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Ileal conduit

Principles of bowel surgery:

  • Proper exposure and mobilisation
  • Preserve vascular supply
  • Avoid spillage, use clean instruments, packs
  • Serosa to serosa anastomoses
  • Clean off mesentery from working segments
  • Haemostasis at suture/staple lines
  • Ensure mesenteric and antimesenteric sides restored
  • Water under the bridge

 

Pre-operatively:

  • Stoma nurse consult
  • Ensure no complicating factors – short gut, IBD, pelvic radiation
  • Check the scans and make sure no surprises – duplex ureters, stones
  • Stoma siting
    • Avoid belt line
    • Aiming for point of maximum convexity when patient sitting/standing allowing them to see stoma for changes
    • Through rectus muscle

 

Technique:

  • Bring left ureter underneath sigmoid mesocolon prior to beginning conduit
  • Identify and mobilise caecum and terminal ileum – usually peritoneal bands adhering to posterior wall
  • Identify chosen segment – at least 15 cm from TI, looking for the ‘final arcade’, taking about 15 cm. Score with diathermy to mark, stay suture on distal skin end
  • Use lights to identify vascular arcades while assistant holds up bowel – isolate segment with preserved blood supply – diathermy through mesentery in windows then use Ligasure to seal vessels (or clips/ties)
  • Clean up each end of conduit to free serosa from mesentery
  • Harvest conduit with EndoGIA stapler – normally blue
  • Restore continuity with side to side stapled anastomosis:
    • Over the top of the isolated conduit
    • Cut corners off antimesenteric corner of each end
    • Stapled anastomosis on antimesenteric side – ensure mesentery is rotated away and out of stapler
    • Staple off the top / open lumen under 3 x babcocks
    • 3-0 PDS crotch suture to take off tension + interrupted closure of mesenteric window
  • See where ureter naturally wants to sit on conduit and cut hole with Metz
  • Spatulate ureter on side which will face conduit – cut across 50 % then quickly spatulate up
  • Bricker anastomosis:
    • Apex of ureteric spatulation to apex of conduit cut, 4-0 PDS double armed, tie then bring under ureter
    • Run back side of anastomosis first – small 1 mm bites of ureter
    • Always leave needle on outside to avoid confusion
    • Place Bander stent – loaded with wire – place down conduit (Roberts/Yankeur/cystoscope sheath) then up ureter to kidney then withdraw wire
    • Complete other side of anastomosis over stent – need to excise remaining portion of ureter and send
  • Wallace alternative:
    • Spatulate both ureters and suture together the apices of the spatulation, then run suture down each medial edge to form Wallace plate, which is anastomosed to opened end of conduit
  • Mature the stoma
    • Excise skin and fat at premarked spot down to sheath (cut on diathermy point perpendicular whilst holding up with Moynihans
    • Cruciate incision on fascia
    • Roberts to split rectus fibres in line on to posterior sheath then open posterior sheath
    • 2 fingers classically through sheath, then Babcock down from outside to grab stoma and bring through
    • Monocryl 4-0 – 4 x deeper sutures, 2 next to mesentery which points to opposite shoulder and 2 next to them
      • Serosa then quite low on conduit then dermis – to ensure eversion – do 4 sutures with clips, then lifts clips simultaneously to evert
    • Complete with interrupted monocryl between

 

 

Turnbull loop stoma:

  • Good for obese patients with short thick mesentery
  • Blind ending bit of bowel sits cephalad under fascia
  • Loop brought through fascial incision and secure to fascia with sutures, incised open about 4/5 of the way towards the blind cranial end
  • Caudal edges everted and sutured to skin/dermis

Conduit can’t reach?

  • Avoid by premeasuring conduit and ensuring adequate length harvested (contracts)
  • Check fascial opening and left ureter mobility
  • Avoid anchoring suture between conduit and retroperitoneum
  • Lengthen the mesetnery
    • Further mobilise the caecum and TI +/- right colon
    • Relaxing incisions in peritoneum over mesentery
    • Deepen the mesenteric incison (risks ischaemia)
  • Turnbull loop stoma
  • Short incision in distal mesentery to free up stoma end
  • Start again or add another segment with end to end join

 

Bricker vs Wallace:

  • Wallace likely has lower stricture rate
  • But if tumour or dense stricture occurs with Wallace, potentially both kidneys can be obstructed
  • If Wallace falls apart there is a hole in the conduit

 

Complications of ileal conduit

Early:

  • Stomal necrosis
    • Mesenteric injury, or twisting/kinking of mesentery
    • Dusky, dark, oozing conduit with metabolic acidosis
    • Exploration and re-do
  • Ureteroileal leak
    • Poor technique, poor healing, radiation, intra-abdominal or pelvic collection or haematoma
    • If presents delayed at 1-2 weeks consider ischaemic ureter
    • Elevated serum Cr, drain outputs, reduced urine output, prolonged ileus, fevers or flank pain
    • Most commonly left side
    • CT to ensure no large urinoma which needs drainaing
    • CT IVP or loopogram to determine point of leak
    • Initially manage conservative – stent or nephrostomy, drain urinoma off suction, optimise nutrition, catheter in conduit
    • Repair/re-do if not responding to conservative – timing dependent on patients condition
  • Bowel leak
    • Enteric contents in drain, prolonged ileus, sepsis, fevers, peritonism
    • Early re-look and repair or resection if feasible
    • Optimise nutrition
  • Ileus / small bowel obstruction
  • Pyelonephritis

Late:

  • Ureteroileal stricture
    • 5 – 10 %
    • Likely related to chronic ischaemia, more common on left due to needing further mobilisation and compression and angulation under sigmoid mesocolon
      • But – don’t forget could be malignant
    • Most successful way to manage is re-operation and reimplantation, but often difficult and associated with morbidity
    • Balloon dilation can be trialled – success < 20 % after 3 years
      • Longer strictures > 1.5 cm, left sided and early strictures < 12 months less likely to respond to endoscopic treatments
    • Open reimplantation
      • Can be difficult due to scarring and adhesions around ureters
      • Consider stent placement prior (antegrade if necessary) to help identify ureter, and catheter in conduit
      • Mobilise conduit fully to try avoid extensive proximal ureteric mobilisation
      • Send for frozen sections if any concern of malignancy
    • Hydronephrosis and renal deterioration
      • Recurrent UTIs and pyelonephritis, obstruction from strictures, other intrinsic renal disease and metabolic acidosis
      • Radiological hydronephrosis is common finding and usually related to reflux of the ureteroileal anastomoses
      • Colonic non refluxing anastomoses may have marginally lower rates of renal deterioration, but no difference in ileal non-refluxing vs refluxing
    • Stomal retraction
      • More common in obese – prevent with good length conduit and good rosebud
      • Loop stoma has very low retraction rates (trade off higher hernia rates)
    • Parastomal hernia
      • Very common – up to 50 %
      • Usually can be managed conservatively
      • May cause issues with pouching of urine, small bowel obstruction, unsightly
      • Consider mesh repair
    • Metabolic
    • Stones
    • Recurrent UTIs/pyelonephritis
    • Malignancy

 

Stomal stenosis

  • May be a result of leak and inflammation, retraction and hyperkeratosis; or due to inappropriate skin opening, or due to abdominal wall spasm
  • Can lead to stomal obstruction and upper tract dilation
  • Hyperkeratosis / skin thickening may need catheter diversion to avoid urine contact with skin
    • Reports of treatment with EBRT and topical vitamin C and acetic acid
  • Other management options for stenosis include:
    • Surgical revision – circumferential incision with complete mobilisation to level of fascia, mobilisation intraperitoneally to gain length, excision of stenotic segment and hyperkeratotic skin and refashioning
      • Rarely require reopening of midline to gain length
    • Incision of stenotic ring and re-suturing or skin flaps

Parastomal hernia repair:

  • Options include midline laparotomy and intra-peritoneal mesh, relocation to opposite side without laparotomy, and lateral approach
  • Intraperitoneal
    • Previous midline laparotomy opened. Elevated fascial edge with Moynihans. Sharply divide adhesions then reduce the parastomal hernia sac. Cut polypropylene mesh to shape with an exit for the stoma, and apply to posterior sheath / intraperitoneally as “underlay”
  • Translocation
    • Circumferential incision around stoma. Reduction of parastomal hernia, and new stoma incision on contralateral side. Tunnelling of stoma to other side with Rampley’s. Risks of intraperitoneal adhesions, and incisional hernia at initial site.
  • Lateral approach
    • 10 cm lateral to stoma – dissect to sheath and complete dissection to stoma – reduce sac. Primary prolene suture repair of sheath and then onlay mesh above level of sheath.
  • Robotic assisted …