Published: 2021-12-28

Long segment “Hanging-snout” end ileosotmy a safe “Surgical disaster mitigating” technique for an “Un-brookeable” end ileum: a study of 23 cases over 12 years

M. S. Ray, Sarvpreet Singh Malhi, Jayum Asopa, Harpreet Kaur, Manvinder Singh Grewal, Naresh Modi, Digpal Thakore, Rashmi Ray


Background: In 1952, Professor Bryan Brooke described his technique for everting an ileostomy in order to minimise skin excoriation1. Pouting, mucosa-everting Brooke’s ileostomy have been accepted as the best technique for stoma formation in almost all cases, save a few difficult situations – such as edematous friable bowel with bulky short mesentry! In such cases formation of standard Brooke’s ‘Pouting’ ileostomy is not only difficult, but an impossible and a dangerous surgical exercise! In these situations where the bowel is “Un-Brookeable” due to aforementioned causes. Over a period of 12 years we could device a formula – “Ray’s Criteria” to decide at operation, if a given ileum in a particular patient, is safely “Brookeable” (i.e. evertable into a neat Brooke, spouting ileostomy) or is   “Un-Brookeable”.

Methods: 23 patients were included in this study over 12 years, who due to the peculiarity of their body morphology (obesity or thick abdominal fat), edematous friable bowel with bulky mesentry, the ileum could not be drawn outside the abdomen and everted as Brooke’s ileostomy. The “Brookeability” of the exteriorized ileum was decided based on satisfying two issues of Ray’s criteria.

Results: By using “Ray’s criteria”, we could seggregate patients safely as “Brookeable” and “Un-Brookeable”. Those deemed “Un-Brookable” underwent “Long segment Hanging snout” end ileostomy, which is the theme of our study.

Conclusions: We are emphatic in stating that by using “Ray’s criteria” we could accurately segregate cases into “Brookeable” and “Un-Brookeable” ileum.


Brooking, Restoration of bowel continuity, Un-Brookeable, Ray’s criteria

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Brooke BN. The management of an ileostomy, including its complications. Lancet. 1952;2:102–4.

Cheetham M, Schein M, Rogers PN, Leppäniemi A, Rosin D, Jonathan E. Efron Schein’s Common Sense Emergency Abdominal Surgery. Fourth edition. U.K: tfm Publishing Limited; 2016

Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain MLNG, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Medicine. 2013;39(7):1190–206.

Shabbir J, Britton DC. Stoma complications: a literature overview. Colorectal Dis. 2010;12(10):958–64.

Guarner F, Malagelada J. "Gut flora in health and disease". The Lancet. 2003:361(9356):512–9.

Azpiroz F. Intestinal gas dynamics: mechanisms and clinical relevance. Gut. 2005;54(7):893-5.

Tomlin J, Lowis C, Read NW. Investigation of normal flatus production in healthy volunteers. Gut. 1991;32(6):665-9.

Matikainen M, Santavirta J, Hiltunen KM. Ileoanal anastomosis without covering ileostomy. Dis Colon Rectum. 1990;33(5):384-8.

Cameron, John L. Current Surgical Therapy. 8th ed. Philadelphia: Elsevier Mosby, 2004.

Ellis, H. The First Successful Elective Laparotomy. Journal of Perioperative Practice. 2015;25(10):207-8.

Westphalen, N. ‘Warfare, Ships and Medicine: Prehistoric Origins’, Journal of Military and Veteran’s Health. 2020;28(1):16-28.

Quebbeman, Frances Elizabeth. "Medicine In Territorial Arizona" . University of Arizona; 1996. Archived from the original on 10 December 2013. Retrieved 7 December 2013

Kaidar-Person O, Person B, Wexner SD. Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg. 2005;201:759-73.

Doughty, Dorothy. History of Ostomy Surgery. Journal of wound, ostomy, and continence nursing: official publication of The Wound, Ostomy and Continence Nurses Society / WOCN. 2008;35:34-8.

Turnbull RB, Weakley FL. St Louis: Mosby; 1967. Atlas of intestinal stomas; pp. 32–9

Slaney G. Bryan nicholas brooke. BMJ (Clinical research ed.). 1998;317(7171):1529.