Blowhole for Cecal Eugene
Cecostomy Decompression
D. Gierson, MD, F. Kristian
Storm,
MD
Blowhole cecostomy is a method for achieving decompression of the distended cecum. Emphasis is placed on a McBurney-type incision, a watertight suture line joining bowel to muscle, and avoidance of opening the cecum until the suturing is done.
is a method of safe, sure de¬ of the distended cecum. It is a simple procedure, and no tube is required. Venting of cecal gas is assured. Our technique is derived from those described by Hunt1 and Turnbull et al.2
cecostomy Blowhole compression
TECHNIQUE Local Vi% lidocaine (Xylocaine) with epinephrine' or light gen¬ eral anesthesia is used. A transverse incision is made through McBurney point (Figure). The muscles may be cut or split. It is important to remain lateral to the rectus muscle and to keep the incision small to ensure that the cecum is encountered and not the small bowel. The distended cecum will "pop" into the wound, and is identified by the presence of tenia. It is desirable to have a por¬ tion of the cecum protrude above the skin, as this facilitates place¬ ment of a colostomy bag. The seromuscular layers of the cecum are sutured to the exter¬ nal or internal oblique muscles (Figure), care being taken to in¬ clude the aponeurosis of these muscles in each suture; 3-0 silk su¬ tures, with swaged-on needles, are used. Care is taken not to penetrate the mucosa of the bowel. These interrupted sutures are placed circumferentially, and closely spaced to ensure a water¬ tight seal. If there is doubt that a watertight seal has been achieved, a second layer of interrupted, nonabsorbable sutures is placed, joining the cecal wall to the subcutaneous fat.'2
Accepted for publication Oct 29, 1974. From the Department of Surgery, UCLA Medical Center, Los Angeles, and the Sepulveda Veterans Administration Hospital, Sepulveda, Calif (Dr. Gierson). Dr. Gierson is currently with the Southern California Permanente Medical Group, Harbor City, Calif. Reprint requests to Southern California Permanente Medical Group, 1050 Pacific Coast Hwy, Harbor City, CA 90710 (Dr. Gierson).
The cecum is incised with scalpel through the tenia or through a lateral-inferior area (Figure). Large quantities of gas and stool will spill out. A lateral-inferior incision facilitates gravity drain¬ age into the subsequently placed colostomy bag. Cautery should not be used, as explosion may result.' " Bleeding of the cut edges of the cecostomy is controlled by clamp and silk ligature. The skin is not closed. We have used blowhole cecostomy in two patients.
REPORT OF CASES
62-year-old man who was bedridden with multiple sclerosis developed urinary retention and a urinary tract infec¬ tion. The abdomen became distended, cecal diameter was 15 cm (abdominal roentgenogram), and a diagnosis of impending cecal perforation due to colonie ileus was made. A blowhole cecostomy was created under light general anesthesia. This decompressed the bowel, and elective closure of the cecostomy was done five months later. Case 2.—A 73-year-old man with gangrene of the right foot de¬ veloped severe abdominal distention one week after a right belowknee amputation. An abdominal roentgenogram revealed a cecum 14 cm in diameter. Barium enema and sigmoidoscopy failed to show any lesion. Using local anesthesia, an emergency blowhole cecostomy was done. One area of the cecal wall was nearly rup¬ tured. The cecostomy decompressed the colon and continued to function well until it was closed five months later. Case 1.—A
COMMENT Blowhole cecostomy can be performed under local anes¬ thesia. It is safe and simple. Decompression of the cecum is guaranteed, and the problems of a tube cecostomy are avoided. Such problems include occlusion of the catheter with stool, intraperitoneal spillage of stool, and postopera¬ tive rupture of the cecum. Tube cecostomy has failed to decompress the cecum in as many as 50% of cases,*-' and inadequate function of the tube can be fatal.81" Many au-
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colon due to intrinsic cancer. West J Surg Obstet Gynecol 67:101\x=req-\ 105, 1959. 2. Turnbull RB, Weakley FL, Hawk WA, et al: Choice of operation for the toxic megacolon phase of nonspecific ulcerative colitis. Surg Clin North Am 50:1151-1169, 1970. 3. Gierson ED: Vasoconstrictor agents in local anesthetic preparations. Lancet 2:1142, 1972. 4. Barrkman MF: Intestinal explosion after opening a caecostomy with diathermy. Br Med J 1:1594-1595, 1965. 5. Ragins H, Shinya H, Wolff WI: The explosive potential of coIonic gas during colonoscopic electrosurgical polypectomy. Surg Gynecol Obstet 138:554-556, 1974. 6. Albers JH, Smith LL: A comparison of cecostomy and transverse colostomy in complete colon obstruction. Surg Gynecol Obstet 95:410-415, 1952. 7. Maynard AD, Turell R: Acute left colon obstruction with special reference to cecostomy versus transversostomy. Surg Gynecol Obstet 100:667-674, 1955. 8. Balslev I, Jensen H, Nielsen J: The place of cecostomy in the relief of obstructive carcinoma of the colon. Dis Colon Rectum 13:207-210, 1970. 9. Hopkins JE: Tube cecostomy: An appraisal. Dis Colon Rec-
tum
A, Transverse 5-cm incision at McBurney point. Cecum, identified by tenia, distends through wound. B, Anterior and transverse views of watertight seal between cecum and abdominal wall. Cecum su¬ tured to fascia with 3-0 silk. C, Cecum opened along tenia.
thors have noted dissatisfaction with tube cecostomy,11114 although good results have been reported.15·16 Perforation of the cecum results in a mortality ap¬ proaching 50%.1? The occurrence of cecal perforation is dif¬ ficult to predict in advance. However, the normal cecum is less than 9 cm in diameter1"1!l and in several reports of ce¬ cal rupture, the diameter was 9 cm or larger.17-2""24 Thus we have adapted the "rule-of-nine": "A cecum 9 cm or larger is in danger of rupturing." This circumstance requires careful therapy. References 1. Hunt CJ: Surface cecostomy versus right colon colostomy as the procedure of choice in decompressing the acutely obstructed
12:379-385, 1969.
10. Jackson PP, Baird RM: Cecostomy: An analysis of 102 cases. Am J Surg 114:297-301, 1967. 11. Gregg RO, Dixon CF: Operable malignant lesions of the colon producing obstructions. Surg Clin North Am 21:1143-1152, 1941. 12. Hendricks W, Griffin WD: Symposium on clinical advances in surgery: Intestinal obstructions. Surg Clin North Am 27:51-72, 1947. 13. Michel ML, McCafferty EL: Acute obstruction of the colon: With special reference to factors of mortality. Arch Surg 57:774\x=req-\ 790, 1948. 14. Rack FJ, Clement KW: Cecostomy and colostomy in acute colon obstructions. JAMA 154:307-309, 1954. 15. Wanebo H, Mathewson C, Conolly B: Pseudo-obstruction of the colon. Surg Gynecol Obstet 133:44-48, 1971. 16. Westdahl PR, Russel T: In support of blind tube cecostomy in acute obstruction of the descending colon: Analysis of 93 emergency cecostomies. Am J Surg 118:577-581, 1969. 17. Wojtalik RS, Lindenauer SM, Kahn SS: Perforation of the colon associated with adynamic ileus. Am J Surg 125:601-606,1973. 18. Lowman RM, Davis L: An evaluation of cecal size in impending perforation of the cecum. Surg Gynecol Obstet 103:711\x=req-\ 718, 1956. 19. Davis L, Lowman R: Roentgen criteria of impending perforation of the cecum. Radiology 68:542-548, 1957. 20. Robertson JA, Eddy WA, Vosseler AJ: Spontaneous perforation of the cecum without mechanical obstruction. Am J Surg 96:448-452, 1958. 21. Eckman WG, Wenzke F, Abramson W: Perforation of the cecum complicating adynamic ileus. Am J Surg 96:718-720, 1958. 22. Yeo R: Spontaneous perforation of the caecum: Case reports and a review of the literature. Postgrad Med J 43:65-67, 1967. 23. Carrasquilla C, Arbulu A, Fromm S, et al: Cecal perforation due to adynamic ileus. Dis Colon Rectum 13:252-254, 1970. 24. Muggia AL: Perforation of the cecum associated with hypokalemic ileus. Am J Gastroenterol 57:169-171, 1972.
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Cecostomy Decompression
D. Gierson, MD, F. Kristian
Storm,
MD
Blowhole cecostomy is a method for achieving decompression of the distended cecum. Emphasis is placed on a McBurney-type incision, a watertight suture line joining bowel to muscle, and avoidance of opening the cecum until the suturing is done.
is a method of safe, sure de¬ of the distended cecum. It is a simple procedure, and no tube is required. Venting of cecal gas is assured. Our technique is derived from those described by Hunt1 and Turnbull et al.2
cecostomy Blowhole compression
TECHNIQUE Local Vi% lidocaine (Xylocaine) with epinephrine' or light gen¬ eral anesthesia is used. A transverse incision is made through McBurney point (Figure). The muscles may be cut or split. It is important to remain lateral to the rectus muscle and to keep the incision small to ensure that the cecum is encountered and not the small bowel. The distended cecum will "pop" into the wound, and is identified by the presence of tenia. It is desirable to have a por¬ tion of the cecum protrude above the skin, as this facilitates place¬ ment of a colostomy bag. The seromuscular layers of the cecum are sutured to the exter¬ nal or internal oblique muscles (Figure), care being taken to in¬ clude the aponeurosis of these muscles in each suture; 3-0 silk su¬ tures, with swaged-on needles, are used. Care is taken not to penetrate the mucosa of the bowel. These interrupted sutures are placed circumferentially, and closely spaced to ensure a water¬ tight seal. If there is doubt that a watertight seal has been achieved, a second layer of interrupted, nonabsorbable sutures is placed, joining the cecal wall to the subcutaneous fat.'2
Accepted for publication Oct 29, 1974. From the Department of Surgery, UCLA Medical Center, Los Angeles, and the Sepulveda Veterans Administration Hospital, Sepulveda, Calif (Dr. Gierson). Dr. Gierson is currently with the Southern California Permanente Medical Group, Harbor City, Calif. Reprint requests to Southern California Permanente Medical Group, 1050 Pacific Coast Hwy, Harbor City, CA 90710 (Dr. Gierson).
The cecum is incised with scalpel through the tenia or through a lateral-inferior area (Figure). Large quantities of gas and stool will spill out. A lateral-inferior incision facilitates gravity drain¬ age into the subsequently placed colostomy bag. Cautery should not be used, as explosion may result.' " Bleeding of the cut edges of the cecostomy is controlled by clamp and silk ligature. The skin is not closed. We have used blowhole cecostomy in two patients.
REPORT OF CASES
62-year-old man who was bedridden with multiple sclerosis developed urinary retention and a urinary tract infec¬ tion. The abdomen became distended, cecal diameter was 15 cm (abdominal roentgenogram), and a diagnosis of impending cecal perforation due to colonie ileus was made. A blowhole cecostomy was created under light general anesthesia. This decompressed the bowel, and elective closure of the cecostomy was done five months later. Case 2.—A 73-year-old man with gangrene of the right foot de¬ veloped severe abdominal distention one week after a right belowknee amputation. An abdominal roentgenogram revealed a cecum 14 cm in diameter. Barium enema and sigmoidoscopy failed to show any lesion. Using local anesthesia, an emergency blowhole cecostomy was done. One area of the cecal wall was nearly rup¬ tured. The cecostomy decompressed the colon and continued to function well until it was closed five months later. Case 1.—A
COMMENT Blowhole cecostomy can be performed under local anes¬ thesia. It is safe and simple. Decompression of the cecum is guaranteed, and the problems of a tube cecostomy are avoided. Such problems include occlusion of the catheter with stool, intraperitoneal spillage of stool, and postopera¬ tive rupture of the cecum. Tube cecostomy has failed to decompress the cecum in as many as 50% of cases,*-' and inadequate function of the tube can be fatal.81" Many au-
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/20/2015
colon due to intrinsic cancer. West J Surg Obstet Gynecol 67:101\x=req-\ 105, 1959. 2. Turnbull RB, Weakley FL, Hawk WA, et al: Choice of operation for the toxic megacolon phase of nonspecific ulcerative colitis. Surg Clin North Am 50:1151-1169, 1970. 3. Gierson ED: Vasoconstrictor agents in local anesthetic preparations. Lancet 2:1142, 1972. 4. Barrkman MF: Intestinal explosion after opening a caecostomy with diathermy. Br Med J 1:1594-1595, 1965. 5. Ragins H, Shinya H, Wolff WI: The explosive potential of coIonic gas during colonoscopic electrosurgical polypectomy. Surg Gynecol Obstet 138:554-556, 1974. 6. Albers JH, Smith LL: A comparison of cecostomy and transverse colostomy in complete colon obstruction. Surg Gynecol Obstet 95:410-415, 1952. 7. Maynard AD, Turell R: Acute left colon obstruction with special reference to cecostomy versus transversostomy. Surg Gynecol Obstet 100:667-674, 1955. 8. Balslev I, Jensen H, Nielsen J: The place of cecostomy in the relief of obstructive carcinoma of the colon. Dis Colon Rectum 13:207-210, 1970. 9. Hopkins JE: Tube cecostomy: An appraisal. Dis Colon Rec-
tum
A, Transverse 5-cm incision at McBurney point. Cecum, identified by tenia, distends through wound. B, Anterior and transverse views of watertight seal between cecum and abdominal wall. Cecum su¬ tured to fascia with 3-0 silk. C, Cecum opened along tenia.
thors have noted dissatisfaction with tube cecostomy,11114 although good results have been reported.15·16 Perforation of the cecum results in a mortality ap¬ proaching 50%.1? The occurrence of cecal perforation is dif¬ ficult to predict in advance. However, the normal cecum is less than 9 cm in diameter1"1!l and in several reports of ce¬ cal rupture, the diameter was 9 cm or larger.17-2""24 Thus we have adapted the "rule-of-nine": "A cecum 9 cm or larger is in danger of rupturing." This circumstance requires careful therapy. References 1. Hunt CJ: Surface cecostomy versus right colon colostomy as the procedure of choice in decompressing the acutely obstructed
12:379-385, 1969.
10. Jackson PP, Baird RM: Cecostomy: An analysis of 102 cases. Am J Surg 114:297-301, 1967. 11. Gregg RO, Dixon CF: Operable malignant lesions of the colon producing obstructions. Surg Clin North Am 21:1143-1152, 1941. 12. Hendricks W, Griffin WD: Symposium on clinical advances in surgery: Intestinal obstructions. Surg Clin North Am 27:51-72, 1947. 13. Michel ML, McCafferty EL: Acute obstruction of the colon: With special reference to factors of mortality. Arch Surg 57:774\x=req-\ 790, 1948. 14. Rack FJ, Clement KW: Cecostomy and colostomy in acute colon obstructions. JAMA 154:307-309, 1954. 15. Wanebo H, Mathewson C, Conolly B: Pseudo-obstruction of the colon. Surg Gynecol Obstet 133:44-48, 1971. 16. Westdahl PR, Russel T: In support of blind tube cecostomy in acute obstruction of the descending colon: Analysis of 93 emergency cecostomies. Am J Surg 118:577-581, 1969. 17. Wojtalik RS, Lindenauer SM, Kahn SS: Perforation of the colon associated with adynamic ileus. Am J Surg 125:601-606,1973. 18. Lowman RM, Davis L: An evaluation of cecal size in impending perforation of the cecum. Surg Gynecol Obstet 103:711\x=req-\ 718, 1956. 19. Davis L, Lowman R: Roentgen criteria of impending perforation of the cecum. Radiology 68:542-548, 1957. 20. Robertson JA, Eddy WA, Vosseler AJ: Spontaneous perforation of the cecum without mechanical obstruction. Am J Surg 96:448-452, 1958. 21. Eckman WG, Wenzke F, Abramson W: Perforation of the cecum complicating adynamic ileus. Am J Surg 96:718-720, 1958. 22. Yeo R: Spontaneous perforation of the caecum: Case reports and a review of the literature. Postgrad Med J 43:65-67, 1967. 23. Carrasquilla C, Arbulu A, Fromm S, et al: Cecal perforation due to adynamic ileus. Dis Colon Rectum 13:252-254, 1970. 24. Muggia AL: Perforation of the cecum associated with hypokalemic ileus. Am J Gastroenterol 57:169-171, 1972.
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