What are the steps of a robotic diverting colostomy?

Steps of a Robotic Diverting Colostomy

A robotic diverting colostomy should be performed using a standardized approach with careful patient positioning, port placement, and meticulous surgical technique to minimize complications and optimize patient outcomes.

Pre-operative Preparation

• Assess the need for diversion based on underlying pathology (perianal Crohn's disease, rectal cancer, fecal incontinence)
• Determine optimal stoma location through pre-operative marking by a stoma nurse
• Consider bowel preparation based on underlying condition
• Administer prophylactic antibiotics prior to incision
• Consider ureteral stenting in cases with complex pelvic pathology 1

Patient Positioning and Setup

• Position patient in modified lithotomy with arms tucked
• Secure patient to operating table to allow for position changes
• Perform pneumoperitoneum via Veress needle or open Hasson technique
• Place ports in a configuration that allows access to intended colostomy site:
  • Camera port at umbilicus
  • Two robotic working ports in right lower quadrant
  • Assistant port in left upper quadrant

Surgical Technique

1. Initial Assessment

   • Perform diagnostic laparoscopy to evaluate abdominal cavity
   • Identify optimal colostomy site (typically transverse or sigmoid colon)

2. Colon Mobilization

   • Mobilize the selected segment of colon with careful preservation of blood supply
   • Create a mesenteric window if performing a loop colostomy

3. Stoma Site Preparation

   • Create a circular incision at the pre-marked stoma site
   • Excise a disc of skin and subcutaneous tissue
   • Incise the anterior rectus sheath in a cruciate fashion
   • Separate rectus muscle fibers bluntly
   • Incise posterior rectus sheath and peritoneum

4. Exteriorization of Bowel

   • For loop colostomy: Pass a soft drain or vessel loop through the mesenteric window to facilitate exteriorization 2
   • For end colostomy: Divide the bowel with a robotic stapler at the selected site 3
   • Exteriorize the bowel through the stoma site

5. Diversion Technique Options

   • Loop Colostomy:

     • Exteriorize a loop of colon
     • Place a supporting rod or bridge beneath the loop
     • For total diversion: Apply a non-cutting stapler across the distal limb to prevent fecal passage 4

   • End Colostomy:

     • Exteriorize the proximal end of divided colon
     • Close the distal end (Hartmann's pouch) or bring it out as a mucous fistula

6. Stoma Maturation

   • Secure the serosa of the colon to the fascia with absorbable sutures
   • Open the anterolateral aspect of the colon
   • Evert the edges and suture the full thickness of the bowel to the skin using absorbable sutures

Special Considerations

• For rectal cancer requiring neoadjuvant therapy, a right-sided loop transverse colostomy is preferred as it can be left in place to protect a future anastomosis 5
• In patients with Crohn's disease, a diverting stoma may improve quality of life but often becomes permanent (only 16.6% of patients achieve successful ostomy reversal) 5
• For emergency cases with unprepared bowel, a totally diverting loop colostomy technique can be used to prevent fecal contamination 4

Post-operative Care

• Apply appropriate stoma appliance
• Monitor for early complications (bleeding, retraction, ischemia)
• Initiate stoma care education
• Assess stoma function within 48-72 hours

Potential Complications

• Early: bleeding, ischemia, retraction, parastomal abscess
• Late: parastomal hernia, prolapse, stenosis
• Long-term stoma problems may include skin rashes, leakage and ballooning 5

Remember that mortality rates for colostomy are approximately 2%, with additional risks including bleeding, cardiopulmonary events related to anesthesia, and parastomal hernia 5. Careful technique and appropriate patient selection are essential for optimal outcomes.