๐๐ถ๐ฑ๐ฑ๐ฒ๐ป ๐ถ๐น๐ฒ๐ผ๐๐๐ผ๐บ๐ (Ghost ileostomy) as a rescue procedure in major colorectal surgeries: a novel technique to prevent re-laparotomy in anastomotic leak cases:
โขAnastomotic leak is a major cause of morbidity & mortality of patients worldwide, and it has remained stable over the last years. Routine construction of protective ileostomy is associated with stoma and negatively affects patientsโ quality of life in low colorectal surgeries. Developing another technique to minimize those drawbacks with at least the same clinical success can help patients with anastomotic leak. โHidden Ileostomyโis an alternative to protective ileostomy that can achieve that balance.
โขEven after years of advances in surgery, anastomotic complications remain a challenge after colon and rectal resections. Anastomotic leak (AL) prevalence has been reported to be between 8.1 and 11% after colon and rectal resections with a mortality rate of 18.6%.
๐ง๐ฒ๐ฐ๐ต๐ป๐ถ๐พ๐๐ฒ:
A hidden ileostomy is a stage before exteriorizing the ileostomy. After completing the major surgery, we locate the loop of the terminal ileum to construct the loop ileostomy. The loop selected for stoma should be at least 20 cm proximal to the ileocecal valve. For anatomical orientation, we marked the afferent loop with non-absorbable suture in the serosal layer. We taped the ileum loop by passing a silicone tape through a mesenteric window created close to the bowel, preferably in an avascular area as in Fig. 1. Both ends of silicone tape are exteriorized through a small incision through the abdominal wall (Fig. 2). Then we brought this loop ileostomy under the abdominal wall and left it unopened, making sure the loop is loose, not tight, then we fix both ends to the skin as in Fig. 3. This silicone loop will be covered with a sterile dressing.If the patient develops a postoperative anastomotic leak, it is easy to exteriorize the pre-fashioned ileostomy through a 2โ3 cm small incision. Both silicon ends will be gently pulled out, and the afferent loop is already marked with non-absorbable serosal suture for anatomical orientation, then stoma will be sutured to the skin in standard fashion. The intraoperative diagnostic endoscopy can be done to assess the extent of anastomotic leak and accordingly managed it. This procedure can be done under local anesthesia and sedation. So, the need for prolonged reoperation or unnecessary re-laparotomy could be avoided, and the risk of general anesthesia will be minimized without further morbidities to the patient.
๐๐ฑ๐๐ฎ๐ป๐๐ฎ๐ด๐ฒ๐:
The technique could reduce the postoperative morbidity and mortality, and length of hospital stay of patients in cases of the leak. It may also help reduce the cost burden on the patient and avoid a ๐ฟ๐ฒ๐ฑ๐ผ ๐น๐ฎ๐ฝ๐ฎ๐ฟ๐ผ๐๐ผ๐บ๐. This procedure can be done under ๐น๐ผ๐ฐ๐ฎ๐น anesthesia and ๐๐ฒ๐ฑ๐ฎ๐๐ถ๐ผ๐ป without general anesthesia, which may further increase the patientโs morbidity and costs. This technique could ๐๐ฝ๐ฎ๐ฟ๐ฒ a ๐ฟ๐ผ๐๐๐ถ๐ป๐ฒ construction of loop ileostomy for many patients, ๐ฎ๐๐ผ๐ถ๐ฑ ๐๐๐ผ๐บ๐ฎ-๐ฟ๐ฒ๐น๐ฎ๐๐ฒ๐ฑ ๐ฐ๐ผ๐บ๐ฝ๐น๐ถ๐ฐ๐ฎ๐๐ถ๐ผ๐ป๐,psychologicalimpact, quality of life of the patients, & risk associated with stoma closure.
๐๐ถ๐๐ฎ๐ฑ๐๐ฎ๐ป๐๐ฎ๐ด๐ฒ๐:
If the silicon loop is too tight, it may cause postoperative small bowel obstruction, so intraoperatively we must be sure that the loop is loose and the bowel not under tension. Postoperatively patients must be monitored closely for any symptoms or signs of bowel obstruction. In suspected cases, the abdominal sonography could be an adjunct tool for further evaluation. The silicon loop is a foreign body-like drain, and it may be associated with the risk of Infection. So, local care and regular sterile dressing must be considered.
๐๐ผ๐ป๐ฐ๐น๐๐๐ถ๐ผ๐ป:
A hidden ileostomy is an alternative and feasible technique in selected cases in colorectal surgery. This technique could be adopted in our practice instead of routine instruction of ileostomy, especially in the equivocal anastomosis.