FIGURE 98-11 ​Ideal sites for stomas. ​A, ​Infant.

The end stoma can be brought out through a counterincision in the lower right or left
quadrants. The sites marked with an “X” are unsuitable because they are too close to the rib cage, the anterior superior iliac spine,
the flank, or the groin. ​B, ​Older child or adolescent. The best site for the stoma is in the mid rectus abdominis muscle in the right
lower quadrant. The opposite side is an alternative. Areas marked with an “X” are unsuitable. The same sites are used with
minimally invasive procedures.

straight course for the bowel and avoid distortion of the layers by traction on the edge of the incision. The entire
opening should be just wide enough to allow for comfortable passage of the ileum without interfering with the
blood supply. In laparoscopically placed stomas, adequate stoma exit size and bowel orientation are critical. With
either approach, the bowel is secured intraperitoneally to avoid torsion and inter- nal hernias and then secured with
fine absorbable sutures to the rectus sheath. Depending on the size of the child, the ma- tured ileostomy must
protrude 2 cm or more to allow proper pouch fixation. This pouch is applied at the end of the proce- dure (​Fig.
98-12​, ​C)​ . Stomas in neonates, particularly those established for necrotizing enterocolitis, should not be ma- tured
because this will interfere with the already tenuous blood supply. The exteriorized end of the stoma is simply
anchored to the skin with four delicate sutures of a synthetic absorbable material. An antibacterial ointment is
applied, and dressings are avoided. A pouch is applied with the onset of defecation. In infants, the mucosa grows
rapidly over the exteriorized serosal surface. Deep, full-thickness sutures in the bowel should be avoided because
they may cause a fistula from the lumen to the peristomal tissue, which will interfere with stoma pouch adherence.
The preferred colostomy site is the lower left quadrant. The guidelines for placement are similar to
those for ileostomies. The most common site problem, particularly in newborns, is that the stoma is
placed too caudally, close to the inguino- abdominal skin folds. When an infant flexes his or her hips, the
resulting folds tend to lift the edges of the stoma appliance, leading to leakage. In children with
imperforate anus, the meconium-filled sigmoid colon and the pelvic peritoneal ref- lection are identified
once the abdominal cavity is opened.

A suitable portion of the uppermost sigmoid colon is selected, and the bowel is exteriorized. When the
dividing technique is used (see ​Fig. 98-5​, ​A​), the stomas are placed at each end of the incision and the
intestine is secured with fine, synthetic, ab- sorbable suture to all layers of the abdominal wall. There should
be enough space between the two openings to permit a good fit for a pouch over the proximal stoma (or the
distal stoma must be flush with the skin) (see ​Fig. 98-9​). To avoid excessive nar- rowing of the stoma, an
appropriately sized Hegar dilator or catheter is inserted into the intestinal lumen at the time of wound closure.
End colostomies should only protrude slightly. With a loop stoma (see ​Figs. 98-5​, ​B ​and 98-8), the incision is
the length of that loop or only slightly longer. With the loop technique, a temporary catheter is placed through
the mesen- tery of the selected segment, which is then lifted above the level of the skin. Triangulating sutures
approximate the two limbs to each other and to the peritoneum on both sides to prevent in- ternal hernias. The
full circumference of the intestine is then attached to the peritoneum and fascia. Sutures lift the posterior
bowel wall above the skin level. The intestine is opened longitudinally, and the edges everted. In all children
with imperforate anus, the distal, meconium-filled segment of intes- tine is evacuated and flushed out at the
time of colostomy placement. This is important to avoid formation of a fecaloma. In patients with
Hirschsprung disease, the construction of the loop stoma must also be meticulous and may include tightening
of the distended intestine to decrease the possibility of prolapse. This is particularly important in the distal
segment. Rods or skin flaps placed under the loop are unnecessary if an appropriate “spur” between the two
openings was created.
To facilitate subsequent takedown, when exteriorizing both ends of the small or large intestine, these
should be kept as close as possible without interfering with the pouch. If the dis- tal limb is placed
underneath the abdominal wall, it is tagged with a nonabsorbable suture or a metallic clip (or both) and
placed as close as possible to the exiting stoma to simplify identification at reanastomosis. Placing a
metallic clip also helps with radiographic identification of the proximal end of the distal bowel and its
patency when a barium enema is performed before reestablishment of bowel continuity in children with
necrotizing enterocolitis.
Several of these techniques can be adapted for a minimally invasive approach.​43,107,119–123​ ​In addition to
smaller access sites, laparoscopy can be helpful in the precise identification of intestinal loops and
targeted lysis of adhesions. However, the surgeon must exercise caution because the advantages of the
laparoscopic approach can be negated by less than optimal handling of the bowel and exteriorization
through openings of inadequate size.

FIGURE  98-12  ​Eight-year-old boy with intractable ulcerative colitis that failed to respond to aggressive medical management
including corticoste- roids, azathioprine, and infliximab. He underwent a total abdominal colect- omy and ileostomy as a
preliminary stage to an ileoanal anastomosis. ​A, ​The patient in a supine position. The stoma site had been determined
several days before the procedure. The boy was asked to wear a two-piece pouch using the selected site as a guide. ​B,
Bringing the already anesthe- tized patient into a sitting position confirmed the adequacy of the stoma site away from major
abdominal folds. ​C, ​Skin barrier with flange (two-piece system) applied to the ileostoma at the completion of the colectomy.
D, ​Six weeks later the stoma was well healed with mild residual edema. ​E, ​Same boy wearing a two-piece system with an
opaque pouch. He emptied the pouch three to four times during the day and two to three times evening and nights. He
enjoyed full physical activities including basketball. He did not use an ostomy belt and changed the skin barrier and pouch
every E 3 days. Bowel continuity has since been reestablished.

Stoma Care
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Proper care of an enterostoma begins with preoperative prepa- ration whenever possible.​24,25,124 ​Parents, as well as
older children, must be carefully taught and reassured before leav- ing the hospital and on subsequent follow-up
visits. Ileos- tomies and proximal colon colostomies always require pouches. With the well-formed stools that
result from sigmoid stomas, some parents of infants have used a skin barrier and diapers instead. A plant leaf has
been recently suggested as an alternative.​125 ​A large selection of stoma appliances are com- mercially available
including disposable and reusable pouches for all ages and sizes, even the smallest premature infants. Skin
barriers, adhesives, powders, vented pouches, and odor con- trol solutions are among the products that make the
care of today’s ostomate easier.​1,2,27,112,126
Properly fitted appliances should remain in situ for several days; 3 days is a reasonable expectation. There are
two basic types of pediatric appliances: the one-piece pouching system in which the adhesive skin barrier is
already attached to the pouch and the two-piece system in which the adhesive skin barrier is separate from the
pouch. In the latter, the pieces snap together with a flange (see ​Fig. 98-12​, ​C ​and ​E​). Because of the holding power
of contemporary adhesive skin barriers, additional fixation with tape or belts is usually not necessary. The skin
barrier is cut to the proper stoma size with the help of a template provided with the pouches. In addition to
instructions provided by the surgeon, nurses, and the enteros- tomal therapist, parents are encouraged to contact
one of the enterostomal societies such as the United Ostomy Association of America (an affiliate of the
International Stoma Association) or the Wound Ostomy and Continence Nurses Society​23,127 ​and make use of the
extensive printed and electronically available educational material. Although “continent stomas” using special
intra-abdominal intestinal pouches,​83,128 ​mag- netic caps,​129 ​valves,​130 ​inflatable plugs,​131 ​and other forms of
luminal occlusion​132 ​have been attempted, there is limited experience with such operations or devices in children.
Candidiasis remains a common problem in the parastomal skin, and local antifungal medication should
be used at the ear- liest sign of irritation. With skin excoriation, the area is exposed to air and a synthetic
barrier is applied. A hair dryer can be useful. Mild stomal bleeding is usually self-limiting. Excision and/or
application of silver nitrate may be necessary to control granula- tion tissue around the mucosa-skin
interface in the early stages. Remaining sutures are often the cause and should be re- moved. Routine
dilatation of stomas is not recommended. Mal- functioning stomas often require early takedown or
revision before more serious complications occur. Occasional irrigation of the distal intestine can be
useful and help eliminate malodor- ous mucus plugs. Dietary and select pharmacologic manipula- tions
are helpful in producing firmer stools. Children with high ileostomies must be carefully monitored to
prevent electrolyte

imbalance and insufficient nutrient absorption.​49,133,134

Reestablishing Intestinal Continuity

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Timing of enterostoma closure varies widely depending on the underlying condition, health status of the child,
and presence or absence of stoma-related complications.​78,135–139 ​Unneces- sary delays in the reestablishment
of bowel continuity tend to increase morbidity and should be avoided.​62,63,137 ​The more proximal the stoma, the
earlier it should be closed to decrease metabolic complications.​62,133,134 ​Children who previously underwent
resection because of ischemic intestine must have a preoperative contrast study of the distal segment to rule
out strictures or complete luminal obstruction. Use of routine stud- ies in other settings has been questioned.​140
Reestablishment of small bowel continuity generally does not require intestinal preparation. Takedown of a
colostomy is preceded by antegrade intestinal irrigation, supplemented by conventional enemas. Although
perioperative intravenous antibiotics are routinely administered, the use of intraluminal antibiotic solutions is
controversial​141 ​and probably not indicated. When reestablish- ing continuity involves the left colon or
sigmoid, the insertion of a soft catheter into the rectum assists the intraoperative identi- fication of that loop,
particularly if the anatomy has been altered by peritonitis or a previous operation. Good exposure with full
mobilization of the intestinal ends is important. Laparoscopy can be helpful in select patients.​142 ​Although
extraperitoneal closure has been used in children, it is not recommended for routine use.​143 ​For the intestinal
anastomoses, a single-layer technique using fine interrupted sutures of synthetic absorb- able suture material
provides excellent results. Primary wound closure is generally safe and advantageous.​139,144,145 ​Early post-
operative feeding after colostomy closure is encouraged.​146

Complications of Enterostomas
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Problems related to construction, care, and closure of stomas in the small and large intestines are numerous
and com- mon. They can lead to significant morbidity and occasional mortality (​Table 98-3​). Analysis of
pediatric series reveals complication rates that often reach and sometimes exceed ​50%.​16–18,46–70,132–139
In addition, stoma revision or early takedown is frequently necessary.​47,54,68,135 ​Complications of
enterostomas used for feeding are often accentuated by the patient’s underlying disease, particularly in
malnourished, neurologically impaired children.​57,72,109 ​Stomas used for evacuation of the small intestine
are associated with a higher morbidity than are