Following is what I would do for an isolated ileal conduit without cystectomy.
Before the surgery
Treat constipation at home. No need for admission the day before the surgery.
Day of surgery
Have ostomy nurses mark the stoma and provide the stoma bags to place after surgery. The usual location is on the right side medial to the linea semilunaris at a spot in between the belly button and the ASIS. For preoperative prophylaxis, Cefoxitin covers the needed organisms.
Key surgical steps
- Ileal conduit length is about the length from the sacral promontory to the stoma site.
- When cutting the mesentery make it long on the distal side which will go up to the stoma and shorter on the proximal side which will be where the ureters will be attached to.
- For 2 single ureters the best option is probably Wallace anastomosis to the end of the bowel.
- If doing a Bricker anastomosis, incise serosa first then excised a piece of mucosa to create a defect in the bowel. Then interrupted sutures on the posterior wall, then the stent, then finish anastomosis.
- When passing the left ureter under the sigmoid check for kinks.
- It the conduit is watertight and all the ureters are stented, a drain might not be needed.
- Stoma sutures to dermis and not epidermis.
- Can use diversion stents but they only come in 8 Fr. Could use Feeding tubes instead or regular 5 Fr stents.
- 4-0 PDS for ligating the ureters distally and handling the ureters
- 4-0 PDS for bowel anastomosis.
- 5-0 PDS for uretero-ileal anastomosis and ureter to ureter anastomosis
- 4-0 silk to mark bowel, tie mesenteric vessels and close the mesenteric window.
- 5-0 chromic to suture stents to ureter or bowel.
- 0 PDS for the fascia, 4-0 vycril for subcutaneous sutures and 4-0 monocryl for the skin
- For the stoma, 3-0 vycril to secure to fascia, 4-0 vycril for rosebud sutures and 5-0 vycril for skin sutures.
The family was explained the procedure in detail and all their questions were answered. We discussed the possibility of ureteral strictures, stomal hernias, kidney infections and skin problems.
Ostomy nurses marked the site for the stoma preoperatively.
The patient was brought back to the operating room and placed supine for induction of general anesthesia. A time out was completed. Antibiotics were given: Cefoxitin.
The anesthesia team placed an epidural***.
The patient was then positioned in slight frog leg with a bump under the sacrum and secured to the bed with straps/tape. The bed was flexed to open the pelvis.
A *** Fr Foley catheter was placed using sterile technique before the prep.
The patient was then sterile prep and draped in the usual fashion.
A midline incision from the umbilicus to the pubic bone was made with a knife and deepened with the cautery down to the fascia. The midline was identified and then incised with cautery up and down.
The peritoneum was identified superiorly and it was cut with scissors. The incisions were then carried with cautery towards either side of the bladder being careful with the vas deferens.
A Book Walter retractor was then placed at his point to expose the pelvis for dissection of the ureters.
The left ureter was identified where it crossed the vessels and a peritoneal window was made. The ureter was dissected and a vessel loop was placed around it. Dissection was carried distally towards the bladder. The ureter was ligated distally and divided with 4 0 PDS. Another 4-0 PDS suture was placed on the proximal end of the ureter for handling.
The right ureter was dissected in a similar fashion. The 2 peritoneal windows were connected behind the sigmoid colon to be able to pass the left ureter towards the right side.
Attention was directed now towards harvesting the ileal segment. A spot 15 cm away from the ileocecal valve was marked with that 4-0 silk suture. Distance in between the sacral promontory and the ostomy site was measured to be ***.
A *** cm segment of ileum was identified with at least 2 good arcades. The distal end was marked with 4-0 silk (long) and the proximal end with short 4-0 silk.
The mesentery was cut superficially and a mosquito was used to get under the bowel. The bowel was divided with cautery using cut current. Distally the mesenteric incision was made as long as possible to allow the segment to reach the skin. Proximally the mesenteric incision was shorter. All the mesenteric vessels were clamped and then ligated with 4-0 silk.
The ileal segment was then placed caudal and the bowel was reanastomosed with a running 4 0 PDS suture started from each end taking bites only of the serosa and muscle but no the mucosa.
The mesenteric window was closed with interrupted 4-0 silk sutures.
Attention was directed now to the ureteral ileal anastomosis.
The left and right ureters were joined together after a wide spatulation in a Wallace type fashion with a running 5 0 PDS and then the posterior wall of the ileum was sutured to the posterior edge of the ureters. After this step stents were placed on each ureter***. The stents were secured to the bowel with 5-0 chromic***. After this step the anterior wall of the ileum was sutured to the ureters with 5-0 PDS completing the anastomosis.
Attention was now directed to the stoma formation. The previously marked skin of the stoma site was excised. The fat underneath was also removed. The fascia was identified and a cruciate incision was made. Two fingers were able to be passed through the incision into the abdomen. The distal end of the conduit was brought out and then 3 0 Vicryl was used to secure the serosa to the cruciate incision at 4 quadrants having 2 cm of the conduit protruding out the skin.
The ureteral ileal anastomosis was retroperitonealized by placing some peritoneum around the proximal end of the bowel covering the anastomosis. This was done with running and interrupted 4-0 Vicryl.