Closure of loop ileostomy / 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

• anastomotic leak and faecal fistula through the wound
• wound infection
• incisional hernia at the old stoma site
• adhesive small bowel obstruction
• injury to adjacent bowel needing resection
• extension of the wound or a formal laparotomy
• need for a new stoma if closure is unsafe
• change in bowel habit after closure

Pre-operative details for this operation

1. Original operation and date of stoma formationindication for the stoma, time since formation in weeks
2. Type of stomaLoop ileostomyLoop transverse colostomyLoop sigmoid colostomy
3. Distal bowel assessedWater-soluble contrast enemaColonoscopy / sigmoidoscopyBothresult: anastomosis healed, no leak, no stricture, no distal disease
4. Anal sphincter functionclinical tone, continence
5. Bowel preparationclear liquids for 24 hours, or other
6. Nutritional status and Hb

Anaesthesia and position

1. AnaesthesiaGeneralSpinal
2. PositionSupine
3. NG tube and urinary catheterBothCatheter onlyNeither

Operative findings

1. Stoma conditionhealthy / prolapsed / retracted / parastomal hernia
2. Adhesions around the stomaFilmyDense
3. Bowel after mobilisationserosal tears or enterotomies found and repaired, bowel wall thickness, bleeding from trimmed edge
4. Fascial defect sizeand whether enlarged

Procedure (steps)

1. Painting and draping, stoma packed offantiseptic; stoma covered or plugged with a swab
2. Skin incisionCircumstomal, 2 to 3 mm from mucocutaneous junctionEllipticalMidline laparotomy
3. Bowel dissected off subcutaneous fat and fasciatraction with Allis or artery forceps; sharp dissection on the serosa
4. Peritoneum entered and adhesions freed with fingerany extension of the fascial opening
5. Bowel mobilised enough for a tension-free closuresutures fixing bowel to fascia cut
6. Bowel checked for injuryeach limb irrigated under pressure with saline
7. Edges preparedeversion reversed (ileostomy); mucocutaneous junction and skin excised; edge trimmed to healthy bleeding bowel
8. Continuity restoredHand-sewn transverse closure (enterotomy only)Stapled side-to-side anastomosisResection and anastomosissuture material, size, single or two layers, stapler type and cartridge
9. Patency and leak checkfinger or thumb test of lumen
10. Bowel returned to the abdomenomentum over the closure if available

Closure, drains and dressing

1. Fascia / rectus sheathinterrupted or continuous, suture material and size; include anterior rectus sheath
2. SkinPurse-string subcuticular with small central gapLeft open, packedPrimary closure with subcutaneous drainLoose interrupted
3. Peritoneal drainNonePlaced
4. Dressingtype; pressure dressing if closed

Specimens and implants

1. SpecimenStoma edge / mucocutaneous ring, discardedStoma edge sent for HPEResected bowel segment sent for HPE
2. Stapler cartridges usedtype, length, number fired, sticker pasted

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. Vitals and abdominal examinationwatch for fever, tachycardia, distension, peritonism
2. NG tuberemove when aspirate is low, usually by 48 hours
3. Oral intakeliquids when bowel sounds return, then low-residue diet
4. Wound careinspect daily; open packing or purse-string dressing; report any faecal discharge
5. Bowel movementrecord first flatus and first stool
6. Catheter removalwhen mobile
7. VTE prophylaxis and mobilisationas per risk score
8. Perianal skin care and pelvic floor / sphincter exercisesfrequency and loose stools are common after closure

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