Intestinal Stomas
(1) Colostomy
Definition:
It is an artificial opening made between the large bowel and skin, to
divert faeces and flatus to the exterior, where it can be collected in an external
aplliance. Effluent is usually solid.
(1)Temporary Colostomy.
Indications:
1- Distal Obstruction.
2- Defunction a low rectal anastomosis after Anterior resection of the rectum.
3- Following traumatic injury to the rectum or colon.
4- During operative treatment of a high fistula in ano.
5- Fulminant Colitis (IBD).
6- Complicated Diverticular disease.
Site of the colon used:
A segment which has a mesentery:
1- Transverse colon. (Disease involve Lt. side of the colon)
2- Sigmoid colon. (|Disease involve the rectum or rectosigmoid junction)
Types of temporary colostomies:
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.
Closure: follows the surgical cure or healing of the distal lesion for which the
temporary stoma was constructed (a distal loopogram) is best performed to check
there is no distal obstruction or any problem at the site of previous surgery). Also
the stoma should be mature (at least 2 months after establishment of the colostomy).
Steps of loop colostomy:
# GA is important since since traction on the mesentery causes pain and nausea.
# A transverse incision 8-10cm long, with removal of a disc of skin, is made for
transverse colon (in the Rt. upper abdomen midway between the umbilicus and
xiphisternum over the rectus abdominus muscle and extending laterally to the
lateral border of the rectus muscle), while for the sigmoid colon (in the Lt. iliac
fossa with a muscle cutting incision).
# Cut down all layers including the rectus muscle which is divided transversely
ligating and dividing the epigastric artery.
# The most proximal loop of colon is prepared by removing the omentum from its
anterior surface (only in Transverse colon), then a small hole is made in the
mesocolon through which a rubber tube is passed to fascilitate delivery of the colon
through the incision.
# The laparotomy wound should be closed at this stage.
# The colonic loop is held by an underlying glass rod or by a colostomy bar or skin
bridge incised initially. The colon is then opened on its antimescolic border
longitudinally (along the taenia coli).
# Sutures are used to fix the colonic serosa to the abdominal wall, and colonic
mucosa to the surrounding skin.
# The finished loop colostomy should allow one finger to pass down on each side.
2- Double Barrelled colostomy:
the colon is divided so that both ends can be
brought separately to the surface with a skin bridge intervening.
Advantage: ensures that the distal segment (colon, rectum) is completely
defunctioned (Absolute Rest).
3- Hartmann’s 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.
(2) Permanent Colostomy
Indications:
1- Rectal carcinoma excision( A-P resection) ----- End colostomy
2- Inoperable rectal or colonic carcinoma ------ Loop colostomy
Technique of End Colostomy:
The best site is through the lateral edge of the rectus sheath 6cm above and
medial to the anterior superior iliac spine. The colon is stitched in place
immediately by sutures placed between the colonic margin and the surrounding skin
,i.e; it is usually sutured flush to the skin. The point at which the colon is brought to
the surface must be carefully selected to allow a colostomy bag to be applied
without impinging on a bony prominence. An important point after the colostomy
has been made is to close the lateral space between the intraperitoneal segment of
the colon and the peritoneum of the pelvic wall to prevent internal herniation and
strangulation of the bowel.
A sigmoid colostomy is usually brought out at the Lt. iliac fossa.
A Transverse colostomy is usually brought out in the Rt. Hypochondrium.
Complications of Colostomy construction:
1- Prolapse. (it leads to dysfunction, it is not important in temporary colostomy
which sooner or later will be closed, only in permanent cases which will need
refashioning or resiting)
2- Retraction. (due to tension and infection)
3- ParaColostomy Hernia.( especially in end terminal colostomy). Treatment should
include resiting the colostomy and the hernia defect closed.
4- Bleeding.
5- Necrosis and gangrene of the distal end. (due to loss of viability due to
interference with its blood supply, too much ligation of mesenteric vessels).
6- Stenosis of the colostomy orifice. (occurs at the mucocutaneous junction, due to
infection and cellulitis which is followed by scarring).Treatment should include
refashioning of colostomy site with excision of skin disc.
7- PeriColostomy Abscess and Fistula. (occurs when a misplaced suture that fixes
the colon to the deeper layers of the abdominal wall instead of passing through the
serosa, passes through the whole thickness of the bowel). The abscess bursts and
forms a fistula. Treatment should include laying the track open and leaving it to
granulate.
8- Colostomy diarrhea.
(2) Ileostomy
Definition:
It is an artificial opening made between the ileum and skin of the
abdominal wall, to divert intestinal contents to the exterior, without a sphincter to
control the timing of its emptying. Effluent is usually liquid.
(1) End Ileostomy.
Indications:
In cases where total proctocolectomy is done.
1- Ulcerative colitis.
2- Crohn’s disease.
3- Familial polyposis Coli.
(2) Loop Ileostomy.
Indications:
as an alternative of a loop colostomy for Defunctioning (for
protection)
1- Low rectal anastomosis following a anterior rectal resection procedure.
2- Ileoanal pouch procedure following Total proctocolectomy.
Technique of Ileostomy:
The ileostomy opening should be 5cm lateral to the umbilicus and brought out
through the lateral edges of the rectus abdominus muscle. It is usually made in the
Rt. Iliac fossa. It should be spouted.
Complications of Ileostomy:
1- Prolapse.
2- Retraction.
3- ParaIleostomy Hernia.
4- Bleeding.
5- Necrosis and gangrene of the distal end.
6- Stenosis of the Ileotomy orifice.
7- Skin reaction around the stoma. (Excoriation, erosion, sloughing)
8- Fluid and electrolyte imbalance. (Ileostomy Flux).
(3) Caecostomy
Indication:
1- Trauma to the caecum.
2- Closed loop syndrome. (In desperately ill patients with advanced obstruction)
Site:
Rt. Iliac fossa.
Types of Bowel Stomas
1- End (terminal).
2- Loop.
3- Double Barrel. (Two ends brought to the surface seperately with a skin bridge
intervening)
4- Paul-Miculikz. (Two ends brought to the surface together where the adjacent
serosal surfaces are hitched by sutures, and adjacent mucosal surfaces are sutured)
5- Seperation proximal faecal fistula from a distal mucous fistula.
Criteria taken into consideration when positioning a stoma:
1- Away from any bony prominence.(Anterior superior iliac spine , Symphysis
pubis)
2- Away from the umbilicus.
3- Away from any previous surgical incision.
4- Visible when the patient stands.
5- Comfortable for the patient.
How to differentiate a colostomy from ileostomy?
Colostomy
Ileostomy
Site
Rt. upper abdomen
Lt. iliac fossa
Rt. iliac fossa
Discharge
Formed faeces or
faeculent fluid
Fluidy
Color of discharge
Brownish or Blackish
Brownish, Greenish -
Yellowish
Odor of discharge
Very offensive
(excessive gases)
Less offensive
Stoma
Large
Constructed flush or
slightly elevated from
the skin
Small
Constructed as a nipple
like projection above
the skin
Reaction of the
surrounding skin
Usually normal
Erythematous,
oedematous
(from
enzymatic digestion)
Types of stoma appliances:
1- Two piece
(Bag and ring are separate). Advantage: less trauma to the stoma
from frequent changing.
2- One piece
(Bag and ring are matted). Disadvantage: higher chance of trauma to
the stoma with granulomas and bleeding, excoriation and ulcerations around the
stoma.
