FIGURE  98-3  ​Examples of decompressing, diverting, or evacuating stomas. ​A,  ​End stoma (​inset  s​ hows typical maturation).

​11 ​B,  ​Double-barrel

stoma.​10 ​C,  ​End-to-side anastomosis with distal vent for irrigation.​13 ​D,  ​Side-to-end anastomosis with proximal vent.​15 ​E,  ​Loop stoma.​8 ​F, ​End
stoma with closed subfascial distal of the end of the intestine (​inset ​shows rodless end-loop stoma).

Enterostoma Exit 
Proximal Stoma 
Through celiotomy incision Through separate opening
With proximal and distal limbs close to each other With proximal and distal openings apart
Multiple stomas Variations of the above

Distal Stoma 
Exteriorization as mucus fistula adjacent to or separate from proximal intestine
Partial closure and placement next to the proximal stoma​92​ ​Closure and replacement into abdominal cavity
Closure after placement of a catheter for subsequent access for irrigation or contrast studies

various urinary tract dysfunctions to provide a catheterizable conduit to the urinary bladder.​98,99

Choice of Enterostoma
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FEEDING JEJUNOSTOMY 
Various approaches for establishing direct long-term access to the jejunum are now available. “Open” placement through a small,
left upper quadrant incision permits excellent identifica- tion of the stoma site in the proximal jejunum, as well as secure attachment
of the bowel to the abdominal wall.​36,37,100,101 ​Di- rect percutaneous endoscopic jejunostomy (PEJ) is applicable to older patients but
difficult in small children due to limita- tions imposed by the endoscopic equipment.​102 ​A number of image-guided jejunostomies
have been described but have been within the purview of radiologists in a few pediatric centers.​37,103,104 ​Laparoscopic or
laparoscopically assisted tech- niques are now used with increasing frequency in all age groups.​105–107 ​Bringing the loop directly to
the abdominal wall and placing a skin-level access device is simple and effective. Peristomal leakage is always a concern. An
alternative intended to decrease this problem is the more complex Roux-en-Y approach.​108,109 ​However, this method has a greater
potential for serious complications such as volvulus and internal hernias with intestinal obstruction.​110,111
The choice of access device depends on the type of stoma and the age of the child.​27,112 ​Because straight catheters can be
diffi- cult to immobilize or replace in conventional tunneled jejunos- tomies, a good alternative is a T-tube for infants (because
it does not obstruct the narrow lumen) (see ​Fig. 98-1​, ​C​), and an original type button (​Fig. 98-1​, ​D)​ or other nonballoon
skin-level device for older pediatric patients. Balloon-type devices are suitable for the Roux-en-Y loop (see ​Fig. 98-2​). As
with a gastrostomy, these devices are both replaceable as an office procedure.

ILEOSTOMY 
In intra-abdominal interventions requiring intestinal resection, such as neonatal necrotizing enterocolitis, many surgeons prefer
to exteriorize a single-end stoma through a counterincision

FIGURE  98-4  ​Examples of options for the management of infants after intestinal resection. ​A, ​Exteriorization of proximal intestine through a counter-
incision and closure of distal intestine beneath the abdominal wall. ​B,  ​Same procedures as in ​A  ​with exteriorization of proximal end of distal
intestine through the wound edge. ​C, ​Arrangement after resection of two intestinal segments.

FIGURE  98-5  ​Sigmoid colostomies. ​A,  ​Separated stomas. The proximal intestine is at the upper end of the incision, and the mucus fistula is at
the lower one. ​B,  ​Loop colostomy. The intestine is exteriorized over a rod or skin bridge or with the help of sutures. The circumscribing
comma-shaped incision is used for takedown and pull-through procedures.

(see ​Figs. 98-4​, ​A,  ​98-6, and 98-7). A more expedient alternative is to bring the proximal intestine through the end of the
incision (see ​Fig. 98-4​, ​B​). However, with this approach, wound complications are more common. In addi- tion, if the stoma
must remain for a prolonged period of time and the child gains weight, the fold created by the laparo- tomy incision may
interfere with fitting of the stoma appliance (see ​Fig. 98-7​).
With a healthy distal intestine and anticipated downstream patency, the distal limb may be closed and placed intra-
abdominally adjacent to the proximal stoma. Otherwise, exte- riorization as a mucus fistula is prudent (see ​Fig. 98-4​, ​B​). The
use of an exteriorized loop stoma rather than an end stoma is an alternative in which the intact mesentery pro- vides maximal
perfusion.​79 ​A double-barreled stoma is a time-honored option.​77,78 ​To save as much intestine as possi- ble, the placement of
multiple stomas may be necessary (see ​Fig. 98-4​, ​C)​ . Although some ileostomy types were developed specifically for newborns
with meconium ileus, they are no longer used. However, T-tube ileostomies have been useful for the instillation of liquefying
solutions.​82
In children with ulcerative colitis or familial polyposis, the enterostomal principles are similar to those established
for adult patients. Choices for a temporary protective diverting
FIGURE 98-6 ​One-year-old boy with severe necrotizing enterocolitis with loss of distal ileum and colon down to the peritoneal reflection before rea-
nastomosis. Liquid stools precluded earlier reestablishment of intestinal continuity. Notice the appliance mark and the appropriate distance from the
incision, the umbilicus, the inguinoabdominal fold, and the right anterior superior iliac spine.

FIGURE  98-7  ​Same child as in ​Figure 98-6 ​in a sitting position. Notice the deep crease produced by the transverse supraumbilical incision. A stoma
brought out through such an incision would have precluded proper use of the pouch, and a revision would have become necessary.

ileostomy include a simple loop, an end (distally closed) loop, and an end stoma, with the closed distal end under the fascia (see
Fig. 98-3​, ​F)​ .

APPENDICOSTOMY, TUBE CECOSTOMY, OR TUBE SIGMOIDOSTOMY 

The choice of antegrade colonic enema (ACE) depends on the type of colonic pathology being managed. With normal
peris- talsis, either the right​41 ​or left​40,113 ​colon may be chosen for access. However, if dysmotility is a concern, access to
the right colon is indicated. If the appendix is present, it is exteriorized with or without interposition of a “valve” by
either an “open,”​88 ​or laparoscopic approach.​43,90 ​If the appendix is no longer avail- able, the wall of the cecum may be
fashioned into a conduit that is then brought to the skin level.​114​ ​Exteriorizing the appendix at the umbilicus has cosmetic
advantages. Either the appendix or the conduit so constructed is then catheterized to instill the enema fluid. A simpler
technique, especially if there is no appendix, is the placement of skin-level device in the cecum by an open​115 ​or
percutaneous approach.​87 ​For patients with normal colonic motility, access to the left colon by means of a sigmoid
irrigation tube can be advantageous.​40

COLOSTOMY 
Most colostomies fall into three categories: right transverse, left transverse, and sigmoid. The significant physiologic and ana-
tomic differences among these three must be taken into con- sideration when choosing the site for the stoma. For infants with
high imperforate anus, the high (proximal) sigmoid is the preferred site for exteriorization (see ​Fig. 98-5​).​62,116 ​The main
advantages are firmer stools with less tendency for skin excoriation, less tendency for prolapse, less surface for urine
absorption, and less contamination of the urinary tract in male children with rectovesical fistula. Sigmoid stomas assist
evacua- tion of meconium from the often dilated distal portion of the bowel during the initial procedure. The precise site is
easily iden- tified using the pelvic peritoneal reflection as a guide. A further advantage is that there are no scars in the
epigastrium. However, if the low or mid sigmoid is inadvertently exteriorized, there may be interference with the blood
supply, as well as insufficient bowel length for the future pull-through.​67,116 ​If the stoma is placed in the transverse colon, there
is always adequate bowel length for pull-through, and the intestine is easy to mobilize and has a smaller diameter and no
meconium. The disadvantages of transverse colon colostomy, however, are sizeable: The stools are looser, skin maceration
and dehydration are more common, there is a greater prolapse rate, and there is an increased possi- bility of urinary tract
problems. In addition, adequate evacuation of meconium is nearly impossible. Although high sigmoid loop colostomy is still
used (​Fig. 98-8​), contemporary preference is for separation of the stomas, particularly in boys (​Fig. 98-9​).​67 ​In children with
Hirschsprung disease requiring a pre- liminary colostomy, the best site is the dilated segment that con- tains normal ganglion
cells found proximal to the transition zone. A loop colostomy is usually chosen, although the ten- dency for prolapse is
increased.​68 ​Because most transition zones are in the sigmoid colon, this lower left quadrant stoma is taken down at the time of
the definitive corrective operation (see ​Fig. 98-5​, ​B​). If separation of the stomas is chosen, the distal intestine should not be
oversewn in patients with Hirschsprung disease, particularly if the aganglionic segment is long, because mucus cannot be
appropriately evacuated or washed out. Although similar data are not available in children, properly constructed loop
colostomies are fully diverting in adults.

Select Technical Aspects

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Feeding jejunostomies are generally placed in the left upper abdomen, slightly above the umbilicus, not so cephalic as
to interfere with a possible gastrostomy and/or fundoplication.

FIGURE  98-8  ​Five-month-old child with high imperforate anus. The proximal sigmoid loop colostomy is equidistant from the umbilicus, the anterior
superior iliac spine, and the inguinal fold. The original incision is only slightly longer than the stoma. Notice the raised “spur” between the two lumina,
essential for proper diversion of stool.

FIGURE  98-9  ​Neonate with high imperforate anus. A divided proximal sigmoid colostomy was placed. The separation of the bowel ends mini- mizes the
incidence of stoma-related problems.​67 ​The proximal bowel is slightly everted, and the mucus fistula is flush with the skin. (Courtesy Dr. Mark
Levitt.)
In the “open” technique, the proximal jejunum is approached through a small, upper left quadrant incision. The ligament
of Treitz is identified, and the catheter or skin-level device is inserted in the antimesenteric portion of the intestine, 10 to
20 cm distal to the duodeno-jejunal junction. A purse-string suture of fine multifilament synthetic absorbable material is
placed around the enterotomy and tied. The catheter or skin-level device is then brought out through a counterinci- sion.
A second purse-string suture, made of monofilament synthetic absorbable suture is applied, with the sutures alter- nating
between the intestine and the exit site of the catheter in the abdominal wall. When tied, this second suture approx- imates
the intestinal serosa to the parietal peritoneum in a watertight manner.

If a PEJ is chosen, the retaining intraluminal bumper must be size appropriate. Laparoscopic control can be used to increase
the safety of PEJ, particularly in patients with abnor- mal epigastric anatomy. With laparoscopically assisted jeju- nostomies,
particularly the Roux-en-Y type, proper loop orientation is essential. To minimize leakage (the most com- mon problem with
jejunostomies), appropriately sized skin- level devices must be selected. Devices that are too short or excessive tension on
immobilizing crossbars must be avoided to minimize bowel wall or skin ischemia.
Decompressing ileostomies are usually placed in the right lower quadrant (see ​Figs. 98-4 ​and ​98-6​). The umbilicus is a
possible site for a stoma​118 ​and is an excellent choice for the dis- tended proximal intestine in newborns who have gastroschisis
with atresia (​Fig. 98-10​).
Figure 98-11​, ​A ​illustrates both appropriate and undesir- able stoma exit sites in neonates, infants, and small children (e.g.,
those with necrotizing enterocolitis). ​Figure 98-12​, ​B ​demonstrates ideal exit sites in older children or adolescents (e.g., those
with ulcerative colitis or familial polyposis). Lap- arotomy incisions in the lower quadrants should be avoided in patients who
may eventually have long-standing or permanent stomas because such incisions can create an uneven surface that interferes
with pouch adherence.
When an enterostoma is anticipated, it is important that the site of the stoma and possible alternatives are marked on the
abdominal wall before any incision is made. This planning is desirable in both elective and emergency settings. For elective,
long-standing stomas, the best location is determined and marked the day before the operation (​Fig. 98-12​, ​A ​and ​B​). The exit
site should be located over the convex midportion of the rectus muscle, away from the incision, umbilicus, bony prominences,
and skin folds. Special attention must be paid in overweight children because of the deep creases of the abdom- inal wall. In
older children, if a vertical midline laparotomy is planned, it is advisable to create the opening for the ileostomy before making
the incision. This is done in order to achieve a

FIGURE  98-10  ​Four-month-old child with gastroschisis and small bowel atresia during reestablishment of bowel continuity. The dilated and edema- tous
ileus was brought out as an end stoma through the umbilical site. The proximal closed end of the colon was attached to the side of the ileum
underneath the abdominal wall. This maneuver allows prompt identification of the distal bowel, minimizing dissection and incision size.