Colonoscopy-Assisted Colostomy--An Mternative to Laparotomy Report of Two Cases

Asish Mukherjee, M.D., Virendra A. Parikh, M.D., Pedro S. Aguilar, M.D. From the Division of Colon and Rectal Surgery, Grant Medical Center, Columbus, Ohio

PURPOSE: The objective of this study was to evaluate the drainage from multiple sites in the perineum and feasibility of performing fecal diversion with the help of a scrotum. Antibiotics were effective initially but failed colonoscope without a concomitant laparotomy. METH- ODS: Colostomies were performed on two patients who to control subsequent flareups. Examination revealed needed fecal diversion and who would benefit from avoid- extensive induration, with multiple sites of purulent ing the morbidity of laparotomy. A colonoscope was used in discharge. The entire skin of the buttocks and part of each case to guide the surgeon in selecting the appropriate the scrotum were involved. The anoderm was spared, bowel segment. RESULTS: No complications related to the colostomy were noted in either patient. CONCLUSIONS: and no lesions or internal fistulous openings were The technique of colonoscopy-assisted colostomy that we noted at anoscopy and rigid sigmoidoscopy. Wide have described offers an acceptable method of creating excision and skin grafting were recommended. There a stoma without the need for laparotomy. [Key words: Colonoscopy; Colostomy; Fecal diversion] was an obvious need for fecal diversion without any Mukherjee A, Parikh VA, Aguilar PS. Colonoscopy-assisted specific need to perform a laparotomy. Colostomy colostomy--an alternative to laparotomy: report of two was performed without a laparotomy by use of the cases. Dis Colon Rectum 1998;41:1458-1460. technique described later.

he construction of a colostomy is frequently T needed in situations where fecal diversion is the Case 2 only goal, and an abdominal exploration is unneces- An 89-year-old female had intractable discharge sary. In such cases a laparotomy is the cause of un- from a large rectovaginal fistula. She had undergone desirable morbidity and is performed as an unavoid- pelvic irradiation for vaginal cancer 18 months before. able technical necessity. Laparoscopic and trephine This had entailed both external irradiation and inter- colostomies have been used in these situations. 1' 2 stitial implants. The cancer was of the squamous-cetl Both these procedures are able to circumvent a lap- type, invading the rectovaginal septum. At the time of arotomy but are not without significant disadvan- this study, she was experiencing vaginal discomfort tages. We describe a method of colonoscopy-assisted and itching that was not tolerable even with a high cotostomy that is safe and inexpensive and can afford degree of nursing care. Biopsies did not reveal any accurate determination of the bowel level. evidence of recurrent or residual cancer, and a cor- rective surgical procedure was considered inappro- REPORT OF CASES priate in view of the unhealthy condition of the irra- Two patients were chosen for this procedure in diated vagina and the patient's advanced age. The view of their need for a fecal diversion without any patient needed a diverting colostomy to ameliorate foreseeable benefit in subjecting them to an abdom- her condition. A laparotomy would not benefit her inal exploration. and would only be a potential cause of further mor- bidity. In this case, too, a colonoscopy-assisted colos- Case 1 tomy was performed without a laparotomy. A 59-year-old male with non-insulin-dependent di- abetes had a long history of extensive hidradenitis suppurativa affecting the groin, perineum, and but- Operative Technique tocks. He was experiencing swelling, discomfort, and Bowel preparation and antibiotics were adminis- tered, and consent for possible laparotomy was ob- Address reprint requests to Dr. Aguilar: Division of Colon and tained in each case. The patient was positioned in Rectal Surgery, Grant Medical Center, 300 East Town Street, Suite 200, Columbus, Ohio 43215. lithotomy with a gentle Trendelenburg tilt. After ad- 1458 Vol. 41, No. 11 COLONOSCOPY-ASSISTED COLOSTOMY 1459 ministration of general anesthetic, the flexible colono- scope was introduced per rectum and advanced to the descending colon under visual guidance. The endo- scope was maintained in this position and the abdo- ,.. ~ j Hooking Colon men was prepared and draped in the standard man- ~ I .2~ By Palpation Of ner. A circular incision was made at the premarked ~ Colonoscope colostomy site, within the belly of the rectus, After excising the skin and subcutaneous fat, the anterior rectus sheath was incised in a cruciate manner. The vertical fibers of the rectus were separated with a Kelly clamp, and the peritoneum was opened. Small retractors were used to separate the edges of the wound. At this point the colonoscope in the lumen of the gut could be palpated easily by a simple digital exploration (Fig. 1). The loop of the sigmoid colon could then be grasped with fingers and was pulled out into the wound (Fig. 2). This procedure is easy if Figure 2. Sigmoid loop located by palpation of intralumi- nal endoscope. the sigmoid loop is redundant but could be relatively difficult if the mesocolon is short. In the latter situa- tion the application of Babcock's forceps at the de- Colostomy Completed sired location on the sigmoid loop followed by trac- tion and manipulation would be needed in a manner similar to the delivery of the cecum in appendectomy'. , Supportilg Tubing A Penrose drain was inserted through mesocoton to stabilize the sigmoid loop. The colonoscope was withdrawn further, and the proximal-to-distal orien- tation of the sigmoid loop was clearly identified dur- ing that process. The colonoscope was now removed and the sigmoid loop was opened at the antimeso- colic tenia (Fig. 3). The colostomy was matured by stitching the colonic wall to the subcuticular layer circumferentially. The Penrose drain was replaced Colonoscope Withdrawal with a red rubber catheter, which was fixed to the Figure 3. Completed colostomy. skin with stitches.

ined two weeks after the closure, the colostomy site RESULTS was completely healed. No stomal complications oc- In Case 1 extraperitoneal closure of the stoma was curred at any stage. In Case 2, also, no stoma-related done 15 weeks later, when the perineum was in complications had occurred by the ten-month follow- satisfactory condition. When the patient was exam- up.

Anterior Abdominal Wall DISCUSSION The need to perform a fecal diversion without the additional morbidity of abdominal exploration is fre- quently desirable in situations like intractable perianal sepsis, complex fistula-in-ano, advanced pelvic malignancy, before extensive perineal plastic proce- dures, and broadly in any scenario in which a lapa- rotomy does not serve any therapeutic goal. Laparos- copy offers an alternative, but is associated with Figure 1. Cotonoscope in the sigmoid lumen. significant expense, a steep learning curve, and pos- 1460 MUKHERJEE ETAL Dis Colon Rectum, November 1998 sibly longer operative time. A method of trephine of laparoscopic enterostomies and colostomies in colostomy has been described that is essentially a mini Crohn's disease. Kini et al. 6 reported six cases of laparotomy and does not allow easy identification of laparoscopic trephine colostomies. They concluded the level of the colon and differentiation between the that this technique could overcome the tendency to proximal and distal ends of the sigmoid loop. enlarge the trephine wound for mobilization of the Senapati and Philtips I reported a series of 16 pa- colon with the conventional technique. tients who underwent trephine colostomy with con- The technique we have described averts most of the version to laparotomy required only in three. Their difficulties described above. Performing an intraopera- technique entailed the creation of a left lower quad- rive colonoscopy and palpating its tip helps determine rant trephine wound in the abdominal parietes and the bowel level quite easily. The slow withdrawal of the delivery of the sigmoid loop with the help of Bab- endoscope after the loop has been grasped indicates the cock's forceps. Lateral mobilization with scissors was orientation of the gut without the need for any exotic needed in the presence of adhesions or a short mes- maneuvers. We encountered no stoma-related compli- entry. The authors had to rely on anatomical features cations in our two cases and were able to achieve a like appendices epiploicae and omental attachments significantly reduced operative and convalescence time. to distinguish the transverse from the sigmoid colon Although Sanapati and Phillips 1 alluded to the use of and had to resort to a variety of innovative techniques intraoperative endoscopy, they had used it in isolated to determine the proximal to distal orientation. These cases and had not developed a uniform technique. included palpation of the root of the mesocolon, in- sufflation of air per rectum, intraoperative sigmoidos- CONCLUSIONS copy, and saline injection via a catheter introduced through a colotomy. Potential pitfalls of this tech- Colostomy can be performed with the assistance of nique included retraction of soma, inadvertent trans- intraoperative colonoscopy without the need for a verse colostomy, and difficulty in identifying the laparotomy. This method avoids the disadvantages of proximal loop. They reported a mean hospital stay of unreliable bowel identification of the trephine tech- 11 days. Anderson et al. 2 described the same proce- nique or the higher costs and learning curve of lapa- dure in their study of 24 patients, but they used a roscopic methods. uniform technique of air insufflation ~.qa a rectal cath- eter against a clamped colonic loop to distinguish the REFERENCES proximal and distal limbs. They compared the results 1. Senapati A, Phillips RK. The trephine colostomy: a per- with a group of patients undergoing laparotomy and manent left iliac fossa end colostomy without recourse noted significant advantages in terms of operating to laparotomy. 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