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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

Closure of a Loop Colostomy

Closure of a loop colostomy is facilitated if the posterior wall of the colon has been transected. If it has been transected, a classical colocolostomy is required.

The purpose of this operation is to close the colostomy and reestablish continuity of the colon without stricture at the site of the anastomosis.

Physiologic Changes.   After this procedure, the patient may resume defecation per anum. In addition, the patient will receive more nutritive value from food because the additional colonic surface will allow greater absorption of water and nutrients from the intestinal contents.

Points of Caution. Care must be taken to prevent stenosis at the anastomotic site. If the diameter of the anastomosis is less than 2 cm, the anastomosis should be taken down and resected. A classic end-to-end anastomosis should be performed to ensure adequate diameter to the intestine. If the posterior wall of the colon has been preserved, care should be taken to close the colostomy prior to opening the peritoneal cavity. This will reduce intraperitoneal contamination from the stoma site.

Copious irrigation of the wound should be made prior to primary closure. If gross contamination has occurred, delayed closure of the wound should be considered.


The patient should have a thorough surgical bowel prep prior to closure of the colostomy. This should consist of a clear liquid diet, a nonabsorbable antibiotic (such as neomycin and Sulfathalidine), and a thorough mechanical cleansing of the bowel.

The patient is placed in the supine position, and adequate anesthesia is administered. The abdomen is surgically prepared, and an elliptical incision is made in the skin approximately 2 cm from the margin of the colostomy stoma. This incision is carried down to the rectus fascia, but no farther.

After the incision has been made, Allis clamps are applied to the ends of the elliptical incision, and traction is applied upward. A sharp Metzenbaum scissors is used to trim excessive skin away from the margin of the bowel. Adhesions between the serosal surface of the bowel and rectus fascia are lysed by sharp dissection.

The bowel has been prepped for a Gambee single-layer through-and-through anastomosis. Synthetic absorbable sutures are placed through the wall of the bowel, starting on the mucosa, exiting through the serosa, reentering the serosa on the opposite side, and exiting through the mucosa of the opposite side. Thus the knot will be tied in the lumen of the bowel.

The Gambee anastomosis is near its completion with an inverting suture technique.

When the Gambee anastomosis has been completed, several Lembert sutures are placed north (N), east (E), and west (W) to relieve tension on the suture line and improve wound healing.

After the anastomosis is completed, the peritoneum is entered, and adhesions are dissected with Metzenbaum scissors.

The rectus fascia has been closed with synthetic delayed absorbable suture. A Hemovac suction drain is placed above the closure of the fascia and below the subcutaneous tissue.


The skin is closed with stainless steel clips. Note the suction drain ghosted under the closure. This is removed in 24-36 hours.

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