Presented by:
Martha Smith
Affiliations:
Unity Health- St. Michael’s Hospital
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What is Gynaecologic Laparoscopy in Patients with a Stoma?
Gynaecologic laparoscopy in patients with a stoma involves adapting standard minimally invasive surgical techniques to account for altered abdominal anatomy from a colostomy or ileostomy and previous bowel surgery. Careful preoperative planning is particularly important because adhesions, the position of the stoma, and the pathway of the bowel can affect abdominal entry, port placement, and pelvic dissection. Here’s what it involves:
- Stoma Assessment: The type, location, and anatomy of the stoma are reviewed to understand how the bowel has been brought through the abdominal wall.
- Preoperative Imaging: Imaging and previous operative reports are reviewed to identify altered anatomy, adhesions, bowel position, and other factors that may affect surgical access.
- Multidisciplinary Planning: General or colorectal surgery and the stoma care team may be involved in planning when significant bowel adhesions or potential stoma-related complications are anticipated.
- Modified Abdominal Entry: The initial laparoscopic entry site is selected away from the stoma and areas where bowel adhesions are suspected.
- Individualized Port Placement: Laparoscopic ports are positioned to provide appropriate access to the pelvis while avoiding the stoma, its blood supply, and the underlying bowel.
- Adhesiolysis: Adhesions from previous abdominal or colorectal surgery may be carefully divided to establish a safe operative field.
- Pelvic Surgery: The planned gynaecologic procedure, such as hysterectomy, is performed with careful attention to altered bowel, ureteral, and pelvic anatomy.
- Stoma Protection: The stoma and associated bowel are protected throughout positioning, preparation, and surgery.
- Final Inspection: The abdomen, pelvis, bowel, and stoma-related structures are assessed for injury or other complications before completing the procedure.
With careful planning and modification of laparoscopic access, many gynaecologic procedures can still be performed minimally invasively in patients with a pre-existing stoma.
What are the Risks of Gynaecologic Laparoscopy in Patients with a Stoma?
Previous bowel surgery and creation of a stoma can significantly alter abdominal anatomy and increase the complexity of subsequent laparoscopic surgery.
- Bowel Injury: Adhesions may place bowel directly beneath the abdominal wall or within the operative field, increasing the risk of injury during entry, port placement, or adhesiolysis.
- Stoma Injury: Instruments, surgical positioning, or abdominal wall access can potentially damage the stoma or the bowel supplying it.
- Compromised Stoma Blood Supply: Injury to the mesentery or blood vessels supplying the stoma may impair blood flow and threaten stoma viability.
- Adhesion-Related Complications: Dense adhesions from previous surgery can make abdominal entry and pelvic dissection more difficult and increase the risk of organ injury.
- Ureteral or Bladder Injury: Previous pelvic or colorectal surgery can distort normal anatomy, making urinary tract structures more difficult to identify.
- Bleeding: Adhesiolysis and dissection through previously operated tissue can result in vascular injury and significant bleeding.
- Need for Bowel Repair or Stoma Revision: An inadvertent bowel or stoma injury may require repair, bowel resection, or revision of the existing stoma.
- Conversion to Open Surgery: Extensive adhesions, difficult anatomy, bowel injury, or uncontrolled bleeding may require conversion from laparoscopy to an open procedure.
- Infection: Previous bowel surgery and extensive adhesiolysis may increase the risk of surgical-site, pelvic, or intra-abdominal infection.
- General Surgical Risks: Blood clots, anesthesia-related complications, postoperative ileus, wound complications, and new adhesion formation are possible.
Understanding the patient’s stoma anatomy, reviewing previous surgery and imaging, carefully selecting entry and port sites, and involving colorectal and stoma specialists when appropriate can help reduce these risks.