Stomas

Definitions: Openings of the small or large bowel onto the anterior abdominal wall. Classifications: Stomas

1. Anatomical site Ileum Ileostomy Ileal conduit Colon Transverse colostomy Sigmoid colostomy Caecostomy

2. Stoma type Single lumen End stoma Double lumen (afferent/efferent limb) Loop stomas Double barreled stomas Mucous fistula

3. Duration Temporary Loop stoma End stoma with mucous fistula Double barreled stomas Permanent End stoma

General indications: Permanent Where there is no distal bowel To palliate unresectable distal disease Incontinence Constipation Temporary To defunction a healing anastomosis To defunction an intestinal fistula To defunction an anastomotic leak As part of the Hartmanns procedure Where an anastomosis is likely to fail In the emergency treatment of obstruction

Types of stomas: 1. Loop stoma Temporary Most common in the terminal ileum, transverse and sigmoid colon Loop Colostomy Inidcations: To protect a more distal anastomosis, after low anterior resection Defunction complex perianal fistula procedures Difficult sphincter repairs Fourniers gangrene

How? A loop of transverse, descending or sigmoid colon is brought to anterior abdominal wall, a longitudinal incision is made in the bowel wall, and the bowel edges are suture to the skin. A purpose-made bridge or improvised piece of plastic drain or rubber catheter is used to keep the loop up to the level of the skin whilst healing takes place The bridge usually being removed after 7-10 days. (reduces risk of retraction and improves faecal diversion)

When to close? Usually after 2-3months after the primary surgery (distal anastomosis) which is clinically and radiologically intact.

Loop ileostomy How? 1. The segment of ileum is selected so that it is sufficiently mobile and far enough away from the ileocaecal junction that subsequent closure can be easily performed. 2. The opening in the abdominal wall needs to be larger than for an end ileostomy. 3. A technique using Babcock forceps can again be used, but an alternative is to make a hole in the mesentery just under the bowel and pass a catheter through this. 4. The ends of the catheter are then grasped by forceps passed through the abdominal wall and the stoma brought through by applying tension to the catheter. 5. After closing the abdominal wall, the ileum is opened transversely at the level of the skin on the distal non-functioning side. 6. To facilitate the identification of this side many surgeons will mark the ileum with diathermy prior to passing it through the abdominal wall. Sutures are placed to evert the ileum in a similar manner to an end ileostomy on the proximal functioning side. 7. Everting sutures can also be placed on the distal side to make the whole ileostomy spouted and to facilitate subsequent placement of the ileostomy bag. 8. In the emergency situation when the bowel is tending to retract, a rod can be placed under the loop to keep the ileostomy proud of the skin, but in an elective situation such a rod may be omitted and bags are generally easier to fit without one.

2. End stoma Usually permanent

End colostomy Indications: Abdominal perineal resection In Hartmans procedure Mucous fistula

How?
1. An end colostomy is fashioned by bringing the bowel through the abdominal wall through an appropriately-sized split in the rectus muscle (usually 2 finger breath) and suturing bowel primarily to the skin (Placement through the rectus abdominis reduce risk of parastomal herniation.)

When close? Usually permanent In Hartmans procedure, 3-4months later the end colostomy can be reversible after intra-peritoneal tissues recover.

Hartmans procedure Indications: How? Segmental large bowel resection is performed, but continuity is not immediately restored Primary anastomosis may be inadvisable due to: o Sepsis o An unprepared bowel o Uncertainty over the adequacy of bowel vascularity o Macroscopically obvious residual tumour at the end of a resection for cancer Proximal end is brought out as an end colostomy Distal end closed over and left insitu as blind-ending(rectal) stump Alternatively, brought to anterior abdominal wall as a mucous fistula Ischaemia, perforation or obstruction of the distal colon or rectum

End ileostomy Indications: How? 1. Because of the liquid contents, it is essential to fashion a Brooke-type evaginated stoma, with a spout 23 cm in length, positioned away from skin creases, ribcage and iliac crest. 2. This is to facilitate application of a well-fitting appliance and avoid skin damage from the effluent (which contains activated digestive enzymes and may be at alkaline pH) and stoma damage from the appliance When close? After the tissue recover, ileorectal, ileoileal, ileocolic anastomosis Total colectomy for acute severe colitis (ulcerative colitis or Crohns colitis) o Where ileorectal anastomosis is rarely favoured Ileocolic Crohns disease complicated by intraperitoneal abscess o Where immediate ileoileal or ileocolic anastomosis is not favoured. Spontaneous segmental small/large bowel infarction due to thromboembolic disease.

3. Mucous fistula Not a stoma. Is a defunctioned segment of bowel sutured to the skin as a non-functioning stoma.

Indications: Emergency setting after subtotal colectomy or segmental resection and end ileostomy (when the closed distal end of bowel may break down if left inside the abdomen). Mucus fistula may be exterorrized at a separate site to an end stoma or Suture to end stoma and exteriorized as a double-barrelled stoma (reversal of a double-barrelled stoma can often achieved without a laparotomy, but they are bulky and difficult to manage.)

4. Ileal Conduit (urostomies) Stomas producing urine Isolated loop of 15-20cm of ileum with intact blood supply is separated from the rest of the small bowel which is reanastomosed. The isolated loop is brought to the skin surface and made into a stoma whilst the other end is anastomosed to the cut ends of the ureters