intestinal stomas.pdf

J. Graham Williams, M.Ch., F.R.C.S.

30 INTESTINAL STOMAS

Formation of an intestinal stoma is frequently a component ofsurgical intervention for diseases of the small bowel and the colon.The most common intestinal stomas are the ileostomies (end andloop) and the colostomies (end and loop); the less commonstomas, such as cecostomy and appendicostomy, have limitedapplications and thus are not considered further in this chapter.

For optimal results, it is essential that stoma creation be con-sidered an integral part of the surgical procedure, not merely anirritating and time-consuming addendum at the end of a longoperation. Accordingly, the potential requirement for a stomashould be appropriately addressed in the planning of an intestinalprocedure. A great effort should be made to counsel the patientbefore operation as to whether a stoma is likely to be needed, whatstoma creation would involve, where the stoma would be situated,and whether the stoma is likely to be permanent or temporary.

Operative Planning

PREOPERATIVE COUNSELING

Ideally, as soon as surgical intervention that may involve astoma is contemplated, the enterostomal nursing service shouldbecome involvedthough this may not be possible in an emer-gency setting. Patients often have misconceptions about the effectsstoma will have on their quality of life and consequently may expe-rience considerable anxiety. Adequate preoperative counselinghelps correct these misconceptions and reduce the attendant anx-iety. Enough time should be set aside to allow the counselor toexplore the patients knowledge of the disease and understandingof why a stoma may be required.This process involves reviewingthe planned operation, describing what the stoma will look like,and explaining how the stoma will function. Visual aids (e.g.,videos, CD-ROMs, and booklets) can be very useful in this regardand should be freely available to patients and their families. Assimple a measure as showing the patient a stoma appliance andattaching it to the abdominal wall before the procedure can behelpful in preparing the patient for a stoma. Many patients facingthe prospect of stoma surgery also derive great benefit from meet-ing patients of similar age and background who have a stoma.

CHOICE OF PROCEDURE

A number of common indications for stoma formation havebeen identified [see Table 1].These indications are usually associ-ated with particular types of stoma, but the association is notalways a simple or automatic one. In many situations, more thanone option exists, and it can be difficult to select the best avail-able option for a particular patient.

Loop Ileostomy versus Loop Colostomy

Defunctioning of a distal anastomosis after rectal excision andanastomosis may be achieved with either a loop ileostomy or aloop transverse colostomy. A number of nonrandomized stud-ies1-3 and randomized control trials4-7 have been performed in aneffort to determine which of these two approaches is superior.

Both types of stoma effectively defunction the distal bowel; how-ever, loop ileostomy appears to be associated with a lower inci-dence of complications related to stoma formation and closure,though it may also carry a higher risk of postoperative intestinalobstruction.6The two types of stoma are comparable with respectto patient quality of life, and the degree of subsequent socialrestriction is influenced more by the number and type of compli-cations than by the type of stoma formed.8

SELECTION OF STOMA SITE

A poorly sited stoma will cause considerable morbidity andadversely affect quality of life. For this reason, great emphasisshould be placed on selecting the best site for the stoma on theabdominal wall. In many instances [see Table 1], it may not be pos-sible to decide beforehand whether a colostomy or an ileostomyis to be performed. An example would be the case of a patientwith a tumor in the lower rectum in which the surgeons inten-tion is to perform a restorative resection covered by a loop ileosto-my. In such a case, the surgeon sometimes finds that restorativeresection is not technically possible and elects to perform anabdominoperineal resection or a low Hartmann resection with anend colostomy instead.

A stoma should be brought out through a separate opening in theabdominal wall, not through the main incision: there is a high inci-dence of wound infection and incisional hernia formation if themain incision is used as a stoma site. In general, ileostomies are sitedin the right iliac fossa, sigmoid colostomies (loop or end) in the leftiliac fossa, and transverse loop colostomies in either the right or theleft upper quadrant.These positions are preferred because they areconveniently close to the particular bowel segments to be used forcreating the various stomas. At need, howeveras when finding asuitable site proves difficult because of previous scars or deformi-tyboth the ileum and the colon can be mobilized to provide suf-ficient length to reach most sites on the abdominal wall.

In selecting and marking a stoma site, the following key con-siderations should be taken into account:

1. A flat area of skin is required for adequate adhesion of theappliance.

2. The patient should be able to see the stoma.3. Skin creases, folds, previous scars, and bony prominences

should be avoided.4. The stoma site should not be located at the beltline.5. The site should be identified with the patient lying, sitting,

and standing.6. Preexisting disabilities should be taken into account.

According to received wisdom, the stoma should be broughtout of the abdomen through the rectus abdominis, so that theemerging stoma will be supported and the incidence of paras-tomal hernia reduced. Several studies, however, have shown thatthis approach is not always ideal and that the optimum site for astoma should be selected without regard to its position in relationto the rectus abdominis.9-11 Once selected, the site is marked withan indelible pen or tattooed with India ink and a fine needle.

2004 WebMD, Inc. All rights reserved.5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice30 Intestinal Stomas 1



Operative Technique

GENERAL PRINCIPLES

Most abdominal stomas are formed at the end of an openoperation performed to resect bowel, drain an infectious focus,or relieve obstruction. In this setting, a midline incision is gen-erally the most appropriate choice for gaining access to theabdominal cavity because it leaves the areas to either side of themidline available for stoma placement. Other incisions may beused as well, but more careful operative planning will berequired.

A defunctioning stoma can be created without opening theabdomen by making a trephine hole and using retractors andforceps to identify the relevant bowel loop from which thestoma will be formed. I generally avoid this approach, for tworeasons. First, the trephine hole invariably ends up larger thanis ideal, and the greater size leads to an increased risk of para-stomal hernia. Second, it is often difficult to be sure that thecorrect bowel loop has been identified and the correct endopened as a stoma. These disadvantages can be overcome bytaking a laparoscopic approach. One port is placed though thepreviously marked site. A tissue forceps is passed down this portand used to grasp and orient the relevant bowel segment. If nec-essary, the bowel can be mobilized by means of laparoscopicdissection. The colon is then divided with a linear stapler, andthe proximal end is brought out through a small trephine holemade at the port site.

The fundamental concept in stoma formation is that a stomais simply an anastomosis between a piece of bowel and the skin

of the abdominal wall. For this reason, the same basic principlesthat apply to intestinal anastomosis also apply to stoma forma-tionnamely, maintaining an adequate blood supply to bothsides of the anastomosis, ensuring that the anastomosis is per-formed without tension, and avoiding any preexisting infection.In accordance with these principles, the bowel segment usedshould have as much of its blood supply as possible preservedduring mobilization, and mobilization should be sufficient toallow the bowel to be brought through the abdominal wall with-out tension and without occlusion of the blood supply at the fas-cial level by a too-small hole in the abdominal wall. If these cri-teria are not met, then either the bowel should be mobilized fur-ther or a new bowel segment should be selected. It is importantto make the best possible technical choices at the time of initialstoma formation. If the correct principles are not followed at thebeginning of the procedure, it is generally futile to hope that thesituation will improve thereafter; the usual result is a poor stomathat requires surgical revision.

Creation of Stoma Aperture

It is wise to leave formation of the hole for the stoma until theend of the procedure because unforeseen events during the oper-ation may necessitate a change in the type or the site of the stoma.A circular incision 2.5 cm in diameter is made at the marked site,and the skin is excised.The subcutaneous fat is parted with scis-sors and small retractors until the fascia of the abdominal wall isreached. The fat need not be excised: it supports the emergingstoma, and its absence would leave a potential dead space. A cru-ciate incision is made in the rectus sheath, initially no more than

Table 1 Indications for Different Types of Intestinal Stomas

Disease

Colorectal cancer

Diverticular disease

Ulcerative colitis

Crohn disease

Trauma

Functional disorders

Indication

Defunctioning of bowel

Relief of obstruction

Low tumor (abdominoperineal resection)

Defunctioning of low anastomosis

Resolution of sepsis; defunctioningof bowel

Relief of obstruction

Protection of anastomosis


Eradication of disease

Ileoanal pouch procedure


Defunctioning of bowel after excision



Excision of disease




Defunctioning of anus


Stoma Type

Loop or end colostomy

Loop or end colostomyEnd colostomy

Loop ileostomy or colostomy

Colostomy

Loop or end colostomyLoop ileostomy or colostomy

End ileostomy (after subtotal colectomy)

End ileostomy (after panproctocolectomy)

Loop ileostomy

Loop or split ileostomyEnd ileostomy or colostomy

Loop, end, or split ileostomyLoop or split ileostomyIleostomy (after panproctocolectomy)Colostomy (after rectal excision)Loop or divided loop ileostomy

Colostomy or loop ileostomyColostomy

End colostomyLoop ileostomy or colostomy

Intention

Temporary, often permanentTemporaryPermanent

Temporary

Temporary, sometimes permanent

Temporary, sometimes permanentTemporary

Temporary or permanent

Permanent

Temporary

Temporary, sometimes permanentTemporary, often permanent

Temporary, sometimes permanentTemporary, often permanentPermanent

Temporary

Temporary, sometimes permanentTemporary, sometimes permanent

PermanentTemporary

Presentation

Perforation

Obstruction

Rectal cancer

Perforation

Obstruction

Elective resection for fistula

Acute colitis

Chronic colitis

Crohn colitis

Small bowel disease

Perianal disease

Elective resection for septiccomplications

Colon injury

Rectal injury

Fecal incontinence

Sphincter repair



2 cm in each direction.The muscle fibers of the underlying rectusabdominis are split in the direction of their fibers with an arterialclamp or the tips of heavy scissors.The small retractors are insert-ed deeper to keep the muscle fibers apart, and a small cruciateincision is made in the posterior rectus sheath with an electro-cautery. A swab held against the peritoneum at the stoma site willprotect the intra-abdominal organs and the assistants fingers frombeing injured by the electrocautery point.

On occasion, the epigastric vessels, which lie between the rec-tus abdominis and the posterior sheath, are injured. Should thisoccur, the simplest way of dealing with the problem is to open theposterior sheath from inside the abdominal cavity and suture-lig-ate the bleeding point.

COLOSTOMY

End

The typical site for an end colostomy is the left iliac fossa, andeither the sigmoid or the descending colon is used for the stoma.If the rectum has been excised, the inferior mesenteric vessels willhave been divided, and the blood supply to the distal colon willcome from the middle colic vessels via the marginal artery. It isnot usually necessary to take down the splenic flexure to mobilizethe colon adequately; however, if there is any concern regardingtension on the stoma, full splenic flexure mobilization should beperformed. For a simple defunctioning end colostomy, only a fewsmall vessels in the mesentery will have to be divided.

The colon is divided at the relevant site with either crushingclamps or a linear intestinal stapler.The adequacy of the vascularsupply is checked by inspection. A nontraumatic bowel clamp ora Babcock tissue forceps is passed through the hole in the abdom-inal wall and used to grasp the closed-off end of the colon. Care istaken when drawing the colon through the abdominal wall to keepfrom twisting the colon and damaging the small vessels in the sup-porting mesentery.The end of the colon should sit 2 cm above theskin surface. To prevent wound contamination, the colostomy isconstructed only after the skin incision has been fully closed anddressed. The closed-off end of the colon is excised with a sharpknife, and the colostomy is constructed with a small spout byeverting the bowel wall. The spout helps the patient position thestoma appliance but should not protrude more than 0.5 to 1 cmabove the surface of the skin.The anastomosis is performed withinterrupted absorbable sutures that take bites of the full thicknessof the end of the colon and the subcuticular layer of the skin. Smallbites are also taken of the seromuscular layer of the emergingcolon at the level of the skin [see Figure 1].

This technique is sometimes modified by closing the lateralspace between the abdominal wall and the colon with absorbablesutures in an effort to prevent internal herniation of the smallbowel. An alternative approach is to tunnel the colostomy to thehole in the abdominal wall via an extraperitoneal route. Thisapproach may prevent herniation and colostomy prolapse,9 butthe stoma may be slow to function and difficult to mobilize if areversal or revision operation is performed.

Loop

A loop colostomy is usually performed as a quick and tempo-rary method of relieving acute colonic obstruction or to cover ananastomosis in the distal colon or rectum. Whenever possible, Iavoid using loop colostomies, for the following reasons.

1. Because of the need to accommodate two pieces of bowel, aloop colostomy requires a larger hole in the abdominal wall

than an end colostomy does. This is a particular concern inemergency situations, where the colon may be greatly dilated.

2. The larger hole predisposes to formation of a parastomal her-nia, which can be a problem if the stoma is not reversed.

3. Loop colostomies are more prone to prolapse than endcolostomies are, possibly as a conseqence of parastomal herniaformation.

4. The effluent from the transverse colon can be highly liquid,and the absence of a spout with loop colostomy may lead todifficulties with appliance leakage.

5. When a loop colostomy is used to defunction a distal anasto-mosis, there is a theoretical risk of damage to the marginalartery, which may be the only vessel supplying the distal sideof the anastomosis.

The usual site for a loop colostomy is either the right upperquadrant (using the proximal transverse colon) or the left iliacfossa (using the left colon). The colon segment that will be usedto form the stoma is identified, and peritoneal attachments aredivided to provide sufficient length to reach the desired site onthe abdominal wall without tension. If the transverse colon is tobe used, the omentum is removed. Care is taken not to damagethe marginal artery, which, if occluded, may compromise vascu-lar supply to the distal bowel.

A trephine hole is made at the marked site as described [seeOperative Technique, General Principles, above].The hole is usu-ally larger than it would be in an end colostomy; the bowel loopto be brought out is often bulky, especially when the colon isobstructed. A small window is made in the mesentery immedi-ately adjacent to the colon wall, and a Jacques catheter is passedthrough this aperture.The Jacques catheter is used as a handle by

Figure 1 End colostomy. (a) The end of the colon sits 1 to 2 cmabove skin level. Four absorbable sutures are placed, one in eachquadrant of the stoma. Each suture takes a full-thickness bite ofthe end of the colon, a seromuscular bite of the emerging colon atskin level, and a subcutaneous bite of the edge of the skin open-ing. (b) The stoma is completed by filling in the gaps between thefour quadrant sutures with interrupted sutures that take full-thickness bites of the end of the colon and subepidermal bites ofthe skin edge. The stoma should have a small (0.5 to 1 cm) lip,which facilitates accurate positioning of the colostomy bag.

a

b



which the colon loop is drawn through the trephine hole in theabdominal wall, with care taken to maintain the orientation of thecolon and avoid twisting [see Figure 2a]. The catheter is thenreplaced by a plastic or glass stoma rod, which supports the loopat the level of the skin.

The main incision is closed, and the stoma is matured. A trans-verse incision is made in the apex of the bowel loop [see Figure2b], and the two edges are peeled back and sutured to the skinedge of the trephine hole to produce a double opening [see Figure2c, d].The bridge remains in place for 5 days, by which time thestoma is usually beginning to function properly.The rod can thenbe removed because by this point, the stoma is fixed in place andunable to retract into the abdominal cavity.

Double-Barrel

At one time, there was a vogue for creating a double-barrelcolostomy to defunction the colon. Although the height of the vogue has passed, this type of stoma still has a place in themanagement of colorectal trauma. After resection of a dam-aged segment of the colon, the proximal and distal ends of the colon are tacked together along the antimesenteric surfaceswith interrupted absorbable sutures. The resulting double end is then brought out through a trephine incision at the relevantsite. The double-barrel configuration makes the colostomy easier to close: closure can be performed after mobilization by resection and a sutured anastomosis or via a double-stapledtechnique.

ILEOSTOMY

End

End ileostomy is most frequently performed after colectomyfor inflammatory bowel disease. The most distal segment of theileum is used (i.e., that immediately proximal to the ileocecalvalve), the reason being that it is important to preserve intestinallength, both for nutritional reasons and to allow for the possibili-ty that an ileoanal pouch may have to be fashioned in the future.In certain instances, it is necessary to create an end ileostomyfrom a more proximal segment of the ileum.

The terminal ileum is mobilized, a large avascular window isopened between the ileocolic vessels and the ileal branches of thesuperior mesenteric vessels, and the ileocolic vessels are dividedwhere they branch from the superior mesenteric vessels.The ter-minal ileum is usually supplied by two arcades of vessels, whichjoin the ileocolic vessels adjacent to the cecum. These arcadesmust be divided as close to the ileocolic vessels as possible to pre-serve the blood supply to the terminal ileum [see Figure 3]. Theileocecal fold (Trevess fold) is dissected away from the terminalileum, which can then be divided flush with the ileocecal valve,either with a linear stapler or with a knife between bowel clamps.

The trephine incision is created at the previously marked site,and a Babcock tissue forceps is passed into the abdominal cavityand used to grasp the divided end of the ileum. The terminalileum and the supporting mesentery are gently eased through theaperture, with the mesenteric surface oriented superiorly, until 5

a b

c d

Figure 2 Loop colostomy. (a) A softcatheter or a length of nylon tape ispassed through a small window made inthe mesentery of the colon, and the pre-pared loop of colon is eased through thehole in the abdominal wall with the aid ofthe catheter. The catheter or tube isreplaced by a supporting colostomy rod.(b) A transverse incision is made acrossthe apex of the colon loop. (c) The cutedges of the colon are everted andsutured to the skin edge of the stoma holewith interrupted absorbable sutures thattake full-thickness bites of the colon andsubepidermal bites of the skin. (d) Therod is left in place for 5 days to supportthe loop stoma during the early phase ofhealing.



cm of ileum protrudes above the abdominal skin.The cut edge ofthe ileal mesentery is secured to the peritoneum of the back of theanterior abdominal wall, along the line of the lateral border of therectus abdominis, with an absorbable suture.This measure helpsstabilize the stoma and is thought to prevent stoma prolapse,volvulus, and internal herniation around the stoma.

The stapled end of the ileum is excised to produce a fresh bleedingend.The emerging ileum is then everted to yield a spout about 2.5 cmlong.This is accomplished by placing a suture on either side of themesentery and a third suture on the antimesenteric side, which liesinferiorly.The superior sutures take bites of the serosa of the emerg-ing ileum, 5 cm from the cut end of the bowel, and the inferior sutureincludes a serosal bite 4 cm from the cut edge [see Figure 4].When thesutures are tied,an everted spout is created that points downward intothe ileostomy appliance.12 The mucocutaneous anastomosis is thencompleted with a series of interrupted absorbable sutures.

Loop

A loop ileostomy is employed to rest the distal bowel or to pro-tect an anastomosis.The ileal loop used should be as distal as pos-sible while still maintaining adequate mobility; if there is any ten-sion, a more proximal loop may be required. The technique ofloop ileostomy formation is similar to that of loop colostomy for-mation. A Jacques catheter is used to draw the loop through theabdominal wall trephine hole, ideally with the proximal limb inthe lower position [see Figure 5a]. Care is taken to distinguish theproximal and distal limbs of the loop and to keep from rotatingthe loop during its passage through the abdominal wall. A mark-ing suture is useful for identifying the proximal side of the loop.A supporting rod may be used, but it is not necessary, and it canhinder the fitting of the stoma appliance.

The ileostomy is created by making a circumferential incisionaround 80% of the distal limb at the level of the skin, with the

Right Colic Artery

Ileocolic Artery

LigatedVessels

Superior Mesenteric Artery

Cut Edge ofMesentery

Line of Division Vascular Arcades

Ileal Branch

Stapled Endof Ileum

ab

Figure 3 End ileostomy. Shown is preparation of the terminal ileum. (a) Care is taken when dividing the bloodsupply of the right colon to preserve the arcades supplying the terminal ileum. The line of division of the vesselsand the mesentery is shown (dashed line). (b) The mesentery of the terminal ileum is divided so as to preserve thevascular arcade adjacent to the ileum. A segment of well-perfused ileum at least 10 cm long is created, which canbe brought through the abdominal wall opening to provide sufficient ileum for creation of a spout.

4 cm.

HeadFeet

5 cm.

Figure 4 End ileostomy. The ileum having been brought throughthe abdominal wall, the ileostomy is created by everting the endof the ileum. Three sutures are placed: one on the antimesentericside and one to each side of the mesentery. Each suture takes afull-thickness bite of the cut edge of the ileum, a seromuscularbite of the emerging ileum at skin level, and a subepidermal biteof the skin edge. The spout is created when these sutures are tied.A nontoothed forceps or a Babcock tissue forceps is sometimeshelpful for everting the ileum. Gaps between the three sutures arefilled in with further absorbable sutures, which include only theend of the ileum and the skin edge.

mesenteric side preserved [see Figure 5b]. The cut edge of theproximal limb is then everted to create a spout for the ileostomy[see Figure 5c]. A Babcock tissue forceps is sometimes used toapply gentle traction to the mucosal side of the proximal limb.The cut edge of the ileum is anastomosed to the skin with a seriesof interrupted subcuticular absorbable sutures.The distal limb issutured flush with the skin. On the proximal side, several suturestake bites of the serosa of the emerging ileum at skin level. Thecorners of the incision in the ileum are drawn around the proxi-mal limb of the ileostomy to accentuate the spout effect and cre-ate a thin, semilunar distal limb opening [see Figure 5d].

An alternative approach is to create a divided loop ileostomy,which some consider superior to a conventional loop stoma.13The construction technique for this stoma is similar to that of itsconventional counterpart. The distal limb of the ileostomy isdivided with a linear cutting stapler after the loop is broughtthrough the abdominal wall.The closed distal end is tacked to theside of the emerging spout of the proximal end below skin level,and the proximal end is fashioned into an everted spout as in aconventional end ileostomy. A divided loop ileostomy is slightlymore difficult and expensive to construct than a conventionalloop ileostomy, but it has the advantage of achieving completedefunctioning of the distal bowel (because there is no chance thatthe ileostomy contents will spill over).

Loop-End

A loop-end ileostomy can be useful in cases where the ileumand its supporting mesentery are grossly thickened and the sur-

geon is encountering difficulty in preparing a sufficient length ofwell-vascularized ileum for a conventional end ileostomy. In aloop-end ileostomy, the ileum is prepared as in a conventionalend ileostomy, but the vascular arcades are left undisturbed. Asmall window is made in the mesentery 5 to 10 cm proximal tothe closed end of the ileum, and a nylon tape or a Jacques catheteris used to draw this distal ileal loop through the abdominal wall.The stapled closed end of the ileum lies just within the abdomi-nal cavity. The ileostomy is then constructed in essentially thesame manner as a conventional loop ileostomy.

Split

A split ileostomy is created by bringing out the two cut bowelends at different sites.The proximal end is usually terminal ileum,but the distal end may be either ileum or colon, depending on theindication for stoma formation. This procedure forms a mucousfistula, and only a small stoma appliance is usually required.Thedistal end can be either included in the closure of the abdominalwound or brought out through a separate trephine hole on theopposite side of the abdomen from the ileostomy.The advantageof a split ileostomy is that it completely defunctions the bowelwithout the risk of intra-abdominal leakage from a closed distalstump.The disadvantage is that it is more difficult to close: closureusually necessitates reopening of the main incision.

Continent

A continent ileostomy involves formation of a reservoir andplacement of a nonreturn nipple valve, which is emptied regular-



a b

c d

Figure 5 Loop ileostomy. (a) A softcatheter or a length of nylon tape ispassed through a small window made inthe mesentery of the ileum, and the ilealloop to be used for the stoma is easedthrough the hole in the abdominal walland left protruding a few centimetersabove skin level. A suture is placed tomark the distal limb. (b) A semilunarincision is made in the mesenteric borderof the distal limb at skin level, extendingaround most of the circumference of theileum. (c) A Babcock tissue forceps isinserted into the loop and used to graspthe wall of the proximal limb. The cutedge of the ileum is peeled back to evertthe bowel wall and create a spout fromthe proximal limb of the loop. (d) Thestoma is completed by placing interrupt-ed absorbable sutures between the cutedge of the ileum and the subepidermallayer of the skin. A few of these suturesalso take a seromuscular bite of theemerging ileum at skin level.

ly via a catheter, so that the patient need wear only a small capappliance. The surgical technique is demanding and beyond thescope of this chapter; it is described more fully elsewhere.14

STOMA CLOSURE

Loop Ileostomy

Closure of a loop ileostomy is usually a simple local procedurethat does not require the main incision to be opened.The opera-tion is easier to perform if a period of at least 12 weeks is allowedto elapse between formation of the stoma and closure so thatthere is time for edema and inflammatory adhesions to settle.Dissection is facilitated by injecting epinephrine (1:100,000 solu-tion) into the subcutaneous plane around the stoma.

An incision is made in the peristomal skin 2 mm from themucocutaneous junction [see Figure 6a].The incision is deepenedinto the subcutaneous fat until the serosa of the emerging bowelappears. Sharp dissection is continued circumferentially in thisplane, dividing the fine adhesions between the bowel and itsmesentery and the subcutaneous fat [see Figure 6b]. Blunt dissec-tion should be avoided because it can easily lead to serosal tears.Some difficulty may be encountered at the fascial level, and caremust be taken with the dissection if adhesions are particularlydense. Eventually, the peritoneal cavity is entered, and theremaining adhesions are identified with a finger and divided.

The emerging ileal loop is withdrawn from the abdominal cav-ity, and the mucocutaneous junction and the rim of skin areexcised. The everted proximal end of the stoma is unfolded [seeFigure 6c]; some sharp dissection is usually required to accom-plish this. The freshened edges of the enterotomy are then

approximated with interrupted seromuscular absorbable sutures[see Figure 6d]. Sometimes, a limited ileal resection is required ifthe stoma site is in poor condition, and a conventional end-to-endanastomosis is performed to restore intestinal continuity. It is pos-sible to close a loop ileostomy with a double-stapled technique;however, there does not appear to be much advantage in doing so.Two randomized trials and a nonrandomized study comparingsuture closure with stapled closure yielded conflicting results withrespect to complication rates,15-17 but both randomized trialsreported that extra costs were incurred when staples were used.Once the enterotomy is closed, the loop of ileum is returned tothe abdominal cavity, and the stoma site is closed with interrupt-ed nonabsorbable sutures.

A divided loop ileostomy is closed in the same manner as described above. Care should be taken to identify the closeddistal end and to fully mobilize both limbs of the ileum from the abdomen.The closed distal end is separated from the proxi-mal limb, and the staple line is excised to yield a fresh end.The proximal end is unfolded and a simple end-to-end anasto-mosis is performed with interrupted sutures.There may be a sig-nificant size discrepancy between the two limbs. Again, a double-stapled technique may be employed as an alternative closuremethod.

Loop Colostomy

A loop colostomy is closed in much the same manner as a loopileostomy after the emerging colon is mobilized away from thesubcutaneous fat and the abdominal wall by means of sharp dis-section. Transverse closure is achieved with interruptedabsorbable sutures.



Figure 6 Stoma closure: loop ileosto-my. (a) Epinephrine is infiltrated intothe subcutaneous tissues around theileostomy, and an incision is madethrough the full thickness of the skin 2mm from the mucocutaneous junction.(b) The emerging ileum is mobilized bydividing adhesions between the boweland the subcutaneous fat and theabdominal wall until the bowel is com-pletely free. (c). The everted segment ofileum is reduced by a combination ofsharp and blunt dissection, and the edgeof the opening in the ileum is excised toleave fresh supple ileum for anastomosis.(d) The opening in the ileum is closedwith a single layer of interruptedabsorbable sutures that take bites of theseromuscular layers only. The ileal loopis then returned to the abdominal cavity,and the defect in the abdominal wall isclosed with interrupted nonabsorbablesutures.

a b

c d



Postoperative Care

A clear stoma appliance is cut to the proper size and placed onthe stoma before the patient leaves the operating room. A degreeof edema is to be expected in the first week. In addition, the stomamay appear somewhat dusky; this is a sign that the aperture in theabdominal wall is the correct size. It often happens that thepatient becomes alarmed at the initial appearance of the stomaand requires reassurance that the stoma will look better as timepasses.

When the stoma starts to function, the clear appliance ischanged for the chosen appliance, and the patient is instructed inhow and when to empty the pouch. When confident with thisaspect of stoma management, the patient is instructed in how tocut the plate to the correct size and how to change the stoma bagor flange (if he or she is using a two-piece appliance). An ileosto-my works throughout the day, often showing an increase in activ-ity after meals. The appliance will therefore require regular emp-tying, a task that some patients find inconvenient. A loop trans-verse colostomy may be as unpredictable as an ileostomy in thisregard; however, a sigmoid colostomy may have a more pre-dictable activity, similar to the frequency of normal bowel move-ments. Some patients find that quality of life is improved by irri-gating the colostomy with water instilled via a special appliance.This procedure induces a full colonic clearout and allows thepatient to wear a less obtrusive cap appliance for 24 to 48 hours,until irrigation is repeated.

Detailed discussion of stoma care is beyond the scope of thischapter. A key role is played by the enterostomal therapist, who is an important point of contact for the patient, providing ad-vice, instruction, and emotional support in the postoperative period. Skin complications are common, and most can be man-aged by the enterostomal therapist. Many such complicationsresult from contact between the peristomal skin and digestiveenzymes; common causes include poor appliance fit and stomaretraction. Skin problems can usually be resolved by means ofsimple measures such as switching to a different appliance, us-ing a convex flange, applying barrier cream, or filling dips in the peristomal skin with stoma paste. Given that surgical compli-cations such as fistula formation and parastomal hernia may pre-sent as skin problems, it is important that the surgeon and theenterostomal therapist work closely together in addressing theseproblems.

Troubleshooting

Wound infection after stoma closure is common. Drainage ofthe incision with a small corrugated drain can help reduce theincidence of such infection. Some surgeons leave the stoma siteopen and allow it to heal by second intention.

Incisional hernia can develop in the stoma site, and its inci-dence is increased by wound infection in the postoperative peri-od. Because the defect is relatively narrow, the hernia can lead tosignificant symptoms. Repair is usually necessary.

Breakdown of the anastomosis lying beneath the incision willlead to a fecal fistula, with discharge from the stoma site. If the fis-tula is simple and there is no distal obstruction, it is likely to healspontaneously. Expert nursing is required to manage the fistulaeffluent while healing occurs to prevent damage to the surround-ing skin.

If there is a complex inflammatory mass at the closure site,spontaneous healing is less likely. Laparotomy may be required,with resection of the stoma site and reanastomosis or furtherstoma formation, depending on the patients condition.

Complications

Complications after stoma formation are frequent and varied[see Table 2] and can adversely affect quality of life.The complica-tion rate has been reported to be about 25% after a colostomy for-mation and as high as 57% after an end ileostomy18 and 75% aftera loop ileostomy.19 Cumulative complication rates at 20 yearshave reached 76% in patients undergoing ileostomy for ulcerativecolitis and 56% in those undergoing ileostomy for Crohn dis-ease.20 As noted [see Postoperative Care, above], many complica-tions can be successfully managed with enterostomal care.18 Thisis fortunate because the results of surgical correction are oftenunsatisfactory, with many patients requiring further surgical revi-sion of their stomas.21

Careful assessment is warranted when a patient presents withstomal complications. Such complications may be interrelated ormay have a different cause from what initial examination suggests.For example, skin damage may be a result of a poorly fitting appli-ance, but the poor fit may itself be caused by a parastomal herniaor a flush ileostomy. Furthermore, stomal complications mayarise from renewed activity of the underlying disease (e.g., recru-descence of Crohn disease21-23 or recurrence of cancer).

ISCHEMIA

Mild ischemia of the stoma is common in the early postoper-ative period but usually resolves within a few days. More pro-found ischemia can result in necrosis of all or part of the cir-cumference of the bowel end used to form the stoma. Satisfac-tory healing of the stoma depends on an adequate blood supply.Problems with the blood supply are more common with endstomas than with loop stomas; likely causes include excessivedivision of mesenteric blood vessels, tension on the stoma frominadequate mobilization, and a too-narrow aperture through theabdominal wall that constricts the vessels at the fascial level. It isa good idea to prepare the relevant bowel segment for use in astoma some time before the end of the operation so that anyproblems with the blood supply will be evident before the stomais fashioned. An obviously ischemic stoma should be revised at

IleostomyPatients18(N = 150)

Table 2 Incidence of Common Complications of Intestinal Stomas

Complication

Skin problems

Obstruction

Retraction

Hernia

Prolapse

Fistula

Stenosis

Necrosis

No. (%)

24 (17.4)

11 (13.7)

3 (1.5)

43 (36.7)

11 (11.8)

2 (1.0)

10 (7.3)

No. (%)

17 (14)

9 (7)

14 (11)

4 (3)

3 (2)

11 (9)

No. (%)*

44 (34)

27 (23)

19 (17)

16 (16)

12 (11)

11 (12)

6 (5)

1 (1)

ColostomyPatients46(N = 126)

ColostomyPatients9(N = 203)

* All complications recorded at clinic review. Complication rate expressed as cumulative prob-ability from life-table analysis.Retrospective review of all patients who underwent end colostomy formation.All complications recorded at clinic review. Complication rate expressed as cumulative proba-bility from life-table analysis.

the time of operation. Such revision may include mobilization ofa more proximal bowel segment.

Patchy necrosis that is confined to the mucosa can be managedexpectantly and usually heals by second intention. Completenecrosis of an ileostomy is an indication for urgent revision.Necrosis of a colostomy may not necessitate revision if the seg-ment is short. However, a fistula may form at the fascial level, orstenosis may develop as the necrotic segment heals.

STENOSIS

Stenosis of the stoma is a consequence of postoperativeischemia. Mild stenosis can be managed with simple dilatationand may not cause many symptoms, particularly if the effluent isliquid. Substantial stenosis of a colostomy can lead to subacuteobstruction that must be managed with surgical revision.Sometimes, revision can be accomplished as a local procedure. Adisk of skin that includes the stenosed stoma site is excised. Thedistal colon is mobilized and sutured to the new skin opening. Inmost instances, however, it is not possible to mobilize sufficientlength with this approach, and laparotomy is required for ade-quate mobilization.

PROLAPSE

Prolapse may occur with any type of stoma but is most com-mon with loop colostomy. Patients with loop colostomies usuallyhave a degree of parastomal hernia, which allows adequate spacefor prolapse of the emerging bowel. Appearances are often alarm-ing, and symptoms are usually related to difficulties with fitting anappliance or to leakage.The best treatment option is to close thestoma (if appropriate). Another option is to divide the loopstoma, thus creating an end colostomy, and then to return theclosed distal end to the abdomen. Amputation of the prolapsed

stoma corrects the problem in the short term, but the prolapseoften recurs quickly. Repairing a coexisting parastomal hernia canlower the risk of recurrence, but it involves a more extensive oper-ation [see Parastomal Hernia, below]. Neither ensuring that theemerging stoma is brought through the rectus abdominis nor fix-ing the mesentery to the abdominal wall appears to prevent stomaprolapse.20

RETRACTION

Stoma retraction is more of a concern with an ileostomy thanwith a colostomy because of the possibility of leakage from theappliance. Retraction generally results from poor adhesion be-tween the serosal surfaces of the everted stoma but may alsoreflect the presence of a parastomal hernia. If the retractedileostomy is fixed in position, laparotomy will probably berequired to correct the problem, though it is worthwhile toattempt local mobilization of the stoma after incising the muco-cutaneous junction. If the retracted ileostomy is mobile, the prob-lem can be corrected by inserting a series of interrupted ab-sorbable sutures through the full thickness of the everted stomato fix the walls together. A similar effect can be obtained bypulling the retracted stoma upward with tissue forceps, then fix-ing the walls together with several firings of a noncutting linearstapler inserted into the ileostomy, with care taken to avoid themesentery [see Figure 7].24

PARASTOMAL HERNIA

Formation of an abdominal stoma necessarily involves creatinga defect in the abdominal wall to accommodate the emergingbowel. Such defects may become enlarged as a result of tangen-tial force applied to the edge of the opening, and this enlargementmay lead to hernia formation. The tangential force is related tothe radial force and the radius of the opening; in turn, the radialforce is related to the intra-abdominal pressure and the radius ofthe abdominal cavity.25 Consequently, tangential forces aregreater in larger openings in obese patients, who are thus atgreater risk for parastomal hernia. Patients undergoing emer-gency procedures in which dilated bowel is used to form a stomaare also likely to be at increased risk for hernia formation. Caremust be taken to make an opening that is just large enough for theemerging bowel. An incision that admits only two fingers isappropriate for most elective indications.

Several authors have addressed the problem of enlargement ofthe stoma opening by reinforcing the opening with a prostheticring or a sheet of Marlex mesh.25,26 One randomized trial com-pared the incidence of parastomal hernia in patients undergoingconventional end colostomy with the incidence in patients under-going colostomy with insertion of a partially absorbable lightweightmesh between the posterior rectus sheath and the rectus abdomin-is.27 At 12 months, eight of the 18 patients with a conventionalcolostomy showed evidence of parastomal hernia formation, com-pared with none of the 16 with a mesh-reinforced colostomy.27

There remains some controversy over the issue of where thestoma site should be located in relation to the rectus abdominis.Some authors claim that hernia formation is less frequent whenthe stoma emerges through the rectus abdominis28-30; however,other authors dispute this claim,9-11 and a clinical and radiologicstudy of paraileostomy hernia found no differences in incidencebetween stomas brought out through the rectus abdominis andstomas brought out more laterally.31

The incidence of parastomal hernia formation varies widelyamong published studies [see Table 3].This wide variation reflectsboth differences in length of follow-up and differences in the



Figure 7 Illustrated is an alternative method of stabilizing aretracted ileostomy. The ileostomy is everted to its full extentwith a Babcock tissue forceps. The site of the mesentery is identi-fied. A noncutting linear stapler is inserted with the anvil in thestoma, with care taken to avoid the mesentery. The stapler isfired several times to fix the two walls of the ileum together.

methods used to identify parastomal hernias. Given that manyhernias are small and asymptomatic, the true incidence of herniaformation may well be higher than the reported figures. It is gen-erally accepted, however, that paracolostomy hernias are morecommon than paraileostomy hernias. It is unclear why this is so,but the reason is likely to involve the size of the opening in theabdominal wall.

Parastomal hernias are often asymptomatic, and in obese pa-tients, they may not be apparent on clinical examination. Patientsusually present with an unsightly bulge at the stoma site, but theymay also have other symptoms, such as leakage around the stomaappliance, skin problems, or difficulty in irrigating a colostomy.Rarer presenting symptoms include intestinal obstruction andstrangulation of the bowel loop within the hernia. Clinical exam-ination usually suffices for making the diagnosis, particularlywhen performed with the patient standing. Small hernias inobese patients can be a challenge to diagnose; in this setting,computed tomographic scanning limited to the stoma area canbe helpful.31

Surgical repair of a parastomal hernia often yields disappoint-ing results and should be considered only if the patients symp-toms are troublesome. Many patients manage reasonably well bywearing a suitably adapted appliance and a support belt. Whensurgical repair is indicated, it follows one of three possibleapproaches:

1. Local repair.This approach to hernia repair is the simplest ofthe three but also the least successful.32-34 The stoma is mobi-lized, and the sac is identified and removed.The defect in thefascia of the abdominal wall is narrowed around the emergingbowel with a series of interrupted nonabsorbable sutures.The repair is completed by recreating the mucocutaneousanastomosis.

2. Repair with prosthetic mesh. Mesh repairs have becomeincreasingly popular as different meshes have become avail-able and as surgeons have become aware of the advantages ofthese materials in hernia surgery. The mesh can be insertedintra-abdominally,35,36 in the preperitoneal plane [see Figure8],32,37 or in the subcutaneous plane.38,39 Regardless of wherethe mesh is inserted, the basic principle is the samenamely,to achieve and maintain a narrowing of the stoma site by sur-rounding the emerging bowel with a sheet of mesh in which ahole is cut to accommodate the stoma.

3. Stoma relocation. The stoma can be moved to a fresh site onthe abdominal wall without reopening the main incision.Thestoma is fully mobilized, and a new hole is made in the abdom-inal wall. A plane is developed between the peritoneum andthe abdominal contents by means of blunt finger dissectionbetween the existing stoma site and the new one. The mobi-lized stoma is then passed through the new hole.40 If difficul-ties are encountered, a laparotomy will be required. An alter-



Table 3 Incidence of Parastomal Hernia Formation

Duration of Follow-up (yr)

3.4 (mean)

121

16

110

17

16

110

8

126

NA

136

< 8

116

< 10

< 20

NA

10

2.6 (mean)

8

7

Patients withHernia (No. [%])

3 (2.5)

16 (5.2)

2 (1.0)

42 (11.6)

9 (9.1)

23 (32.6)

6 (4.8)

26 (48)

3 (1.5)

9 (8.1)

9 (6.9)

14 (10.8)

13 (28.2)

5 (4.5)

16 (16.0)

15 (6.2)

43 (36.7)

4 (1.8)

9 (11.3)

126 (39.1)

Stoma Type

Ileostomy

Colostomy*

Colostomy*

Colostomy

Colostomy

Colostomy

Colostomy

Colostomy

Ileostomy||

Ileostomy

All stomas

Colostomy

Ileostomy**

Colostomy

Ileostomy

All stomas

Colostomy

Ileostomy

Colostomy

Colostomy

Total No. of Patients

119

307

200

362

99

227

124

54

203

111

130

130

46

111

150

242

203

224

80

322

Date

1966

1970

1973

1974

1974

1975

1984

1986

1987

1988

1988

1989

1990

1992

1994

1994

1994

1995

1997

2001

Author(s)

Watts et al47

Burns48

Saha et al49

Kronborg et al50

Harshaw et al51

Marks and Richie52

Burgess et al53

von Smitten et al54

Carlstedt et al55

Weaver et al22

Sjdahl et al30

Porter et al46

Williams et al31

Hoffman et al56

Leong et al10

Martin et al57

Londono-Schimmer et al9

Carlsen and Bergan58

Mkel et al59

Cheung et al60

* Details of method of follow-up not provided. Prospective follow-up of patients undergoing stoma construction. Retrospective studyof patients undergoing stoma construction. Figure represents cumulative rate, based on life-table analysis. ||Incidence based onreoperation rate. Patients presenting to a specialist stoma clinic. **Patients specifically reviewed for hernia formation.

native approach is to reroute the stoma through a new fascialdefect while maintaining the existing skin aperture.The origi-nal fascial defect is repaired with mesh.41

The best method of repair has not been established.42 Mostpublished studies have included relatively few patients who were followed for a relatively short time. With longer follow-up,recurrence rates as high as 76% have been reported. Local repair is associated with the highest recurrence rate,43 and sto-ma relocation carries an increased morbidity (from incisionalhernia at the original stoma site).44 Nor is mesh repair free ofproblems: intra-abdominal placement of mesh is associated witha significant risk of adhesions to the mesh and of small bowelobstruction.45 The risk of mesh infection is highest when themesh is placed in a superficial position through a parastomal incision.

At present, the best approach is to tailor repair to the individ-ual patients condition and situation. For more specific recom-mendations, randomized trials of the different methods of para-stomal hernia repair will be required.There is a growing amountof evidence in favor of inserting prosthetic mesh at the time of stoma formation in an effort to reduce the incidence of thiscomplication.

OBSTRUCTION

Conditions that may cause intestinal obstruction after stomaformation include stenosis of the stoma, parastomal hernia, post-operative adhesions, and recurrent disease (e.g., Crohn disease inthe proximal ileum or recurrent cancer). Management dependson the cause of the obstruction. Retrograde contrast studies areuseful for identifying the site and determining the likely cause ofobstruction.

FISTULA

A fistula may form adjacent to a stoma as a consequence ofinadvertent full-thickness placement of a suture through bothwalls of the stoma during formation, pressure necrosis at skinlevel from a tightly fitting stoma appliance, or recurrent disease,especially Crohn disease in the ileum proximal to the stoma.Surgical treatment usually involves laparotomy and reformationof the stoma at a new site.

OTHER COMPLICATIONS

Other, less common complications arising after stoma forma-tion include bleeding, perforation, skin ulceration, and the devel-opment of cancer [see Table 4].



Hernia Defectin Fascia

Hernia DefectClosed

Abdominal WallMuscle

IntactPeritoneum

Mesh Insertedover Peritoneum

a b

Table 4 Additional Complications Arising after Stoma Formation

Complication

Bleeding

Perforation

Skin ulceration

Cancer formation

Treatment

Review of stoma applianceand technique

Laparotomy and revision ofstoma

Review of stoma applianceand technique

Resection

Cause

TraumaInflammatory polyps

Traumatic (irrigation)Recurrent disease

Contact dermatitis

Recurrence at stoma siteDe novo cancer formation

Differential Diagnosis

Portal hypertensionRecurrent disease

Stercoral (constipation)

Pyoderma gangrenosum

Inflammatory polyps

Figure 8 Depicted is preperitoneal mesh repair of parastomal hernia. (a) The midline incision is reopenedwithout disturbing the stoma. The space between the peritoneum and the muscles of the abdominal wall isopened widely, with care taken not to damage the bowel as it emerges from the abdominal cavity. The con-tents of the hernia are returned to the abdominal cavity, and the defect in the peritoneum is repaired withabsorbable sutures. (b) A piece of nonabsorbable mesh is cut to shape to cover the defect in the abdominalwall and to just accommodate the emerging bowel. The mesh swatch is placed round the bowel on the intactperitoneum, and the two tails of the swatch are sutured together so as to encircle the bowel. The defect in themuscle layer is closed with a few interrupted nonabsorbable sutures.

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Acknowledgment

Figures 1 through 8 Tom Moore.



References

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