ==

* Original area of concern has completely healed, and there is functional anatomy distal to the ileostomy site
* The distal problem is unsalvageable, and in order to minimise fluid imbalances or restore full access to the colon, the ileostomy is taken down and converted to a colostomy

== '''Contraindications''' ==

* Less than 6-12 weeks since index operation
* Distal obstruction
* Uncorrected distal problem
* Persistent poor performance status or nutritional status
* Ongoing chemotherapy or immunosuppression
* Uncorrected coagulopathy

== '''Preparation''' ==

* Need to examine the distal anastomosis in some way:
** Gastrografin enema or CT with rectal contrast to examine the distal colon and anastomosis for leaks or strictures
** Flexible endoscopy to visually examine the distal anastomosis and integrity of colonic conduit
* Anal manometry if concerned about continence of sphincter

== '''Pitfalls''' ==

* Anastomotic leak at the takedown site, leading to intra-abdominal abscess or ECF
* Reactivation of former distal area of concern
* SSIs
* Anastomotic stricture and adhesions, causing SBO

== '''Technique''' ==

* Transverse elliptical skin incision around the stoma: 1-2mm above and below, 1cm to either side (can also do circular 2mm around)
* Allis clamps on each lateral skin tongue
* Use diathermy to cut down through subcutaneous fat, then Metz scissors to meticulously dissect the seromuscular layer of bowel away from fat, down to anterior fascia
** Assistant with Langenbach's
** Careful to avoid injuring the bowel, but you still stay very close to it
* Continue very patient dissection down through fascia until the peritoneum is entered. 
** Once you can get a finger in, start burning onto finger circumferentially
* Check for peritoneal adhesions, then gently deliver the bowel externally.
* Adhesiolysis - usually the mesentery is folded on itself, and can be unfolded with sharp dissection
* Anastomosis
** If the bowel can be easily exteriorised - stapled resection and anastomosis (excise mesentery horizontally across between the planned anastomosis sites, make small antimesenteric enterotomies, fire the GIA stapler, then fire again across the top and oversew)
** Limited mobility - either resect the ileostomy and do an end-to-end handsewn, or just close the ileostomy incision
* If having trouble, either extend the fascial incision or make a laparotomy, to allow adhesiolysis
* Closure abdominal wall - interrupted 0 PDS or Nylon
** If there's a large hernia, just remove the hernia sac and close the abdomen, save mesh for later
* Wound irrigation
* Skin closure - either leave open and pack or close with purse-string/interrupted Monocryl

== '''Post-op:''' ==

* Clear fluids immediately, with gradual escalation of diet (be conservative)
* Usually home day 3-4

== '''Complications''' ==

* Wound infection (20%)
* Prolonged ileus
* ECF
* Abdominal abscess
* Anastomotic leakage
* Internal hernia

[[Category:Small bowel]]