STOMA

M. Iqbal Rivai MD
 STOMA
Greek in origin means “mouth” or “opening”
Intestinal stoma: opening of the intestinal tract onto the abdominal
wall

TEMPORARY PERMANENT
to allow the bowel carried out as a life-saving measure
a period of rest & recovery
 CLASSIFICATION

Anatomy Duration Configuration

• Colostomy • Temporary • End
• Ileostomy • Permanent • Loop
• Urostomy • Double-barrel
• Others
TYPES OF INTESTINAL OSTOMIES
TYPES OF INTESTINAL OSTOMIES

End Ostomy

Loop Ostomy

Double-barrel

Divided Stoma
 INDICATIONS

Disease Presentation Rationale Configuration Time

Rectal cancer (LAR) Defunction Loop ileostomy or Usually

(anastomosis protection) colostomy Temporary
Colorectal Cancer

Very low cancers A part of APR End colostomy Permanent

Obstruction Decompression End or loop Usually

colostomy Temporary

Perforation Defunction End or loop Usually

colostomy Temporary

* APR: abdominal perineal resection

 INDICATIONS

Disease Presentation Rationale Configuration Time

Elective fistula Defunction Loop ileostomy Usually

Diverticular disease

(anastomosis protection) or colostomy Temporary

Perforation Defunction End or loop Usually

colostomy Temporary

Obstruction Decompression End or loop Usually

colostomy Temporary
 INDICATIONS

Disease Presentation Rationale Configuration Time

Acute colitis Defunction End ileostomy Temporary or

Ulcerative colitis

(after subtotal colectomy) permanent

Chronic disease Eradication of disease End ileostomy Permanent

(after panproctocolectomy)

Elective Defunction Loop ileostomy Usually

(after ileal pouch surgery) Temporary
 INDICATIONS

Disease Presentation Rationale Configuration Time

Crohn’s colitis Defunction Loop or split Temporary
ileostomy or or
colostomy permanent
Crohn’s disease

Small bowel disease Defunction Loop or end or Permanent

split ileostomy

Elective Eradication of disease End ileolostomy Permanent

(after panprocto-
colectomy)
Septic complication Defunction Loop or end Usually
or perianal disease ileostomy temporary
 INDICATIONS
Disease Presentation Rationale Configuration Time

Colon or rectum Defunction Ileostomy or Usually

colostomy temporary
Functional Trauma

Anal sphincter Defunction Ileostomy or Usually

colostomy temporary

Fecal incontinence Defunctioning anus End or Permanent

colostomy

Sphincter repair Defunction Loop ileostomy Temporary

or colostomy
 OPERATIVE STEPS
1. Site selection
2. Selection & preparation of bowel segment
3. Alignment of layers of abdominal wall
4. Skin & subcutaneous tissue incision
5. Anterior rectus sheath fascial incision
6. Separation of rectus muscle fibers
7. Posterior rectus sheath fascial incision
8. Passing bowel through abdominal wall
9. Placing the bridge & maturing the stoma
 ILEOSTOMY
Site selection
 Right lower quadrant, but must be
visible to the patient
 Through the rectus muscle
 Centered on a flat area or on the crest
of a fat
 Roll away from scars, creases, or
bony prominences
 The site should be chosen prior to the
operation after examining the patient
in the supine & sitting positions
 ILEOSTOMY

Selection & preparation of bowel segment

 At least 6 cm of viable distal or
terminal ileum with the
adjacent marginal artery
should be preserved to
maintain an optimal blood
supply
 The mesentery should not be
stripped

End Ileostomy
 ILEOSTOMY

Selection & preparation of bowel segment

 An ileal segment 20 – 30 cm
proximal to the ileocaecal junction
is identified.
 The segmen mesentery &
vasculature are preserved

Loop Ileostomy
 ILEOSTOMY

Alignment of layers of abdominal wall & incision of anterior

rectus fascial
 The fascial incision should be
just large enough to allow
passage of the limb of bowel,
generally 2.5 cm
 Placing the stoma through the
rectus muscle reduces the
incidence of a peristomal
hernia
 ILEOSTOMY
The fascia in thick abdominal
walls tends to retract laterally
relative to the midline skin
incision.
The opening in the fascia for the
stoma will be too close to the
midline incision, causing difficulty
closing the midline incision &
kinking of the bowel as it traverses
the abdominal wall.
By placing a clamp, proper
alignment can be restored
 ILEOSTOMY

Separation of rectus muscle fibers

 Careful separation by spreading in a longitudinal direction may
reduce the risk of injury to the inferior epigastric vessels

Passing bowel through abdominal wall

 The bowel should be guided through the abdominal wall from the
skin side, but not pulled. Rather, gentle pressure from the
abdominal side to deliver the bowel onto the skin surface
 ILEOSTOMY
Placing the Bridge & Maturing the Stoma
 ILEOSTOMY
Placing the Bridge & Maturing the Stoma
 ILEOSTOMY
Placing the Bridge & Maturing the
Stoma
 Evert the end of the ileostomy
 The first bite  full thickness
through the distal cut edge of the
bowel.
 The second  seromuscular bite ± 5
cm proximal to the cut edge.
 The last bite  dermis at the edge of
the ileostomy incision
 Avoid pressure from the stoma
wafer
 TYPES OF COLOSTOMIES

End stoma
Double-barrel
& Brooke maturation
stoma

End-loop stoma Loop stoma

with Hartmann’s
closure
 COLOSTOMY
1. End colostomy
 Avoid using the sigmoid colon when
creating an end colostomy, especially a
permanent one, (possibility that the
blood supply to the sigmoid colon could
be compromised during resection) 
ischemia & subsequent stricture or
retraction of the stoma
 Stoma must reach the skin around the
stoma aperture without tension
 COLOSTOMY
1. End colostomy

Closure of peritoneum to assist

Tunneling of the bowel
in fixation of bowel
to prevent herniation and to help prevent prolapse and herniation
 COLOSTOMY
1. End colostomy

Sutures are place in four quadrants and held with hemostats

 COLOSTOMY
2. Loop end colostomy

Delivery of a loop (end) colostomy Replacement of penrose drain

using a penrose drain with a plastic supportive rod
 COLOSTOMY
2. Loop end colostomy

Suture placement for maturation of

Opening of distal limb of loop proximal limb and eversion of proximal
limb of loop colostomy
 COLOSTOMY
3. Loop colostomy
 Use of the loop colostomy has
declined over the past 20 –25 years
because loop ileostomy is generally
considered a better form of fecal
diversion
 However, loop colostomy still may
have an important role in the
management of acute large bowel
obstruction Closed distal limb partially
 Loop colostomies have a higher matured distal limb as a distal
mucus fistula.
incidence of prolapse and parastomal The opening of the mucus fistula is
hernia than end colostomy incorporated into the ostomy
appliance opening
 COLOSTOMY
Indication of “blow-hole” colostomy
1. Toxic megacolon
2. Toxic megacolon during pregnancy
3. Severe Clostridium difficile
-associated colitis
4. Adult Hirschsprung’s disease
5. Malignant distal colonic obstruction
with metastases

Turnbull Blowhole colostomy.

A decompressive colostomy created
with a diverting loop ileostomy
 COMPLICATION

Overall complication rate between 21 – 70%

1) Parastomal Hernia
 Incidence 0 – 48.1%
 End stoma > loop stoma
 Colostomies > ileostomies

Management:
 Abdominal support belts, avoid heavy lifting
 Aproximately 20 – 30% require surgical repair
 COMPLICATION
1) Parastomal Hernia
Surgical options:
 Primary fascial repair without mesh
 Stoma relocation
 Parastomal hernia repair with mesh
 Laparoscopic parastomal hernia repair

* Repair should typically be performed by using mesh reinforcement or by

relocating the stoma
* Prosthetic mesh may be used during parastomal hernia repair with low short-term
risk of intestinal erosion or mesh infection
* Laparoscopic parastomal hernia repair with mesh may be a safe alternative to open
mesh repair
 COMPLICATION

1) Parastomal Hernia
Prevention:
 Limiting the size of the ostomy fascial opening
 Stoma creation through rather than lateral to the rectus muscle
 Fixation of the ostomy limb to the abdominal fascia
 Extraperitoneal stoma placement
 Preoperative stoma marking
 COMPLICATION
2) Stoma prolapse
 Incidence 2 – 42%
 Especially loop colostomies

Management:
 An acute prolapsed & incarcerated stoma
can sometimes be reduced with topical
sugar. Sugar leads to desiccation of the
prolapsed tissue with a subsequent
reduction in edema
 Surgical repair
 COMPLICATION

2) Stoma prolapse
Surgical options:
 Resection of the prolapsed segment
 Conversion of a prolapsed loop ostomy to an end ostomy
 Reanastomosis for temporary stomas
 Stoma relocation
 COMPLICATION
3) High Output Stoma
 Daily output > 2 L or amount that leads to dehydration
 Lead to electrolyte abnormalities
 Caused by extensive small bowel resection, intrinsic bowel
diseases (Crohn’s) or bacterial overgrowth & post-operative
states

Management:
 Identify & treat the underlying disease
 Electrolyte, oral & IV fluid replacement, anti-diarrheal &
antisecretory medication
 Stoma reversal should be consider as a possible treatment
 COMPLICATION
4) Peristomal skin irritation
 Incidence 3 – 42%
 Causes:
 Candida albicans
 Contact dermatitis (stoma nursing products)
 Pyoderma gangrenosum (Crohn’s)

Management & prevention:

 Modern stoma equipment (adhesive seals, caulking paste) & improved stoma
nursing
 Ileostomies should always be everted & the spout ideally 2-3 cmabove the skin
level to allow the effluent to flow into the pouch rather than on the skin
 The opening in the appliance should exactly match the outer diameter of the
stoma
 COMPLICATION

5) Stricture / stenosis
 Incidence 1 – 10%
 Most common cause: ischemia & infection (Crohn’s)

Management:
 Initially multiple session of mechanical dilation (possibility
promotes further fibrosis & stricture)
 Definitive treatment requires stoma revision
 COMPLICATION
6) Stoma retraction
 Incidence 1 – 6% colostomies; 3 – 17% ileostomies
 High body mass index related to retraction

Management:
 Convex stoma appliance may decrease the leakage
 Definitive treatment usually requires stoma revision

Prevention:
 Sufficient length of the bowel to
prevent tension & retraction
 COMPLICATION
Complications
Category
Early Late
Poor location Prolapse
Retraction * Stenosis
Ischemic necrosis Parastomal hernia
Stoma related
Detachment Fistula

Wrong limb exteriorized Gas & odor

Excoriation Dermatosis
Peristomal skin Dermatitis Parastomal varices
Cancer
High output / loss of
Bowel obstruction
Systemic fluid (dehydration) *
Non-closure
Closure related Leakage * Incisional hernia
* May be late
Quality of life  developed
 ESSENTIAL GUIDELINES FOR
OSTOMY CREATION
1. When feasible, laparoscopy ostomy formation is preferred to
laparotomy

2. Whenever possible, both ileostomies & colostomies should be

fashioned to protrude above the skin surface

3. Lightweight polypropylene mesh may be placed at the time of

permanent ostomy creation to decrease parastomal hernia rates

4. Postoperative care pathways may prevent hospital readmission for

dehydration in ileostomy patients
* Hendren S, et al. 2015. Dis Colon Rectum 2015; 58:375-387
 GUIDELINES FOR OSTOMY
CLOSURE

1. Stapled & hand-sutured techniques are both acceptable for loop

ileostomy closure

2. Ostomy-site skin re-approximation should be performed when

feasible & purse-string skin closure may have advantages
compared with other techniques

3. Laparoscopic Hartmann reversal is a safe alternative to open

reversal in experienced hands

* Hendren S, et al. 2015. Dis Colon Rectum 2015; 58:375-387

THANK YOU