Cases & Commentaries
Which End Is Which?
A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic diverting colostomy to divert her fecal stream and allow the perineum and anal lesions to heal. During the surgery, pneumoperitoneum was established and the “floppy descending” colon was identified, mobilized, and divided. The “proximal” end was brought up to skin and sutured, and the distal end was stapled closed.
After 9 days, the failure of gas or stool to appear in the colostomy bag prompted an abdominal CT scan, which demonstrated large bowel obstruction. On return to the OR for laparotomy, it became apparent that the diversion had involved the transverse colon rather than the descending colon. In addition, the distal portion of the bowel had been brought up to the skin as the colostomy, while the proximal end had been stapled shut. This produced a complete bowel obstruction. Surgeons corrected the orientation and performed a new colostomy. After the second operation, the patient’s perianal fistulae and infected anal sinuses improved as initially intended.
This case describes an uncommon but much feared complication in laparoscopic surgery—creation of a blind distal colostomy with surgically-induced total bowel obstruction. No studies document the incidence of this complication, but the case illustrates important practical issues related to orientation and landmarks in laparoscopic surgery in general and colorectal surgery in particular.
The core problem here consisted of failure to identify the appropriate limb of colon to bring up for colostomy, which can occur in two ways. The first is that sigmoid colon is appropriately identified, but the distal limb mistakenly brought out as the stoma. The second is that a floppy, redundant transverse colon is misidentified as sigmoid colon, so that the wrong end is brought up, as occurred in this case.
Because anatomy can be so deceiving (even in open surgery), it is worth identifying the steps in the procedure where problems in orientation are likely to arise. During the course of an operation, key visual cues are essential to identify the proper anatomical landmarks.
As with all laparoscopic procedures, this operation begins with gaining access to the abdomen laparoscopically, establishing pneumoperitoneum with CO2, and inserting manipulating trocars into the abdomen. With these initial steps complete, the appropriate segment of colon is mobilized and identified. At that point, a counter-incision is made in the abdominal wall. This incision will serve as the site of the colostomy. It is essential that the orientation of the colon be preserved at this step.(1-3)
In this case, the transverse colon was likely misidentified as the sigmoid colon, and the wrong side of the colon therefore elevated. Difficulties in identifying the correct side of the colon may arise when the patient is obese or has a large greater omentum. This error is not confined to laparoscopy; it can occur during open surgery, especially when multiple adhesions are present. In open surgery, the solution consists of enlarging the incision to adequately expose the entire colon. However, substantially increasing incision size defeats the purpose of laparoscopic surgery. Therefore, it is strongly recommended to place a suture on the proximal or distal end of the colon to act as a landmark and thus avoid problems in orientation. Whether to place the suture on the proximal or distal end is a matter of style, but placing the suture proximally has the advantage of providing traction to help elevate the colon from the abdomen. Whichever method is chosen, it makes sense for surgeons to always use the same placement to prevent mix-ups.
Once the distal end of the colon has been stapled, use of a flexible sigmoidoscope or colonoscope (inserted through the rectum) allows further confirmation that the correct end of the colon has been identified. If so, colonoscopy will reveal a blind pouch and a staple line. If the wrong end has been brought out, the scope will demonstrate normal colon lumen. A second confirmatory test consists of instilling air or water (rather than a colonoscope) into the distal limb of the colon through the rectum. If colonic contents are expressed, the distal end had been opened inadvertently. This instillation method is only useful after the colostomy has matured or been opened at the end of the operation. Otherwise, the fact that colonic contents are not expressed may falsely reassure the surgeon (ie, a false negative test). For these reasons, the colonoscopy method is the more reliable of the two.
The problem with any laparoscopic surgery is that normal cues for anatomic identification are easily lost, so that the surgeon becomes disoriented. Moreover, surgeons must become accustomed to the different tactile responses of tissues during laparoscopy compared to open surgery. Surgeons require practice manipulating tissues that remain one foot or more away from their hands without traumatizing them.(4)
Experience with laparoscopic cholecystectomy, the first laparoscopic operation performed in large numbers by general surgeons, illustrated the impact of the so-called surgical learning curve on patient outcomes. In the first few years, many surgeons misidentified structures and as a result injured the common bile duct in patients because of orientation difficulty.(5,6) Laparoscopic training courses have evolved to include instruction on ways to prevent catastrophic complications from occurring.(7) These techniques are now incorporated into general surgery training programs and are required by the American Board of Surgery and the Residency Review Committee in Surgery.(8) Unfortunately, simulators for laparoscopic colon surgery do not yet exist, so practice in advance laparoscopic courses with animals (usually pigs or sheep) and direct clinical experience represent the only two means for surgeons to acquire proficiency with this technique.
Any time error prevention relies solely on vigilance, errors will eventually occur—due to distraction, fatigue, or other factors.(9,10) Thus, even the most experienced and vigilant surgeon needs to keep in mind the possibility of errors such as occurred in this case when assessing problems in the post-operative period. Prolonged (> 36 hours) post-operative ileus should prompt further evaluation. On average, patients have an ileus that is much shorter with the laparoscopic procedure than with open procedures.(11-13) Thus, a 9-day lag in colostomy function, which would be excessive even after an open procedure, was a significant red flag in this case and perhaps should have led the surgeons to the diagnosis earlier. It is important to note that mechanical obstruction can occur for reasons other than the error described in this case; for example, the colon may be twisted when brought out of the abdomen. Whatever the cause of the obstruction, a contrast study using Gastrografin through the colostomy could have been performed to confirm or rule out an anatomical problem or other cause of obstruction.
In conclusion, the error in this case, an iatrogenic bowel obstruction caused by reversing the colon loops during laparoscopic surgery, is preventable by correctly identifying all parts of the colon during laparoscopy and maintaining orientation throughout the procedure. Intraoperative confirmation of orientation should be the rule. This is best accomplished using flexible sigmoidoscopy (or limited colonoscopy) to identify the blind end from the rectum. Even when great care has been taken during the operation, the possibility of technical complications due to intraoperative bowel misidentification—including reversal or torsion--must be considered during the postoperative course when ileus is prolonged.
- Positively identify both the proximal and distal parts of the colon during laparoscopic colon surgery.
- Confirm that the blind loop is the loop contiguous with the rectum (as intended) by either intraoperative colonoscopy or by demonstrating that no stool is extruded after an air or water enema.
- Suspect obstruction (including but not limited to iatrogenic obstruction) when a post-laparoscopic ileus has not resolved within 36 hours.
Andre R. Campbell, MD Associate Professor of Surgery University of California, San Francisco
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