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