COLOSTOMIES

By Odei-Ansong Francis
kwame77k@yahoo.com
 Outline
• Introduction
• Anatomy of large interstine with a small physiology
• Indications
• Preop preperations
• Stoma sitting
• Operative technigues
• Post op. care
• Ileostomy
• Complications
• Review article
• Care of colostomy
• Closure of colostomy
• Prognosis
• Summary.
 Introduction
• An iatrogenic colo-cutaneous fistula used in
situations in which diversion of, decompression
of, or access to the bowel lumen is needed
• Stoma through laparotomy incision include the
risk of wound infection, dehiscence, and
evisceration.
• Whenever feasible, a primary stoma site, as well
as alternative sites, be selected and marked
before surgery
 Introduction history

• In 1710; Alexis Littre of paris first performed

colostomy thru the anterior abdominal wall
• 1776; H. Pillore a surgeon from Rouen, also
performed caecostomy on a px with ca rectum. Px
died 28days after
• First successful colostomy was done by Duret of
brest, on a 3day old child with imperforate anus and
lived to 45yr
 Introduction history

• Amussat studied all 29 colostomies done since Pillore, 21

being kids with imperforate anus. Noted that 20 died within
a matter of days.
• Only 4 infants survived, all treated at Brest(remind Duret)
• Of 8 adults, 5 survived.
• concluded that their deaths were due to peritonitis and
therefore blamed abdominal approach.
• Devised the lumbar approach which lasted for over 30yrs.
• With the introduction of ATB in the 1880s, it lost its
popularity.
 Large intestine
• 1.5 m. (5ft.)
• Cecum; 7.5cm diameter, 10cm in length.
• Appendix; 3cm below ICV, variable length and position
of tip.
• Colon; identified by taeniae coli, Sacculations (haustra)
& appendices epiploicae.
Ascending 15cm.
Transverse 45cm,fixed b/n hepatic and splenic
flexures. Attached to the superior is the greater
omentum
Descending 25cm, ends at pelvic brim.
 Large intestine+anal canal
• Sigmoid; 15 to 50 cm (average 38 cm) and is
very mobile , has the narrowest diameter.
• Rectum; is 12 to 15 cm in length
lacks teniae coli or appendices epiploicae.
along with the sigmoid colon serves as a
fecal reservoir.
• anal canal
 Intestinal secretions
Na+ Cl- K+ HCO3 - H+
Fluid
mEq/L mEq/L mEq/L mEq/L mEq/L
Saliva 30-60 15-40 20 15-50 N/A
Gastric 60-100 90-140 10-20 N/A 30-100
Duodenal 140 80 5 50 N/A
Bile 140 100 5-10 40-50 N/A
Pancreatic 140 75 5-15 90 N/A
Jejunal 100 100 5-10 10-20 N/A
Ileal 130 110 10 30 N/A
Colonic 60 40 30 20 N/A
Diarrhea 130 30 90 N/A N/A
 Types
• Classification is normally based on;
Duration
Anatomic part of bowel used
Loop, End, Double barrel colostomy
Retro¬ or transperitoneal
 Aetiology /Indication
• Adults;
 Colorectal ca
 Obstruction
 Traumatic perineal injury
 Fistulae
 Protect a distal anastom.
 Ruptured diverticulum,
 Ischemia
 Inflammatory bowel
disorder.
 Aetiology /Indication
• Children

 Necrotizing enterocolitis
 Hirschsprung disease
 Meconium ileus
 Imperforate anus
 Complex hindgut anomalies
 Intestinal malrotation
 Intestinal volvulus
 Intestinal atresia, stenosis,
and webs
 Trauma
 Preoperative Preparation
• Hx
• Investigations; FBC, BUE&Cr,
Urinalysis, appropriate X rays.
• correction of fluid and electrolyte imbalance
• blood volume deficits.
• Antibiotics .
 Preoperative Preparation
• Enterostomal therapist
offers preoperative education,
mark site for stomal placement

• Consent after explaining procedure to px

• Bowel preparation; low-residue diet for several days prior to surgery

A liquid diet for at least a day before surgery

• A nasogastric tube NPO after midnight.

series of enemas and/or oral preparations (GoLytely
or Colyte) may be ordered to empty the bowel of
• A urinary catheter stool.
Oral anti-infectives (neomycin, erythromycin, or
kanamycin sulfate) may be ordered to decrease
bacteria in the intestine and help prevent
postoperative infection.
 Stoma Site Selection -assessments
• Positions

• Type of stoma anticipated

• The rectus muscle sheath
• Adequate surface area
• Easily seen
• Smooth skin surface
• Miscellaneous criteria
 Stoma location
Ideal Stoma Sites to Avoid: Other Considerations:
Characteristics:

• Red • Scars/Wrinkles • Type of Ostomy

• Round • Skin Folds/Creases • Occupation
• Raised (about 1" • Bony Prominence • Impairments (e.g. visual,
protrusion) • Under Pendulous Breasts physical)
• Lumen at center of stoma • Suture Lines • Sports/Activity Level
• Smooth skin surface • Umbilicus • Prosthetic Equipment
• Belt/Waistline • Preference (surgeon,
• Hernia patient)
• Mobile Abdominal Tissue • Posture
• Radiation Sites • Contractures
• Diagnosis
• Age
 A LOOP COLOSTOMY SIGMOID COLON.
IN THE TRANSVERSE OR

A, make approx. incisions for a transverse

or a sigmoid colostomy.
B, incise the rectus muscle for a
transverse colostomy.
C, incise the greater omentum and bring
a loop of transverse colon through it.
D, incise the mesentery.
E, bring the transverse colon through the
greater omentum.
F, push a piece tube or a glass rod
through the hole, and suture the
colon to the peritoneum.
G, close the wound.
H, Open and mature colostomy by
suturing mucosa to skin
I, the completed colostomy.
J, after healing of the wound
 End colostomy
• Make an appropriate incision in the abdominal wall
2.5cm disc incision to skin, cruciate to other layers of ant
abdomen. After close paracolic gutter.

• Insert a crushing clamp through it and draw out the end of

his gut.
• put in a few catgut sutures between the seromuscular coat
bowel and the peritoneum of the abdominal wall with 1.5
cm of healthy gut protruding beyond the skin
• Close abdominal wound.
• cut off the crushing clamp to open the colostomy.
• Suture mucosa to skin all round with interrupted 2/0 or 3/0
monofilament.
 Postop care
• Vital signs monitoring
• Pain medication given as necessary
• Support of operative site during deep breathing
and coughing
• Fluid intake and output measurement
• Intravenous antibiotics
• operative site observed for color and amount of
wound drainage
• NG tube
• Add
 coloanal and ileoanal anastomoses,
anastomotic leakage ,incomplete staple rings and tension,
Ileostomy in an irradiated field, presence of mild peritonitis or
contamination, Multiple distal anastomoses

• Indication;
Protects complicated anastomosis
Crohn's disease
Carcinomatosis with distal obstruction
Abdominal trauma
Congenital anomalies
• Post operative problems
fluid & electrolyte
skin
• Considerations; drugs
 complications
Immediate
• Bleeding
• Ischaemia/necrosis: This is generally the result of technical
failure and is usually if the stoma is formed under tension or
• a poor blood supply
Early
• High output: Ileostomies may put out more fluid than
expected (normal 500ml/day) with massive salt and water
loss, which must be corrected
• Obstruction
• Retraction (especially loop colostomy)
Late
• Obstruction
• Prolapse
• Parastomal herniation
• Fistula formation (especially with ileostomies)
• Skin irritation (especially with ileostomies)
• Psychological
 Review article . 2005 Nov;7(6):582-7

• Evaluation of the end colostomy complications and the risk factors influencing them in Iranian patients.
• Mahjoubi B, Moghimi A, Mirzaei R, Bijari A.
• Department of Surgery, Iran University of Medical Sciences and Health Care Services, Tehran, Iran.
bahar1167@yahoo.com
• Abstract
• INTRODUCTION: The aim of this study was to assess the prevalence of end colostomy complications and the
evaluation of factors influencing outcome.
• PATIENTS AND METHODS: Three hundred and thirty patients with end colostomy were studied. All patient were
recalled for examination for recent complications. Early complications included stoma site pain, early dermal
irritation (during the first month after surgery), mucosal bleeding, stomal prolapse and psychosocial
complications. Late complications included peristomal hernia, stomal stenosis, late dermal irritation (after the first
month), stomal retraction, stomal necrosis and other stoma complications (perforation, fistula etc.). Probable
underlying factors were studied. To evaluate risk factors affecting complications, univariable analysis and then
multivariable analysis by binary logistic regression was performed.
• RESULTS: One hundred and one (30.6%) patients had no complications and the remainder had at least one of
early or late complications. Overall, psychosocial complications, 56.4%; mucosal bleeding, 34.5%; early dermal
irritation, 23.5% were the most frequent complications. Peristomal hernia (11.2%) was the most common late
complication. Those aged > 40 years had significant associations with psychosocial problem (OR = 2.77), mucosal
haemorrhage (OR = 2.19), and early dermal irritation (OR = 3.14). The risks of peristomal hernia and early dermal
irritation are greater in the patients with BMI > 25 kg/m2 (OR = 2.08 and 2.55, respectively).
• CONCLUSION: The risk of most prevalent complications of colostomy construction increases in elder patients. The
high prevalence of psychosocial and skin problems in patients with a colostomy, needs special attention especially
from the viewpoint of education by trained stoma nurses and preparation of standard equipment.
 Care of colostomy
• Pouches
• Peristomal skin protective pastes, membranes and powders
• Odor reduction
• Irrigation
• When to call a doctor • severe cramps lasting more than 6 hours
• severe dicharge lasting more than 6hrs
• no output from the colostomy for 3 days
• excessive bleeding from stoma
• swelling of stoma to more than 1/2-inch
larger than usual
• severe skin irritation or deep ulcers
• complication associated with stoma
 Care of colostomy
• Irrigation ;
People with ostomies of
the sigmoid colon or descending
colon may option for irrigation, and
use a gauze cap over the stoma,
and schedule irrigation for
convenient times
Colostomies without
irrigation or
occasional.
. Pouches
. ileo-anal pouch

Ged Galvin
 ostomy pouching system(colostomy bag)
• Wafers/Baseplates
5 parameters required for skin
adhesion: 1) absorption 2) tack and
adhesion, 3) flexibility, 4) erosion
resistance and 5) ease of removal.
wafer/baseplate last b/n 4 to 10 days

• Pouches
a.Closed-end pouches must be
removed and replaced with a
new pouch.
b.Open-end pouches have a
resealable end that can be
opened to drain the contents of
the pouch into a toilet..
 Colostomy closure
• Closure, around 2 wks, but delay of 6–8 wks
allows stoma to mature and for peristomal
plane to become better defined
• Contrast study of distal bowel
• Preoperative Preparation;
low-residue diet, oral antibiotics,
irrigations in both directions through the
colostomy .
 Colostomy closure
• A piece of gauze is held in the
lumen of the intestine(or a stitch
to mucocutaneous jxn)
• Oval or elliptical incision made
through the skin and
subcutaneous tissue about the
colostomy
• free the colostomy loop, excise a
cuff of skin and evert the gut
edges
• Close in 2 layers (connel stitch,
then seromuscular lembert
sutures)
• Close ant. abdomen
 Prognosis
• Depends on the underlying disorder
• The prognosis is good, but getting used to
the colostomy bag can take up to a year.
• Mortality mostly related to the underlying
condition

Rehabilitation must add life to years as well

as years to life. (Zeiter 1969
 Summary
• A colostomy is a lifesaving surgery that
enables a person to enjoy a full range of
activities, including traveling, sports, family
life and work,
• Colostomy is performed for many different
diseases and conditions and therefore can be
temporary or permanent.
• Proper education pre and post surgery, help
improves clients quality of life.
THANKS FOR YOUR ATTENTION
 References;
• Postgraduate surgery-2nd ed
• Farquharson’s textbook of operative general surgery-9th ed
• Operative surgery vivas
• Principle and practice of surgery in the tropics- 4th edition
• Primary surgery textbook
• Colostomy guide 2004
• Sabiston Textbook of Surgery, 17th ed.
• UPMC (colostomy care)2008
• Emedicine article 2008
• surgeryencyclopedia.com
• Others not noted observed