The use of temporary loop ileostomies in colorectal surgery is usually performed to protect high risk anastomosis, such as low colorectal anastomosis, or ileal pouch ileoanal anastomosis. Ileostomy is usually closed between eight weeks and three months following the initial procedure, once the anastomosis has healed properly.
With the advent of the new surgical techniques, procedures with higher risk anastomosis are more often performed, such as transanal total mesorectal excision. Thus, as the rate of derivative ileostomies increases, a revision of the surgical ileostomy closure technique is necessary, especially focusing on our younger trainees.
When closing a temporary ileostomy, the patient is placed in the supine position under general anesthesia. An elliptical incision is made on the skin and subcutaneous tissue around the ileostomy. The muscular wall and fascia are identified and dissection is continued downward with the cautery through the abdominal wall layers. Once the fascia is exposed, both bowel loops are carefully released from the fascia circumferentially to allow access to the peritoneal cavity. The peritoneal cavity is entered and adhesions, if any, are released.
Both ileal segments are brought into the surgical field in order to prepare them to perform the anastomosis. Two enterotomies will be performed on each loop in order to insert the staplers to create the anastomosis. Previously, the mesentery between the enterotomies has to be resected either with clamps and ties or with a sealing device. The Barcelona technique is the preferred one used by our team. Two small enterotomies on the antimesenteric side of each limb at the planned resection margin are carried out. A reticulated 60mm GIA stapler is used with a purple or golden load to perform the common channel enterotomy and enterostomy. The enterotomy is closed and the ileostomy is resected ileostomy using one or two GIA loads. Reinforcement of the anastomosis with interrupted or running suture according to the surgeon’s criteria. An omental patch can be overlapped. Another technique for anastomosis is first performing the resection of the ileostomy, and then performing the anastomosis.
The anastomosis is returned to the abdominal cavity. If needed, a chelotomy can be performed to ease the introduction of the anastomosis in the cavity without tension. Closure of the abdominal wall is performed as usual by layers. The peritoneum can be closed according to the surgeon’s preference and easier visualization of the plane. The fascia is the most important plane as it will hold the abdominal pressure. The subcutaneous tissue is approached and then the skin is closed with staples. Betadine gauzes can be used to clean the area, which is by definition a dirty field, with a high potential risk of infection.