Loop Colostomy

00:00 What is loop colostomy and loop ileostomy? Yes, yeah, yeah.

00:10 When do you do that? Hemi.

00:21 So, why do you want to do a primary anastomosis and then defunction? Right. Yes. That's right. It's absolutely spot-on.

00:32 Classically, we do it for a left hemi.

00:36 Now, if you have anastomosed that part of the transverse colon to the upper part of the sigmoid here, you don't want the patient to start feeding from day one and for the bowel contents to go into the anastomotic part.

00:51 So, you defunction it temporarily.

00:54 In theory, you can defunction it this way, can’t you? You can defunction both ends like this.

01:00 But then to put it back, it's much harder because you have taken the whole end back, then you'll need a GA to put it back.

01:07 What we do is you do a loop colostomy that way, where you bring it as a loop but you don't divide the ends of the bowel.

01:21 You divide one end of the bowel so that it is still in continuity but most of the fecal content is coming out before it's going into the stoma, before it is going to the distal part.

01:35 So, the part is still in continuity so that when you want to reanastomose it, you can do it in local anesthetic.

01:43 So, all you need to do is pull the bowel out, suture the top part and put it back in.

01:49 Yeah. You can do that, yeah.

01:51 We close, you can close the bowel under local.

01:54 But then clearly you need to see, that's the whole purpose.

01:57 If you have an 84-year-old lady who can't go for another laparotomy, So in that case, you quickly defunction it, at least for two days, three days to give a bit of rest to the anastomotic part and then you close it.

02:12 So, that's the whole idea about a loop.

02:13 I suppose the only ones I've seen are the ones that have been out for a couple of, say, a month or so.

02:17 Yes.

02:17 They don't just close it. They do actually remove a bit of the loop.

02:23 The loop, because that is more like debriding and freshening of the bowel.

02:28 I guess they don't do that. They're the ones I’ve seen.

02:30 Then they do it under GA. Yeah.

02:35 But the principle is to protect the distal anastomosis for X amount of days.

02:48 Anterior resection, anterior resection, if you have enough stem distally in the rectum, you can.

02:53 If you have preserved the anal sphincter, then you can anastomose the colon with that part of the rectum.

02:58 Yeah, yeah.

02:59 Those that we call pouch.

03:01 The j-pouch. No, j-pouch is more like a temporary rectum.

03:05 That's classically done in ulcerative colitis.

03:08 That is more of when you don't have any rectum and the sphincter is also compromised.

03:15 You haven't done an AP resection.

03:17 We still got a little bit of the anal canal but there is no sphincter.

03:20 So, the feces just can't keep on going, so you make a pouch to store it temporally.

03:26 Then when it fills up, it all falls.

03:30 Yeah. If you have a sphincter, it is safe to anastomose it because you have a good sphincter.

03:36 The sphincter is tight.

03:37 It is better to anastomosis it so the patient has got a normal bowel, isn't it? Rectum, yeah, that's right.

03:52 When you do a panproctocolectomy, you probably can anastomose because you are taking off the entire colon.

03:57 You are bringing up an ileostomy here, isn’t it? Because there's nothing to anastomose.

04:05 Subtotal also, yeah. It’s very tricky to anastomose.

04:08 You’ll end up with ileostomy.

04:10 So, you say it’s a condition where you might potentially go into...

04:15 Panproctocolectomy or a subtotal colectomy.

04:17 It changes the way you might do a subtotal colectomy? Again, you see, depending on the extent of the disease.

04:24 Yeah, because panproctocolectomy is quite aggressive.

04:26 You are pretty much taking off the whole of the bowels.

04:29 They try subtotal first then and they go in...

04:31 Not always but yes.

04:33 Many times you try to conserve as much as you can.

04:35 You see patients inevitably end up with ileostomy because there's nothing to anastomose.

04:41 You imagine taking off from here all the way there, what are we really going to anastomose? If you anastomose that bit of the ileum to that much of the rectum, patient is going to be in the toilet all the time.

05:09 Whoa! He’s getting very crude now.

05:13 No, you’re right.

05:14 If you are able to preserve the sphincter, you always try for it, isn't it? But if you just can't, what can you do? Ileostomy is a very bad idea as well.

05:25 Colostomy is okay.

05:27 Colostomy is okay in the sense functionally, it works well.

05:30 Ileostomy is a nightmare because it excoriates the skin.

05:34 Patient has to empty about 25 times a day, about 10-15 times a day.

05:38 It's big, so the decision is not taken lightly to do an ileostomy.

05:43 Colostomy is okay. You can reverse it.

05:45 No big deal. Sometimes they just empty once or twice.

05:48 It's okay.

05:49 Of course, it's a big deal.

05:51 But considering the clinical picture, it’s no big deal.

05:55 But ileostomy is much worse.

06:00 Panprocto, yeah, procto, yeah, yeah.

06:03 Panproctocolectomy will end up with a stoma, ileostomy.

06:09 Here? Sigmoid colectomy.

06:12 This one? This one, you can get away with a straightforward left hemi.

06:17 Left hemi? Yeah.

06:18 For any of that region? Yeah, because your blood supply, that's middle colic and this is left colic.

06:24 I'm so happy then.

06:25 You're so happy.

06:26 But then clearly, if this goes on 2 centimeters, this is when we have all these MDTs.

06:31 The radiologists will come up with their smart answers.

06:34 They'll say,“No, no, no. You need to, you can't make, we are not sure.

06:38 It could have spread a little bit.

06:39 Why don't we take a bit more of the colon?” Yeah? So, there's no real, absolute thing to say.

06:47 Well, if it is there, you definitely cut it off there.

06:50 Just the same, what is a lymphatic spread, what is a Duke staging, what does the CT show? But for the purpose of your exam, they'll give you very straightforward scenarios.

06:59 You always see this right hemi, left hemi, extended right hemi, extended left hemi, AP colectomy.

07:06 The scenario will be 5-centimeter tumor here, there, and here just to get you thinking and to see whether you have understood the basic concepts.

07:15 They will never give you something which is ambiguous.

07:18 As you very well know in the exam that when you do your MCQ paper, there's an examiner who is also doing the paper, right? Not for every exam, more like a pilot.

07:30 If, say, 10 people in this room get a particular question wrong, all 10 of you get it wrong, they will eliminate that question from the marking.

07:40 So, if they give you something ambiguous there, there's no right answer.

07:45 Colorectal, so they will come and say no.

07:47 Why not? Why can’t you do that? Then that is debatable. They won't use that question.

07:53 So, even if you get an ambiguous question, they won't mark it.

07:55 So, usually in the exam, approximately two to three questions are taken off after you guys have written it because they say this is too dodgy because the paper will be returned by someone.

08:07 When it comes to marking the final assessment, the guy who is looking at it… Imagine it's an orthopedic surgeon.

08:12 We discussed about the garden three classification, undisplaced, displaced.

08:18 He says, “Well, we can do it this way. How do you know this is such?” He might have been trained in that hospital. How is it wrong? Then they'll say, "Fine. Take it off." Usually, those ambiguous, don’t worry it’s ambiguous.

08:35 Right. We’re on track for this. Any question on this? Did you get a fair idea of what you need to know in the exam? I am going on to the inguinal region.

08:48 We are not going to expose him.