• Grasp skin over site with a Kocher clamp.
• Lift and make a circular skin incision.
• Incise dermis with diathermy.
• Remove block of subcut tissue (don't undermine).
• Incise anterior rectus sheath with a linear incision.
• Spread rectus to show posterior sheath and make further cruciate incision.
• The defect should allow 2 fingers.
• Colostomy hole must allow for distended oedematous bowel in obstructed cases
• When colostomy hole is kept open with retractors, the bowel end should pass easily between and not retract if retractors removed.
• Pass 2 babcocks through to grasp bowel end & pull through.
• Closed proximal end should easily reach several cm beyond the skin without support.
• Left colon should be mobilized up to (and sometimes including) the splenic flexure to allow this.
• Mucocutaneous suture of colon to skin edge with absorbable suture (e.g. 3-0 vicryl or 3-0 monocryl).

Key Operative Points : End Sigmoid Colostomy

• Lloyd Davis (lithotomy Trendelenburg)
• Consider doing laparoscopic
• excellent vision; much less likely to bring out wrong end.
• umbilical port, 10-12mm trochar through stoma side, grasp through this
  
• Trephine as above
• Find sigmoid, ensure not twist; no omentum here obviously but are appendices epiploicae to help define it.
• can check lateral white line for orientation help.
• can even do a sigmoidoscopy or a loop colostomy if still unsure.
• Divide loop of sigmoid across (Stapled e.g. nTLC), with 5-6 cm of mesentry.
• Closed distal end is pushed into cavity; can oversew but no need.
• Fashion colostomy by suturing to skin edge with interrupted 2/0 vicryl.
• Fit stoma appliance.
  

• Transverse incision, 5cm, upper right rectus between umbilicus and costal margin
• or 10cm transverse incision midway b/n umbo and costal margin (3-5cm lateral to linea alba) if targeting the mobile midsection of R colon
• Cut rectus, cauterize fibres,control epigastric artery, enter abdo.
• Draw right side of transverse colon and omentum out of wound.
• recognizing colon by haustra, taeniae coli, epiploic appendages.
• Loop should sit without tension.
• Separate omentum, expose colon, turn upward to expose mesentry.
• Create mesenteric window below wall and pass a penrose sling around colon.
• ensure loop not twisted; proximal to right and distal to the left.
• Pass a plastic colostomy rod through the mesentry to form a bridge.
• don't damage the marginal artery of Drummond, which runs a variable distance from the bowel edge (e.g. 1-8 cm).
• no internal / fascia sutures.
• Cut open colostomy, half way through circumference.
• Turn back edges and suture whole thickness of colon to edge of skin with interrupted 2/0 Vicryl sutures on a cutting needle.
• Insert a finger in each loop to make sure it isn't too narrow
• Fix stoma appliance.

Remove bridge device in 7 days
Longer if obesity and difficulty in bringing up the stoma.