easily on the bowel, and a silk number 3-0 traction stitch is taken. Using a scalpel with
blade number 15, an incision is made through the taenia of the sigmoid muscle layer
separating it from the mucosal layer. A tunnel is created by blunt dissection.
(4) The ureter is laid on top of the mucosa, and a small-slit is made in the
mucosa, using a scalpel with a number 11 blade.
(5) With fixation forceps and iris scissors, the ureter is slit to match the
bowel incision. The ureter is anchored to the bowel with number 4-0 chromic ureteral
sutures on Atraumatic needles. The other ureter is anastomosed in the same manner in
a position slightly above the first.
(6) The posterior peritoneum is closed with fine silk sutures. Drainage is
established. The abdominal wound is closed in layers.
h. Operative Procedure for Ileal Conduit.
(1) A urethral catheter is inserted to decompress the bladder, and a rectal
tube is placed in the rectum. Before the incision is made, the stoma site is marked on
the skin. Through a midline abdominal incision, the peritoneum is incised and the
abdomen is entered in the routine manner; abdominal retractors are placed.
The ureters are mobilized and brought through the retroperitoneum.
(3) The distal ileum and mesentery are inspected to identify the blood
supply. A Penrose drain is passed through the mesentery midway between the two
main arterial arcades adjacent to the ileum at the proximal and distal ends of the
selected segment. This segment usually comprises 6 to 10 inches of the terminal ileum,
a few inches from the ileocecal valve.
(4) The vessels of the mesentery are ligated. Care is exercised to preserve
the ileocecal artery and adequate circulation to the isolated ileal segment. The
peritoneum is incised over the proposed line of division of the mesentery. Allen or other
intestinal clamps are placed across the ileum, and the bowel is divided flush with the
clamps. Using gastrointestinal technique, the proximal end of the conduit is closed with
a chromic layer of sutures followed by a second layer of interrupted silk sutures. The
remaining ileum is reanastomosed end-to-end.
The mesentery is closed with interrupted silk sutures.
(6) The closed proximal end of the conduit segment is fixed to the posterior
peritoneum. The ureters are implanted in the ileal segment using plastic technique, with
fine instruments and ureteral sutures of chromic number 4-0 catgut on Atraumatic
needles. The peritoneum and muscle of the abdominal wall lateral to the original
incision are separated by blunt dissection. The distal opening of the ileal conduit is