Laparoscopic treatment of a recurrent colostomy prolapse

  • Abstract
    The creation of a colostomy is a frequent procedure in visceral surgery. Despite new operative techniques, the stoma formation remains an often necessary surgical procedure, which results in a dramatic change in the patients' life. Many complications, such as stoma necrosis, stoma retraction or stoma prolapse can occur. The objective of this video is to demonstrate the various ways in which a laparoscopic subperitoneal colostomy can be performed. This is the case of a female patient presenting a mental handicap and a chronic renal insufficiency with hemodialysis 3 times a week. She has had a definite colostomy for the treatment of anal incontinence, with complete sphincteric destruction. The colostomy was associated with recurrent episodes of prolapse. A laparoscopic approach is worth performing here in order to have a preperitoneal, subperitoneal tunnel between the right hypochondrium and the left subcostal area where the colostomy is located.
  • 00'10" Introduction
    The objective of this video is to demonstrate the various ways in which a laparoscopic subperitoneal colostomy can be performed. This is the case of a female patient presenting a mental handicap and a chronic renal insufficiency with hemodialysis 3 times a week. She has had a definite colostomy for the treatment of anal incontinence, with complete sphincteric destruction. The colostomy was associated with recurrent episodes of prolapse. This patient has had to undergo a repair of the colostomy several times for a colo-colic intussuception, always with prolapse recurrence. A laparoscopic approach is worth performing here in order to have a preperitoneal, subperitoneal tunnel between the right hypochondrium and the left subcostal area where the colostomy is located. This tunnel is carried out through the right hypochondrium port. The LigaSure Atlas® device or a bougie is used to tunnelize the preperitoneal space from right to left. The prolapsed and ischemic portion of colon is divided at the level of the transverse colon.
  • 01'35" Transverse colon division
    We begin by dividing the transverse colon and the lesser omentum using the Endo-GIA linear stapler.
  • 01'55" Mesocolon division
    The division of the mesocolon is then continued with the 10mm LigaSure Atlas® device. It is the prolapsed portion of the colon that is divided here. This portion was incarcerated in the stomy’s opening. This division is carried out without loss of carbon dioxide as, apart from the trocar introduction sites, there is no opening of the abdominal wall. The division is controlled without any problem thanks to the 10mm LigaSure Atlas® device.
  • 02'40" Colon tunnellization and prolapse resection
    A Vicryl loop is placed on the extremity of the transverse colon: this is used as a landmark to pull the colon into the preperitoneal space. To do so, the thread is held by a grasper introduced in the right hypochondrium. The port is then orientated towards the preperitoneal tunnel that was created initially in order to push the thread until the stomy opening is reached. The colostomy may then be approached and the prolapsed portion that caused pain and recurrent blood oozing is resected. Since the whole of the mesocolon and colon had been divided laparoscopically, the maneuver is fairly rapid. At this stage of the procedure, the traction thread can be retrieved before the transverse colon is brought into the preperitoneal tunnel. The colon is prepared in order to reduce the thickness of the colon and to free the fixed portion of the omentum. The landmark thread is pulled in order to bring the colon into the stomy opening for keeping.
  • 04'50" Colon fixation to the aponeurosis
    The colon is deeply fixed to the aponeurosis using a running suture of Polysorb 2/0.
  • 05'07" Skin fixation
    Then the colonic wall is also fixed to the skin using a running suture of Monocryl 3/0.
  • 05'13" Conclusion
    The benefit of this technique is the totally laparoscopic approach in the preparation of the colon. It also allows a preperitoneal route that helps to fix the colon over a length of around 15cm. It also restricts the risk of intussusception accountable for the prolapse in this handicapped patient with chronic renal insufficiency, a disability that forces her to go to the dialysis centre several times a week. Once the colon has been fixed in depth, it is opened and fixed superficially. The preperitoneal position of the colon is checked intra-abdominally. The absence of internal hernias and of colonic torsion is also verified.
  • Related medias
    The creation of a colostomy is a frequent procedure in visceral surgery. Despite new operative techniques, the stoma formation remains an often necessary surgical procedure, which results in a dramatic change in the patients' life. Many complications, such as stoma necrosis, stoma retraction or stoma prolapse can occur. The objective of this video is to demonstrate the various ways in which a laparoscopic subperitoneal colostomy can be performed. This is the case of a female patient presenting a mental handicap and a chronic renal insufficiency with hemodialysis 3 times a week. She has had a definite colostomy for the treatment of anal incontinence, with complete sphincteric destruction. The colostomy was associated with recurrent episodes of prolapse. A laparoscopic approach is worth performing here in order to have a preperitoneal, subperitoneal tunnel between the right hypochondrium and the left subcostal area where the colostomy is located.