- Midline laparotomy
- Incise from above umbilicus to pubis
- Enter peritoneum and explore for perforation, abscess, or free fluid
- Pack and mobilise small bowel to the right to expose the left colon
- Mobilise the left colon
- Start at the sigmoid colon
- Incise the white line of Toldt along the lateral peritoneal reflection
- Carefully dissect medially, identifying and preserving the left ureter and gonadal vessels
- Continue mobilisation up to the splenic flexure
- Mobilise the transverse colon and splenic flexure
- Free the omentum off the transverse colon
- Dissect along the inferior border of the pancreas as needed
- Enter the lesser sac and retract the colon caudally
- Divide the splenocolic ligament to complete the mobilisation of the flexure
- Mobilise the right colon
- Incise the white line of Toldt along the ascending colon
- Reflect the colon medially, identifying the duodenum and right ureter
- Divide the hepatic flexure
- Divide vascular pedicles and mesentery
- Use ligasure, clips, or sutures
- Typically divide the ileocolic, right colic (if present), middle colic, and left colic vessels
- Take care with vascular supply to the small bowel and rectum
- Divide the terminal ileum
- Identify a well-perfused segment
- Divide with stapler or clamps, ensuring adequate length for a tension-free stoma
- Divide the colon just above the rectum
- Close the rectal stump (Hartmann’s pouch) with a linear stapler or suture it closed
- Optionally bring it to the surface as a mucous fistula if concerned about distal sepsis
- Create end ileostomy
- Choose a site in the right iliac fossa, pre-marked and within rectus sheath
- Create circular trephine and deliver ileum to surface
- Check haemostasis and irrigate
- Wash out pelvis and paracolic gutters
- Place pelvic or subhepatic drain if needed (especially in emergency settings)
- Close abdomen
- Closre of fascia with looped PDS or similar
- Skin closure
- Mature the stoma