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Classification of Stomas
GI (bowel diversion)
Incontinent
Permanent
Colostomy
End
Functional
urostomy (urinary
diversion)
continent
temporary
ileostomy
loop
mucus fistula
Types of Ostomy
Stoma types
Pre-operative management
Surgical technique
Consider stoma formation to be like an
anastomosis between bowel and skin
Healing depends on:
Good blood supply
No tension
End ileostomy
End colostomy
Surgical technique
Surgical technique
Surgical technique
Bowel Diversions
Incontinent types of diversions:
Colostomy-opening between the colon and the
abdominal wall.
Ascending colostomy:
semi-liquid stool consistency, increased fluid
requirements, needs appliance and skin barriers,
cannot be irrigated.
Indications for surgery: perforating diverticulitis in
lower colon, trauma, inoperable tumors of colon,
rectum or pelvis, rectovaginal fistula.
Colostomies
Transverse colostomy:
Semi-formed stool consistency, possibly increased
fluid requirement, uncommon bowel regulation,
requires appliance and skin barrier, cannot
irrigate.
Indications for surgery: Same as for ascending
colostomy. May also be performed in children
who are born with imperforate anus
Colostomies
Sigmoid colostomy-Formed stool consistency,
no change in fluid requirements, bowel
regulation possible with irrigations and/or diet;
need for appliances and barriers dependent on
regulation.
Indications for surgery: cancer of the rectum or
rectosigmoid area, perforating diverticulum,
trauma.
Ileostomy
Opening from the ileum or small intestine
through the abdominal wall. Bypasses the entire
large intestine. Stool is liquid to semiliquid
consistency and contains proteolytic enzymes,
Increased fluid requirement. No bowel regulation
or irrigation. Requires wearing an appliance and
skin barrier.
Indications for surgery:
ulcerative colitis,
Crohns disease, trauma, cancer, birth defect,
familial polyposis.
Surgical interventions
1. Loop colostomy
Bringing a loop of bowel to the surface where it is held in place by a
plastic or glass rod passed through the mesentery. Firm adhesion of
the colostomy takes place after 7 days then the bridge can be removed.
Loop stoma
3- Hartmanns Procedure:
This includes a Proximal End Colostomy with a distal closed colonic
segment. This procedure can be used when resecting a tumour of
the Lt. site of the colon or in Complicated diverticular disease.
Double-barrel stoma
(A) End stoma (inset shows everting maturation); (B) double-barrel stoma:
End stoma and mucous hop-Koop stoma; and (F) fistula are divided and
brought through the same incision (inset shows closed mucus fistula sutured
to abdominal wall); (C) loop stoma; (D) decompressing blowhole stoma; (E)
Bis Santulli stoma
Ileoanal reservoir
Kock Pouch
Internal pouch created from a segment of the ileum.
Part of the pouch is brought out low onto the abdomen
as the external stoma. A one-way nipple valve allows
fecal contents to drain when a catheter is intermittently
inserted in the stoma. No external collecting device is
required. Immediately after surgery, a drainage catheter
is left in place for 2-4 weeks. This catheter is irrigated
with 20 ml of NS every 3-4 hours. Patients are taught to
catheterize intermittently with 28fr. Catheter.
Laparoscopic options
Laparoscopic
colostomy / Ileostomy
3 ports usually, SILS
Operative time
usually ~ <1 hour
Complications
20-41% of patients will have complications
Nearly 50% of these will require a revision
Early complications
Ischemia, hemorrhage, stenosis, fistula and retraction.
Late complications
6% -76% incidence
Prolapse, obstruction, hernia and skin irritation
Complication due to poor technique and poor care and
management.
Stoma Ischemia/Necrosis
2.3-17% incidence
Causes
Aggressive stripping of mesentery
Stenotic fascia defect
Extensive tension
Hemorrhage
Mild hemorrhage common and self limiting.
Usually mucosal.
Apply pressure
Active bleeding
Implies failure to ligate a mesenteric vessel
Stomal Stenosis/Stricture
2-14% incidence
Could manifest early or late
Ischemia is usual underlying
factor
Other causes: -Infection and
retraction
Crohns or recurrent
malignancy
Treat initially with dilation
Definitive Stoma revision
Mucocutaneous Separation
Separation along
mucocutaneous border
Occurs to some extent in many
patient
Infection/Fistula
Incidence of 2-14.8%
Fistula may form from Abscess
Beyond immediate post op,
fistula formation or infection
could be signs of recurrent
Crohns disease
Stoma Retraction
Tension:
Tension
Obesity
Steroids use. Poor wound healing
Prolapse
2-26% incidence
Seen mostly in transverse loop
colostomy (30%)
May occur with parastomal
hernia
Managed by reduction and
supportive care until definitive
surgery
Convert to end colostomy if
need be
Ileostomy Prolapse
Parastomal Hernia
Predisposing factors
Skin Complication
3-42% Incidence
Range from mild skin dermatitis to fullthicknes skin necrosis and ulceration
Contact dermatitis
Fungal infection
Intervention
Contact Dermatitis
Effluent Irritation
Edema
Skin Complications
Foliculitis
Skin Complication
(Pyoderma Gangrenosum)
First described
associated with Crohns
in 1970
Diagnosis mainly by
physical exam (80%)
Treatment conflicting
Wound debridement
Steroids injection
Systemic therapy
Skin Complications
(Pyoderma Gangrenosum)
Skin Complications
(Granulomas)
Granulomas are lumpy
lesions due to
inflammation in the
dermis.
Stoma warts
Stoma Appliances
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