| The cecostomy tube insertion procedure is performed on a
tilting C-arm fluoroscopic interventional table. After ultrasound is performed to identify
the liver, gallbladder and urinary bladder, a 22-F silicone catheter is introduced into
the rectum and the retention balloon filled with air from a 50 cc Luer lock syringe. The
abdomen is prepared and draped in sterile fashion using Soluprep solution. The sterile
equipment and local anaesthetic is prepared and readily available prior to administration
of glucagon. Up to 1 mg is given intravenously and the colon inflated with air via the
rectal catheter. The position of the cecum is assessed and the prospective tract site is
determined. Up to 0.5 cc/kg of 1% Lidocaine should be infiltrated under fluoroscopic
control into the skin and soft tissues down to the cecal wall, using a transperitoneal
approach. One should see evidence of tenting of the cecal mucosa by the needle tip, and
often a small bulge can be seen from deposition of anaesthetic into the wall itself (Figure 23). After sufficient local anaesthetic has
been given a small skin incision is made with a #11 scalpel. An 18-Ga single wall puncture
needle, preloaded with two paediatric retention sutures connected to a T-connector and a
syringe filled with sterile water-soluble contrast. The needle is advanced through the
skin and soft tissues until tenting of the cecal wall is again observed. Air should be
insufflated as needed to maintain distention of the cecum. Under fluoroscopic guidance,
the needle is rapidly advanced into the cecum with a single thrust. Contrast is then
injected to confirm the position of the needle within the colon (Figure 24). Under fluoroscopic control, a stiff 0.035-in guidewire is
advanced through the needle to deploy the retention sutures (Figure 25). The wire should be advanced until the stiff portion is well
within the lumen. The needle is then removed and the two sutures are clamped with a
mosquito forceps. Gentle tension on the sutures will appose the cecum against the anterior
abdominal wall. An 8-F Coons dilator is introduced over the wire, maintaining gentle
tension on the retention sutures. This is followed by introduction of an 8.5-F Dawson
Mueller Mac-lock 15-cm catheter. The catheter is locked and its position within the cecum
is confirmed in two planes with a small amount of contrast (Figure 26). The locked "pigtail" of the catheter is pulled up
against the anterior wall of the cecum, and the retention sutures are anchored to a small
roll of gauze and fixed to the skin with adhesive tape. The skin at the tube exit site is
dressed with a 2x2 gauze dressing and Polysporin antibiotic ointment and covered with a
Hypafix dressing. The catheter is then left to drain to a drainage bag. |
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