Transverse Loop Colostomy

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Transverse Loop Colostomy

Transverse loop colostomy is a simple, fast, and relatively easy procedure used for those patients with pelvic disease in whom a temporary fecal diversion is needed and who are not candidates for an end sigmoid colostomy because of medical or technical reasons.

In general, transverse colostomies related to gynecologic malignancies should be performed on the left rather than the right transverse colon. A left transverse colostomy has the advantage of additional length of colon for fecal fluid absorption and allows the right transverse colon to remain available for small bowel bypass if needed in the future.

The purpose of the transverse loop colostomy is to divert the fecal stream.

Physiologic Changes. The fecal stream is diverted. Stool from the transverse colostomy will contain a larger volume of water than stool from a sigmoid colostomy. Therefore, a transverse colostomy may be more difficult to regulate.

Points of Caution. The incision for the colostomy should be well designed. The site for the stoma should be marked the night before surgery while the patient is in the standing position so that the stoma for the colostomy is not on the underside of the abdominal panniculus. The stoma site should be selected so as not to interfere with the waistline of clothing. The incision should be long enough to ensure adequate exposure of the bowel.

The three anatomic characteristics of the colon should be identified prior to performing the operation: the teniae coli, haustral markings, and the colonic relationship to the omentum. Closure of the abdominal wall around the colostomy should be tight enough to prevent hernia but should allow enough space to prevent strangulation and ischemia of the colonic loop.

Technique

The patient is placed in the dorsal position. A transverse incision is made left of the midline and approximately 6 cm above the umbilicus.

The colon is identified by the three anatomic characteristics: haustral markings, teniae coli, and omentum. A Metzenbaum scissors is used to lyse the fine filmy adhesions of the omentum for a distance of 8-10 cm.

The colon is rotated, and the posterior leaf of the omentum is likewise dissected from the surface of the bowel. This leaves a defect in the omentum.

The defect in the omentum is seen with the colon lying underneath. The mesocolon with its vessels is identified.

An avascular portion of the mesocolon is opened for a distance of approximately 3 cm. This is performed by placing the index finger of one hand under the colon and tenting up the avascular portion of the mesocolon.

The index finger of one hand is inserted through the opening in the mesocolon. The colon is elevated through the defect in the omentum. A rod is passed through the mesocolon. The omentum acts as a seal around the colon to reduce spillage into the peritoneal cavity when the colon is opened.

The colon is brought through the incision in the abdominal wall. If a large incision was needed to perform the procedure, a portion of the abdominal wall including the skin is closed with interrupted sutures. The wound is left open 1 finger width to ensure against strangulation. A rubber hose is connected to each end of the glass rod, or the rod is attached to the ring of a contemporary colostomy bag. The colon is ventilated by opening the anterior colonic wall in the longitudinal plane if the bowel has been prepared before surgery. The colostomy should be sutured with a 3-0 synthetic absorbable "rosebud" stitch.