Stoma in detail for PG trainees

1. Surg Cdr Chaminda Amarasekara

2.  Definition
 Classification
 Principles of stoma formation
 Attachment of the stoma appliance
 Stoma care
 Complication of intestinal stomas
 Dietary advice to ostomates
 urostomy

3.  “Stoma” is a Greek word –mouth/ opening
 Surgically created small opening on the
surface of abdomen in order to divert flow of
faeces /urine
 It’s a anastomosis fashioned between
intestine and skin of AAW

4.  Intestinal stoma
◦ Colostomy
◦ Ileostomy

5. Colostomy
Type by anatomic location
1. Sigmoid
2. Transverse
3. Caecostomy

6.  Reconstruction
◦ End Stoma(Consists of a single intestinal lumen)
◦ Loop Stoma
(Gives access to both afferent and efferent limbs)
◦ Double barrel
◦ Bishop-koop( distal ileostomy with end to side ileas
anastomosis)
◦ Santulli (proximal ileostomy with end to side ileas
anastomosis)

7. Type by function
1. Decompression
2. Diversion
Type by duration
Permanent
Temporary

8. Permanent stoma Temporary stoma
 Necessary when there
is no distal bowel
segment remaining
after resection
 Usually below the belt
line
 Permanent colostomy:
LIF
 Permanent ileostomy
:RIF
 Relieve complete distal
large bowel
obstruction causing
proximal dilatation.

9.  Feeding
◦ Percutaneous endoscopic gastrostomy(PEG)
 Decompression
 Diversion
◦ Protection/de function of distal bowel anastomosis
 Previous contaminated bowel
 Iliorectal anastomosis
◦ Urinary diversion following cystectomy

10.  exteriorization
◦ Perforated or contaminated bowel (distal abscess or
fistula)
◦ Permanent stoma (APR or Rectum)

12.  Pre op counseling
 Pre op assessment
 Stoma creation

13.  Psychological & physical preparation
◦ Discuss the possibility of stoma with patients
undergoing elective or emergency colorectal
surgery
 Explanation of indications and complications

14. Marking the stoma site
Asses the patient preoperatively
-lying down
-sitting
-standing

16.  Mark the best site for stoma
- Area should be easy to see and access
- Avoid bony prominence
- Eg Iliac crest,rib cage
- Avoid scars, skin creases, anticipated surgical
wounds & belt line.
- The stoma within rectus abdominus sheath

18.  Stoma creation-ileostomy
 Ileostomy effluent

24.  Distal obstruction
 Ca rectum or sigmoid colon
 Usually done as emergency procedure
 No time for bowel preparation
 Resection anastomosis

25.  Blow – hole decompressing stoma
 Caecum
 Transverse colon
 Tube Caecostomy
 Loop Transverse Colostomy

27.  Advantages
 Safe , useful
 Subsequent definitive procedures can be performed
 Disadvantages
 Does not provide complete fecal diversion
 May be disruption of continuity distal to the stoma

28.  Rarely done now a days
 Difficult to manage post operatively
 Reserved for
 Elderly
 Acutely ill
 Massive distention of colon with impending rupture

29.  Function
 Decompression stoma
 Diverting stoma
 For 06 wks
 Then post wall recesses – stool can enter distal loop
 Long term stoma
 Drawbacks
 Irrigation – difficult
 Parastomal hernia

32.  Aim – for complete diversion of contents
 Indications
 Breech of continuity of distal bowel
 Like – traumatic injury distally
 Diverticulitis
 Perforated un resectable cancer
 Leaked anastomosis
 Threatened anastomosis
 Disease – destruction of rectum & anus
Crohn’s disease , hidradenitis , multiple sphincter injury ,etc

33.  Complete transection
 Proximal segment colostomy
 Distal segment
 Mucous fistula –
 Left closed in abdominal cavity
 Like – HARTMANN resection
 Stoma – same as described earlier

34.  Divides the bowel completely ( 2 stoma
beside each other and separate from each
other)
 Each opening brought in to the surface as
separate stoma
 Proximal end : end stoma
 Distal end mucus fistula

38.  Safe to restore the continuity of intestine
 Evaluate the distal integrity
 Evaluate the sphincter muscle function

39.  How to evaluate
 Endoscopy
 Contrast study
 Manometry
 Circumferential incision around stoma
including small rim of skin
 If midline – open either side of mid line &
mobilize the segment

40.  Closure – transversely
 Stapler
 Hand closure
 Complete transection colon & construction by end to
end anastomosis
 Return to abdominal cavity
 Closure of abdomen
 Precautions
 Haemostasis
 Injury to other loops

45.  End ileostomy – permanent, for patients who
require removal of complete colon & rectum
 Loop ileostomy – temporary, to protect
complex sphincter conserving anastomosis
distally
 Ileostomy fluid liquid, high volume, corrosive
to peristomal skin
 Ileostomy stoma carefully sited with a nipple

46.  Is essential in management of neonates with
certain type of distal intestinal obstruction.
Eg: long segment Hirschsprung disease
complex meconium ileus
Gastroschisis with atresia
 Ileostomies placed to divert bowel contents in
neonatal necrotizing enterocolitis, ulcerative
colitis, familial polyposis

47.  General
◦ Stoma diarrhea
 Water & electrolyte imbalance
 hypokalemia
◦ Nutritional disorders
◦ Stones
 Gallstones
 Renal stones
◦ Psychosexual
◦ Residual disease

48.  Specific
◦ Skin excoriation
◦ Prolapse/gangrene/necrosis of distal end
◦ Bleeding
◦ ischemia
◦ Retraction
◦ Parastomal hernia
◦ Fistula formation
◦ Stenosis of orifice

50.  Stenosis
Predisposing causes
Aponeuretic opening too small
Stomal ischemia
Recurrence –crohn’s disease
Severe stenosis will cause intestinal obstruction

51.  Stomal prolapse
Predisposing factors
Aponeurotic opening too large
Excessive mobilization off redundant
bowel
Raised intra abdominal pressure
Common in loop colostomies

52.  Answer
 Get rid of disease condition
 Maintain continuation of bowel
 Convert loop colostomy to end colostomy may be with
mucous fistula

53.  Obstruction of small bowel
-occurs particularly in loop stomas
Attributed to intra abdominal adhesions
 Hemorrhage
Can be due to
A trivial bleed from fragile granuloma
Recurrent /novel GI disease
parastomal varices

54.  Diversion colitis
- chronic inflammation of distal bowel left
in situ when faecal stream is diverted away
-may develop bloody discharge from the
rectum

55.  Parastomal hernia
 If located lateral to rectus

56.  Skin manifestations
◦ -contact dermatitis from occlusive appliances
◦ -Allergic responses to adhesives
◦ fungal and bacterial infections

58.  Site – proximal to stoma
 Following irrigation or contrast study
 Treatment
 Emergency
 Re explore
 Re construction

59.  Protective skin barrier
 Pouch
◦ Closed end
◦ Drainable

60.  Gently clean the stoma & peristomal skin
 Dry the peristomal skin & apply filling paste
 Cut the center hole of the skin barrier to
match the diameter of the stoma.

61.  Remove the sticker of the skin barrier
 Fix the skin barrier to the peristomal skin

62.  Fix the pouch to the skin barrier
 Clip the other end of the pouch
 Finally apply plaster around the skin barrier

64.  Patients should be advised carefully before
the discharge
 Properly fitted appliances should remain in
situ for several days(3-4days)
 There are two basic type of pediatric
appliance
◦ One piece system
◦ Two piece system

65.  Candidasis remain a major issue
- Anti fungal cream should be started with
early signs
- Application of silver nitrate may be requried
to control granulation around the mucosa –
skin interface at early stages.

66.  Take low fiber food to reduce bulk in stool &
help prevent intestinal obstruction.
 Avoid vegetable known to result in offensive
odour
◦ Reddish
◦ Cabbage
◦ Garlic
◦ cucumber

67.  To reduce flatus avoid
◦ Carbonated beverages
◦ Chewing gum
◦ smoking
 Chew food well
 Drink adequate amount of water

68.  Surgical diversion of urinary system
 Indications:
◦ Bladder Ca
◦ Urinary incontinence
◦ Neuropathic bladder

69.  Formation of urostomy
◦ Needs ileal conduit, a segment of viable ileum made
like a tube where 1 end is open (used as stoma) and
another end is closed (used as reserve)
◦ Ureters are implanted into this isolated segment of
small bowel tube
◦ The open end of conduit is everted to create a
similar spout as ileostomy and allows diversion of
urine from kidneys to out side the abdomen and
collected by stoma bag

71. THANK YOU