Closed Cutaneous Left Iliac Fossa Mucus Fistula After Emergency Subtotal Colectomy

BACKGROUND

Patients with ulcerative colitis often require an emergency subtotal colectomy with end ileostomy. Such individuals may be septic and heavily immunosuppressed making management of the rectal stump problematic. If closed and left within the peritoneal cavity it can break down, resulting in pelvic sepsis. A safer alternative is to leave this as an open mucus fistula usually in the left iliac fossa (LIF). This facilitates localisation of the rectal stump if further surgery is contemplated but leaves the patient with two stomas and is poorly tolerated. A closed rectal stump sutured to the rectus sheath in the lower aspect of the midline wound has been advocated.¹ This avoided a troublesome mucus fistula routinely, but if dehiscence of the rectal stump occurred, allowed this to discharge into the wound, avoiding intra-abdominal sepsis. However, significant contamination may develop in the midline wound predisposing to wound disruption/dehiscence and slow healing. We propose the closed cutaneous LIF mucus fistula as a novel but preferable technique.

TECHNIQUE

A standard subtotal colectomy and end ileostomy is performed. The sigmoid colon is divided above the pelvic brim with a linear stapler, allowing enough length for the rectal stump to be brought to the surface via a left iliac fossa trephine. The staple line on the rectal stump is left intact and the skin is subsequently everted over this and secured to it with 3.0 Prolene sutures (Fig. 1). In most instances the staple line remains intact and the skin simply heals over it.

Figure 1.

Closed cutaneous left iliac fossa mucus fistula after emergency subtotal colectomy

DISCUSSION

A closed cutaneous LIF mucus fistula has several advantages. If the staple line remains intact, patients are left with a single stoma (end ileostomy), a rectal stump that can be easily identified in the future and an intact, well-healed, midline wound. However, if the staple line breaks down, then this discharges onto the surface with minimal subcutaneous contamination essentially forming a controlled open LIF mucus fistula. The midline wound remains intact with no disruption. In view of this, a closed cutaneous LIF mucus fistula is our technique of choice after emergency subtotal colectomy in patients with ulcerative colitis.