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Stoma

dr. Citra Roshian

Pembimbing :
dr. Tommy Ruchimat, Sp.B-KBD

Anatomi Abdomen

Fisiologis

Lambung
motorik

Reservoir
Mencampur
Pengosongan lambung

Pencernaan & sekresi


Pencernaan protein
Sintesis dan pelepasan gastrin
Sekresi faktor intrinsik
Sekresi mukus

Usus Halus
Pencernaan

Absorbsi
Nutrisi

Dibantu oleh enzim


dan hormon

Cairan
Elektrolit

Usus Besar

Mengabsorbsi

cairan dan elektrolit


Reservoir massa faeses
Dengan bantuan bakteri sintesis vitami

The physiology of the colon should be taken into


account when considering stoma construction.
The right side of the colon absorbs water and
has irregular peristaltic contractions.
Stomas made from the proximal half of the colon
usually expel a liquid content.
The left colon serves as a conduit and reservoir
and has a few mass peristaltic motions per day .
The content is more solid, and in many cases the
stoma output can be regulated by irrigation.
Proximal colostomies should be avoided , as they
will combine the worst features of both a colostomy
and an ileostomy: liquid, high-volume, foul-smelling
effluent. The left colon should be used for a
colostomy if possible; the distal transverse colon is
also a reasonable choice.

Lokasi Stoma yang baik

Lokasi Stoma

The most common indication is cancer of


the rectum.
Colostomy is an opening of the large
intestine, no sphincteric control better on
the abdominal wall than in the perineum
(maintanence).
A distal colorectal anastomosis in an elderly
patient with a poorly functioning anal
sphincter may result in what is essentially a
"perineal colostomy." In these cases, it often
behooves the surgeon to construct a good
colostomy rather than to restore intestinal
continuity to an incontinent anus.
Colostomies are also constructed as
treatment for obstructing lesions of the
distal large intestine and for actual or
potential perforations.

Colostomy

End sigmoid
Descending

Emergency / elektif

Sementara / permanent

Kanker rektum (abdominoperineal reseksi)


Tujuan hygiene (tetraplegia / inkontinensia
alvi)
Diversi faeses
Obstruksi
Perforasi
Kasus trauma

Type by Anatomic Location

Type of colostomy categorized by the part of the colon


used in its construction.
The most common type : "end-sigmoid" colostomy.
However, if the inferior mesenteric artery is transected
during an operation for cancer of the rectum, the
blood supply to the sigmoid colon is no longer
dependable, and it should not be used for stoma
construction.
"end-descending" colostomy is preferable to an endsigmoid colostomy.
Other types of colonic stomas include the transverse
colostomy and cecostomy.

Type by Function
More important than the anatomy of
the colon is the function that the
colostomy is intended to perform.
There are two considerations:
(1) to provide decompression of the
large intestine
(2) to provide diversion of the feces.

Types of Decompressing
Stomas

(1)

(2)
(3)

There are three types of


decompressing stomas:
the so-called "blow-hole"
decompressing stoma constructed in
the cecum or transverse colon,
a tube type of cecostomy, and
a loop-transverse colostomy.

"blow-hole"

a tube type of
cecostomy

a loop-transverse colostomy

Loop colostomy

Diverting Colostomy

A diverting colostomy is constructed to provide


diversion of intestinal content. It is performed
because the distal segment of bowel has been
completely resected (as during
abdominoperineal resection), because of known
or suspected perforation or obstruction of the
distal bowel (e.g., obstructing carcinoma,
diverticulitis, leaking anastomosis, or trauma),
or because of destruction or infection of the
distal colon, rectum, or anus (e.g., Crohn's
disease or failed anal sphincter reconstruction).

Diverting
stomas

Loop
ileostomy

Loop ileostomy

End ileostomy

Construction of an End
Colostomy

An end, completely diverting, colostomy usually is


located in the left lower quadrant, where the site is
chosen preoperatively by placing a vertical line through
the umbilicus and another line transversely through the
inferior margin of the umbilicus and by affixing a disk
the size of a stoma faceplate to designate the stoma
opening through the rectus muscle and on the summit
of the infraumbilical fan fold.
An alternative location is through the midline fascia, not
necessarily at the umbilicus. Although this site initially
seems esthetically unappealing, it allows construction
of a stoma with a lower incidence of symptomatic
hernia formation because of the ability to tightly close
the linea alba around the stoma.

End Colostomy

Once a site is chosen, the patient should be


evaluated in multiple body configurations to verify
the adequacy of the stoma site.
A common mistake is to choose the site with the
patient supine and then find when the patient rises
to a standing or sitting position that the chosen site
is completely obscured by fat folds, scar tissue, or a
protruding skeletal structure.
The location should be adjusted up or down, even
considering the use of upper quadrants of the
abdomen if necessary, to allow proper fixation of an
appliance and easy access by the patient.
The site usually is marked with ink in the patient's
room and then is scratched into the skin with a
needle in the operating room after induction of
anesthesia.
This is totally painless for the patient and does not
leave a permanent tattoo should colostomy not be
needed.

An end colostomy most often is constructed


after removal of the rectum for low-lying
malignancy.
The entire left colon is mobilized on its
mesentery, and depending on mobility of the
colon and thickness of the abdominal wall,
may require mobilization of the splenic
flexure.
If the patient has received neoadjuvant pelvic
radiotherapy and/or the inferior mesenteric
artery is transected at its origin at the aorta,
the entire sigmoid colon should be removed
because of concerns regarding ischemia and
a descending colostomy created.

If the colostomy is to be brought through the


left lower quadrant, an opening in the
abdominal wall is made at the previously
marked site by excising a 3-cm disk of skin.
The undesirable oval configuration of a stoma
is avoided by placing traction clamps in the
dermis, the fascia, and the peritoneum.
These clamps are held in alignment when the
opening is made through the abdominal wall.
This duplicates the configuration of the
abdominal wall when the abdomen is closed
and should allow construction of a desirable
circular stoma.

The fat, fascia, muscle, and posterior peritoneum are


then incised longitudinally. No fat is excised.
The opening is then dilated to allow passage of two
fingers, and the closed end of the colon is pulled
through the abdominal wall.
There, mesentery of the colon can be sutured to the
lateral abdominal wall with a running suture, although
the complication of small bowel obstruction due to
torsion of the small bowel mesentery around the colon
mesentery has not been proven to be reduced by this
maneuver.
After the wound is closed and protected, attention is
directed to completing the colostomy.
The stoma is completed by excising the staple or suture
line and by placing chromic catgut sutures between the
full thickness of colon and skin.
If the stoma is constructed because of inflammatory
bowel disease or radiated bowel, a spigot configuration
is utilized by applying principles similar to those for
ileostomy construction. This facilitates a good appliance
seal for anticipated high-volume, liquid effluents .

If the colostomy will be brought through the midline,


no fixation of the mesentery is necessary.
The intended midline colostomy is brought through
the abdominal incision, and the entire incision is
closed, with the sutures adjacent to the colostomy
being tied last.
At least a few interrupted sutures are placed on
either side of the colostomy even if a running
closure of the abdominal wall is used.
As the last sutures are tied, the colon is pulled
through the abdominal wall, and the surgeon's
finger is placed adjacent to the stoma as a spacer to
avoid compromise of the blood supply to the stoma.
The skin is closed and the wound is protected as
attention is directed to the colostomy, where either
the staple line is excised or the clamp is removed,
and full thickness of colon is sutured to full
thickness of skin with interrupted absorbable
sutures.

Once the stoma construction is complete, an appliance is


applied in the operating room. The simplest is a one-piece
appliance with a skin barrier that can be cut to the
appropriate size of the stoma.
This same appliance can be used for colostomy and ileostomy.
The pouch is allowed to fall to the patient's side, because in
the postoperative period, the patient will be supine rather
than upright the majority of the time.
The appliance, which need not be sterile, is held in place with
the skin adhesive of the appliance and is secured with strips
of nonallergenic tape placed in "picture-frame" fashion. The
remaining wound dressing is applied.
Tincture of benzoin should never be used to maintain
adhesion of an appliance to the skin because it has a high risk
of initiating contact dermatitis.
If colostomy function does not begin within 4 or 5 days, the
stoma can be irrigated with small volumes (250 mL) of normal
saline to initiate stoma function. The enterostomal therapy
nurses are involved early in the care of the stoma and in
teaching the patient and family to provide long-term care of
the colostomy. In most cases, the patient is taught the
technique of stoma irrigation, and then each individual
decides in the more distant postoperative course if she or he
wishes to irrigate the stoma or not.

Perawatan stoma

Waktu yg tepat untuk mengganti kantung


Frekuensi mengganti kantung
Proteksi kulit peristoma
Kontrol bau & gas
Management diare
Pencegahan & management gangguan
cairan & elektrolit
Pencegahan & management konstipasi
Irigasi stoma

Komplikasi

Metabolik problems
Parastoma abses, ulcerasi, hernia
Striktur
Volvulus
Caput medusae