Loop ileostomy / loop colostomy

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• stoma necrosis or retraction needing re-operation
• prolapse of the stoma, more with loop colostomy
• parastomal hernia
• high stoma output and dehydration, mainly with ileostomy
• skin excoriation around the stoma
• bleeding from the epigastric vessels in the abdominal wall
• incomplete diversion of faeces
• a second operation will be needed to close the stoma
• wound infection

Pre-operative details for this operation

1. Indication for diversione.g. obstruction with no resection planned, to protect a distal anastomosis, perineal sepsis or trauma, fistula
2. Type of stoma plannedLoop ileostomyLoop transverse colostomyLoop sigmoid colostomy
3. Stoma site marked pre-operativelyYes, by stoma therapistYes, by surgeonNot possible (emergency)site checked lying, sitting and standing; away from scars, bony points, skin creases and umbilicus; over the rectus
4. Imaging and scopy that define the distal diseaseCT, colonoscopy, biopsy report if available
5. Fluid and electrolyte statusurea, creatinine, sodium, potassium; NG tube if obstructed
6. Consent includes permanent stoma possibilityYesNot applicable

Anaesthesia and position

1. AnaesthesiaGeneralSpinalLocal infiltration
2. PositionSupine
3. AccessTrephine at stoma site onlyRight upper quadrant transverse incisionLower midline laparotomyLaparoscopic assisted
4. Urinary catheterYesNo

Operative findings

1. Peritoneal fluidNoneClearTurbidPurulent / faecalturbid or purulent fluid suggests perforation: record whether a full laparotomy was done
2. Bowel distensioncalibre of colon or ileum, viability, serosal tears
3. Segment used and how it was identifiedcolon: taeniae, haustra, appendices epiploicae; ileum: distance from ileocaecal junction
4. Distal pathology seen or feltsite and fixity of tumour, liver surface, peritoneal deposits if a laparotomy was done
5. Proximal and distal limbs identifiedhow orientation was confirmed (marking sutures, air insufflation per rectum)

Procedure (steps)

1. Painting and drapingantiseptic used
2. IncisionDisc of skin excised at marked siteTransverse right upper quadrant incisionLower midline incisionsize of skin disc (about 2 cm) or length of incision
3. Abdominal wall opened through rectusanterior sheath incised, rectus fibres split, posterior sheath and peritoneum opened; epigastric vessels seen and safe
4. Size of trephineabout two fingers' breadth; snug but not tight
5. Bowel loop selected and mobilisedileum: most distal loop that reaches without tension; colon: omentum separated from the segment
6. Mesenteric window made close to the bowelavascular area; tape, drain or catheter passed around the loop
7. Orientation markedmarking sutures on proximal and distal limbs; proximal limb placed cephalad
8. Loop delivered through the abdominal wall without tension or twistheight above skin before opening
9. Support rod / bridgeRod or bridge placedSilastic tube used as bridgeNonetype and size
10. Fixation of bowel to fasciaSeromuscular to rectus sheath suturesNot donenumber and suture
11. Main wound closed before opening the stomaYesNo main wound
12. Bowel openedTransverse antimesenteric incisionLongitudinal along the taeniadecompression by suction if distended
13. Stoma maturedfull-thickness bowel edge to dermis, interrupted absorbable sutures; suture size; ileostomy: proximal limb everted into a spout
14. Stoma applianceclear (transparent) bag applied in OT

Closure, drains and dressing

1. Main wound fasciasuture material and technique
2. Skin of main woundInterruptedSubcuticularStaplesNo separate wound
3. Stoma appearance at endcolour (pink / dusky), height above skin in cm, lumen position, both openings seen
4. DrainNoneIntraperitoneal

Specimens and implants

1. SpecimensNoneBiopsy of distal lesion / peritoneal deposit sent for HPE
2. Peritoneal fluid for cultureSentNot sent
3. Stoma rod / bridgetype and size, date due for removal

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Stoma checkcolour, height and bleeding every shift; inform if dusky, black or retracted
2. Stoma output chartvolume and character every shift; ileostomy output needs close fluid balance
3. Intake-output and electrolytesurine output, daily urea and electrolytes while output is high
4. Nasogastric tube and oral intakeremove NG and start liquids as stoma starts to work
5. Stoma rod / bridge removalplanned day (usually about 8 to 10 days)
6. Stoma nurse review and teachingbag changing, skin care, before discharge
7. Early mobilisation and VTE prophylaxisas per risk score
8. Follow-up plandefinitive treatment of distal disease; closure after distal bowel is assessed

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery