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