INDICATIONS An injury of the caecum which leaves most of it intact.
METHOD if possible, make the caecostomy in the original wound in the patient’s caecum. Otherwise, close this with two layers of sutures, and make a fresh incision for the caecostomy.
Apply a curved non-crushing clamp to prevent the contents of the patient’s gut coming out of the hole, and cover this with a swab. Clamp a large self–retaining de Pezzer catheter, and insert this into the hole. Apply a purse string of 2/0 catgut round the catheter, and tie it, making sure that the bowel wall inverts around it as in Fig. 66-18. Tie the purse string, and then put another one round it (C, and D).
Now make a small hole in the patient’s abdominal wall, just big enough to take the catheter. Make it over the place where his caecum will lie comfortably when his abdomen is closed. Push long artery forceps through this hole, right up to their handles, from outside inwards (D). They will make a useful retractor.
Put 4 or 5 sutures in the peritoneum round the abdominal hole, and in the peritoneum on his caecum round the caecostomy. For the moment, leave these sutures loose.
Grasp the end of the de Pezzer catheter with the forceps, and pull it through his abdominal wall. Now tighten the sutures, so as to anchor the caecostomy to his abdominal wall (E).
Spigot the caecostomy, close his abdominal wall, and leave his skin for delayed primary suture (9.7).
POSTOPERATIVELY Join the de Pezzer catheter by a wide bore connector to a large tube which drains into a bottle of disinfectant beside the patient’s bed. After 36 hours do a gentle washout through the tube. Repeat this frequently thereafter.
As soon as he is well and has good bowel sounds, you can spigot the tube, so that he can walk about. Leave the caecostomy tube in place for 3 weeks.
REMOVING THE TUBE Premedicate him. Tell him you are going to remove it on the count "three". Place a swab round its base where it enters his skin. Hold the end of tube firmly in one hand and its base and his skin in the other. Then, count "One, two, three!" and firmly pull out the tube. His caescostomy will heal spontaneously.
