EXTENSIVE THROUGH

SHORTENING

OF ILEAL CONDUIT

PERISTOMAL INCISION

JOHN F. REDMAN,

M.D.

From the Department of Urology, University of Arkansas College of Medicine, Little Rock, Arkansas

-A conservative ABSTRACT through a peristomal incision.

procedure is described for shortening the redundant ileal segment The procedure may be used to complement a stoma1 revision.

Excessive length of ileal segments after ileal conduit urinary diversion is usually reported to occur in 7 to 10 per cent of cases in which this complication has been noted.‘m3 Although an ileal conduit of ideal length has not been described, certain ileal segments are remarkable because of their redundancy and poor emptying. In the past three years we have had occasion to consider reoperation of the ileal segment because of redundancy, diverticulum formation, or sacculation of the proximal segments. In 9 patients with redundant ileal segments we chose as a conservative measure the resection of a significant portion of the loop through a peristomal incision.

Technique A peristomal incision is made. The cutaneous ring is grasped with an Allis clamp and light traction is exerted (Fig. 1A). With care the dissection is carried along the serosal surface of the bowel. If the ileal segment traverses the peritoneal cavity, care must be exercised to avoid incising adhered small bowel. As the redundant segment is delivered through the incision, care should be taken to avoid damaging the mesentery. The mesentery may be divided parallel with the segment much like cutting the spokes of wheel to gain length and effect straightening. 4 Dissection is terminated

incision 1. (A) FIGURE around stoma; cutaneous ring grasped with Allis clamp. (B) Relatively long segment of ileum being delivered through wound.

UROLOGY

I

JANUARY 1977 / VOLUME

IX, NUMBER

1

45

FIGURE 2. lleostogram taken (A) pt-eoperatively and (B) after shortening of ileum segment through peristomal

incision. (C) Ten-minute postoperative excretory urogram.

FIGURE 3. lleostogram taken (A) preoperatively an postoperatively after dilEi’ shortening.

when visualization is no longer adequate and no further length of protruding ileum is gained with further dissection (Fig. 1B). The stoma is reconstructed using a skin flap as has been previously described.‘-’ Results

adherent small bowel. The opening was closed in layers without sequela. No other complication occurred, and no patient required a further incision into the abdominal cavity. In all 9 patients emptying of the ileal segments improved to some degree. In 3 patients the ileal segment previously had been completely retroperitonealized which did not hamper extensive mobilization.

Nine patients underwent shortening of ileal segments through peristomal incisions (Figs. 2 and 3). Five patients had concomitant stomal stenosis, and 1 patient had stenosis at the fascial level. The remaining 3 patients had no demonstrable stenosis. The minimal length resected was 3 cm. and the maximum 12 cm. In I patient a small incision was made into

Although the technique as described is stated to be a conservative measure to avoid a major intra-abdominal procedure, the surgeon should be adequately prepared for all contingencies.

46

UROLOGY

Comment

/ JANUARY1977 / VOLUMEIX, NUMBER1

Markland and Flocks’ stated the problem in their discussion of stoma1 revision:

well

Accurate complete preoperative assessment is important, as one must be prepared to lyse and free the stoma at all levels. This revision may be a simple procedure but it is best to be prepared for all kinds of trouble, particularly when dissecting the blood supply in dense scar tissue. Occasionally, a new loop may have to be refashioned, a possibility during every stoma1 revision. This technique has undoubtedly been used by others to some extent in the course of stoma1 revision. We have been impressed by the length of ileal segment which can be delivered rather easily through the peristomal incision and find it a complementary procedure to stoma1 revision. We have not been concerned that the ileal segment can be made too short and then preclude subsequent stoma1 revision.9 Little Rock, Arkansas 72201

UROLOGY /

JANUARY 1977 /

VOLUME IX, NUMBER 1

References 1. LOGAN, C. W., SCOTT, R., JR., and LASKOWSKI, T. Z. : Real loop diversion: evaluation of late results in pediatric urology, J. Ural. 94: 544 (1965). 2. BOWLES, W. T., and TALL, B. A.: Urinary diversion in children, ibid. 98: 597 (1967). 3. SCHWARZ, G. R., and JEFFS, R. D.: Real conduit urinary diversion in children: comparative analysis of followup from 2 to 16 years, ibid. 114: 285 (1975). 4. MARSHALL, F. F., LEADBETTER,W. F., and DRETLER, S. P.: Ileal conduit parastomal hernias, ibirl. 114: 40 (1975). 5. RICHARDSON, J. R., JR., LINTON, P. C., and LEADBETTER, G. W., JR.: A new concept in the treatment of stoma1 stenosis, ibid. 108: 159 (1972). 6. PERLMUTTER, A. D.: Spiral advancement skin flap for stoma1 revision, ibid. 114: 131 (1975). 7. DAVID, F. R. D.: A new surgical procedure for revision of ileal conduit stoma in children, ibid. 115: 188 (1976). 8. MARKLAND, C., and FLOCKS, R. H.: The ileac conduit stoma, ibid. 95: 344 (1966). 9. POOR, P., KIRSH, E. D., and PERSKY, L.: The add-on ileal loop, ibid. 114: 281 (1975).

47

Extensive shortening of ileal conduit through peristomal incision.

EXTENSIVE THROUGH SHORTENING OF ILEAL CONDUIT PERISTOMAL INCISION JOHN F. REDMAN, M.D. From the Department of Urology, University of Arkansas Co...
2MB Sizes 0 Downloads 0 Views