Extra-Abdominal Stapler Method for Ostomy Prolapse Repair

Colostomy complications can be a challenging clinical entity to manage. Many patients with long-term stomas have been deemed irreversible by way of either their operative risks or as a consequence of their index pathological insult necessitating stoma formation. Colostomy prolapse is a relatively common occurrence of long-term colostomies and can be complicated by incarceration and strangulation, which will require operative intervention. ¹

Conventionally, the management for prolapse with strangulation or incarceration is with intra-abdominal approaches, necessitating a laparotomy, stoma resection, and re-siting with ostomy recreation. The intra-abdominal approach is conditionally considered a large operation and is not without its morbidities. Within last 30 years, there has been an increase in use of local techniques to manage stomal prolapse complications. ² While several local strategies have been described, not all have received significant literary recognition.

One such underrecognized technique is the extra-abdominal stapler method of ostomy prolapse repair. Originally described in 1990 in the United Kingdom, ³ this technique did not surface in United States’ surgical literature until 2016. ⁴ We believe that this approach in the management of complicated stomal prolapse is performed in United States; however, the literature is lacking in regard to instructional reports.

Briefly, this technique involves the firing of a linear stapler along the longitudinal axis of the prolapsed ostomy, beyond the demarcation of nonviable mucosa, toward the skin margins. Several flaps of nonviable ostomy mucosa are created and rest circumferentially around the stoma aperture. The nonviable flaps are then resected by firing the linear stapler in a transverse plane at the interface of the healthy mucosa and skin margins. ⁴ Herein, we describe 2 patients presenting with acute complications of a prolapsed colostomy, 1 with a loop colostomy and 1 with an end colostomy, that were successfully managed using a local stapler technique for repair.

Our first patient was a 36-year-old male with a history of a motor vehicle collision resulting in a high cervical spine injury leaving the patient paraplegic. The patient developed advanced staged sacral decubitus wounds for which a diverting loop colostomy was performed. The patient presented with concerns of bloody ostomy output. Physical exam revealed an irreducible prolapsed ostomy with signs of ischemia and strangulation.

The second patient was 47-year-old male with a history of perforated, left sided colon cancer requiring emergent resection and an end colostomy. The patient would later present with concerns of abdominal pain and decreased ostomy output for a week. Physical exam revealed an irreducible prolapsed ostomy with signs of ischemia.

Both of these patients were taken to operating room emergently for repair of the ostomy prolapse using the extra-abdominal stapler method. Both of these procedures were performed under general anesthesia. In both cases, multiple firing loads of a linear stapler were used to transect the prolapsed colostomy into 4 portions down to the level of skin (Figure 1). Reloads of the linear stapler were then used to transect across each of these segments at the level of the stomal aperture, remote from signs of mucosal ischemia. The remaining portions of the visible stoma appeared healthy, viable, and well perched. Both the end colostomy and the loop colostomy were treated in the same fashion. The total operative time for both cases was less than 30 minutes. Both patients recovered uneventfully and were discharged after return of bowel function.

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Figure 1.

(1) Pictorial description of extra-abdominal stapler method for ostomy prolapse repair. (2 and 3) Prolapsed ostomy. (4) Firing of GIA stapler to transect prolapsed colon into four portions. (5-7) Transected prolapsed colon into 4 portions. (8) Firing of GIA stapler in transverse plane to transect each portion individually. GIA, gastrointestinal anastomosis.

The extra-abdominal stapler method of ostomy repair is a safe, easy, and quick technique that surgeons should be aware of if laparotomy avoidance is of prudence. Although we used general anesthesia in our cases, the procedures could have been done with monitored anesthesia care. Compared to the trans-abdominal approach, this method requires less operative time, can be performed using minimal anesthesia, carries less comparative morbidity, and, intuitively, will result in a decreased length of hospital stay days. ² For patients with substantial pre-existing comorbidities or complex operative histories, this technique may be particularly befitting for this population.