KOLEGIUM ILMU BEDAH INDONESIA

Reasons why :

Topics to be discussed :

Stoma :
1.
2.
3.
4.
5.

Anatomy & Physiology

Pre-operative Consideration
Types & Indications
Techniques
Post-operative Management

STOMA

Gastrostomy

Jejunostomy

Ileostomy Physiology

8 litres produced daily,

- Saliva
: 1 litre
- Gastric juice
: 2 litre
- Pancreatic juice
: 1 litre
- Bile
: 1 litre
- Intestinal juices
: 3 litre

Most are absorbed

1500 - 2000 ml/day

normally enters the colon

IIeostomy Output :
Day 1-3 : bilious, liquid,
each day output
Day 3-5 : output stabilizes,
slightly
6-8 weeks : steadily ,
200 - 700 ml/day
Correlation with body mass :
- 40 kg : effluent 300 - 400 ml/d
- 80 kg : effluent 800 ml/day
4 - 6 months post op :
- volume varies little
- porridge like
- yellow - brown
- food particles

Ileostomy Physiology
Nutrients are readily absorbed from small intestine
< 100 cm terminal ileal resection :

few nutritional consequences

Bacteriological environtment :

intermediate beetween small intestine & colon

organism 80 x
Coliform 2500 x
: Staphylococci, streptococci, fungi
Bacteroides fragilis : rare

Ileostomy Patients
Adaptation
Slowing small bowel transit time
Gastrointestinal Transit After Proctocolectomy
Control
Ileostomy
Parameter (min ) ( n = 8 )
(n=5)
p value
______________________________________________________
Gastric emptying
120 22
109 10
NS
Small bowel transit 243 32
348 12
0.01
______________________________________________________

Adaptation process > 1 year

Epithelial hypertrophy increased absorptive surface

<

Colostomy Physiology
Ileal content Colon :

1500 - 2000 ml fluid & 120 meq Na

Feces : < 200 ml water & 25 meq Na

Efficient absorption

Colostomy Physiology
Colostomy begins to function :

- output is liquid
- steadily increases in volume
- expelled : irregular
After 10 - 14 days :
- effluent : quite viscous
Slowly a pattern of stool evacuation
develop more predictable

Proximal Colostomy
Right colon :

- mixing
- water & electrolyte
absorption

Ascending or proximal

transverse colostomy :
- effluent :
high volume liquid
- high Na
- expelled :
frequent & irregular

Avoid whenever possible

Middle Colostomy
Distal Transverse &

Descending
Colostomies :
- volume <
- less liquid

Colostomy proximal to splenic flexure

- poorly function
- difficult to manage
- high risk for complications

Distal Colostomy
Sigmoid Colostomy :

- semi solid - solid

- expelled no more
1 - 2 x / day
- volume ~
intact colon

Permanent colostomy

- Sigmoid
- Descending Colon

Permanent colostomy

in Transverse or
Ascending colon :
strongly consider

resecting the colon &

create End ileostomy

Preoperative
Considerations
Ostomy Triangle

Patient Attitudes :

- education &
counseling
Anatomical
considerations :
- can be visualized by
the patient
- 5 - 7 cm skins area
remains relatively
flat
- rectus muscle
- below belt line

Preoperative
Considerations

If available : meet the ETN -

Enterostomal Therapist
ETN :
- provide specific information
regarding stoma appliances, dietary &
clothing, & pouch management
- help select the appropriate abdominal
wall for the stoma

Preop Considerations
Appropriate stoma placement :

postop complications :
ostomates well being

Bass 1997 :

preop counseling & marking by ETN

improve postop Quality of Life

Meet other ostomates

Stomas Sites

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

Wheelchaired patient :
- marked while in the chair
Complex case :
- after siting, leave stoma bag in place
for 24 hours

Indications & Types of

Ostomies
Temporary :

1. Fecal diversion ( Diverting Stoma ) :

- when an anastomosis is unsafe
* loop ileostomy,
* loop colostomy,
* end-loop stomas ( end-loop
ileostomy, end-loop colostomy,
end-loop ileo-colostomy )
Permanent :
- surgical resection or disease
prohibits normal body orifices to function

Types Of Ostomies
1. End Ileostomy

- in partial or total colorectal

resections
2. End Colostomy
- in association with distal colorectal
resection
a. Abdominoperineal resection =
APR = Miles operation
b. Hartmanns operation

End Ileostomy
Loop Ileostomy

End-loop ileostomy

End Ileostomy :
Technique

End Colostomy :
Technique

Hartmanns
procedure

Abdominoperineal
resection

- Part of distal colorectal resection

- transected lateral attachment of the c
along white line of Toldt
- stoma site is prepared
- abdominal wall defect is created in LL
- fascial opening slightly larger
- pass the colon through abdominal wa
without twisting & without tension
- colon should protrude & well perfused
- no need to close the lateral gutter
or suture the colon to posterior abdom
fascia
- close abdominal incision
- mature the colostomy

End Sigmoid Colostomy

Irrigation :
Long standing end colostomy
Stable bowel habit
Aim : trained to defecate on schedule
Mechanism :
- washing out distal colon
- stimulates more proximal colon
500 - 1000 ml warm tap water slow enema
- until sense of fullness occurs
- stoma is allowed to drain
the next 1/2 hour ,
colon continue to evacuate

Loop Colostomy :
Indication & Technique
Created to prevent the fecal stream reaching

rectum & anus :

- incontinence
- severe anorectal infection
- protect complex anal reconstruction

Decompression & Diversion for distal

obstructing tumour

Created in identical fashion as loop ileostomy,

except : stoma is placed in Left Lower

Quadran

Closed Loop Obstruction

End-Loop Stoma
Diverting stoma to divert the fecal

stream away from the down stream

intestine :
Loop ileostomy, loop colostomy, & end-loop stomas

Benefits :
Make stoma management easier
Can be created with remote sections of intestine :
end loop ileotransverse colostomy
Do not require formal laparotomy for stoma take
down

Loop Colostomy :
Technique

Double Barrelled
Colostomy

Postoperative
Management

Apply transparent pouch in OR :

No leak
Surgeons responibility

Rehabilitate the patient in

collaboration with ET Nurse

Wound Healing :
The process by which a damaged
tissue is restored, as closely as
possible to its normal state.

Completeness or otherwise of wound

healing depends upon :
Reparative abilities of the tissue
Type of damage

Local
Factors

Extent of damage
General state of health

Systemic
Factors

Ideal Local Conditions

Prasetyono TOH. General concept of wound healing: revisited.
Med J Indones.2009; 19(.)

Tissue is viable

No Foreign Bodies

Normal Healing Process

Free From Excessive Bacterial Contamination

Acute & Chronic Wound

Chronic :

- Healing process stop in one stage

- 4 - 6 weeks

Keys to manage Difficult

Wound
Adequate debridement
Convert chronic to quasi acute

Teddy OHP 2010

Wound Bed Preparation

Aim :

Optimal Wound Healing Environment

:
Well Vascularized Wound Bed
Stable Wound Bed
Minimal Exudate

Structured & Systematic Approach :

Removal of Barriers

Wound Problems =
Barriers
1. Necrotic Tissue
2. Bacterial Infection
3. Exudate

Wound Bed Preparation

1.

Necrotic Tissue
Debridement

2.

Bacterial Infection Bacterial Load

Management

3.

Exudate

Moisture Control

Facilitate Healing

1. Debridement
= The removal procedure of

devitalized, damaged, or infected

tissue (debris)

Procedure of removal:
Surgical,
Mechanical,
Chemical,
Autolytic

Surgical Debridement
Sharp debridement uses a scalpel, scissors, or

other instrument to cut devitalized tissue from a

wound.

The fast and most efficient method of debridement.

The preferred method in rapidly developing

inflammation of the body's connective tissue and

generalized infection (sepsis).

The procedure is carried out by physician, bedside

or in the operating theatre.

Surgical Debridement
Non vital tissue breaks into parts of what it

composed Lipid-Protein Complex (LPC, exp.

myotoxin) is toxic; provokes inflammatory
response lead to sepsis
Lack of
perfusion
Cell Injury

LPC
Inflammation

Inflammatory mediator

Surgical Debridement :
General Consideration
Bedside
Minor sized, superficial
No anesthesia or

local anesthesia
Control of hemostatic <

Effectiveness <
Low cost

Operating theater
Deep
General anesthesia
Good lighting for best

assessment and
evaluation
Control of hemostatic >
Effectiveness >
High cost

Mechanical Debridement
Saline-moistened dressing is allowed to dry

overnight and adhere to the dead tissue.

As the dressing is removed, the devitalized tissue is
pulled away.

One of the oldest methods of debridement.

Painful since the dressing adhered to non-vital as

well as vital tissue.

Not selective: good and bad tissue

an unacceptable debridement method for clean

wounds where a new layer of healing cells is
already developing.

Chemical Debridement
The use of certain enzymes and other compounds

to dissolve necrotic tissue.

More selective than mechanical debridement.
The body makes its own enzyme, collagenase, to
break down collagen, one of the major building
blocks of skin.
A pharmaceutical version of collagenase is highly
effective as a debridement agent.
The area first is flushed with saline. Any crust of
dead tissue is etched in a cross-hatched pattern to
allow the enzyme to penetrate.
Moist dressing is then placed over the wound.

Enzymatic Debridement

Traditional Collagenase :
- Bromelain : nanas
- Papain
: papaya
- Maggots

Maggots Therapy

Autolytic Debridement
Autolytic debridement takes advantage of the

body's own ability to dissolve dead tissue.

The key to the technique is keeping the wound
moist, which can be accomplished with a variety of
dressings. These dressings help to trap wound fluid
that contains growth factors, enzymes, and
immune cells that promote wound healing.
Autolytic debridement is more selective than any
other debridement method, takes the longest to
work.
Inappropriate for wounds that have become
infected.

2. Bacterial Load
Management
Antibiotic ?
Antiseptic ?

Bacterial burden in the wound bed (Melhuish 1994)

No antimicrobial treatment standard MWH

Observed

Bacterial count

No host reaction

Local
antimicrobial
treatment

Systemic
antibiotics and
local antimicrobial
treatment

Critically colonised
Contaminated

Colonised

Bacterial count rising = signs of

infection increase

Infected

3. Moisture Control
Moist wound healing is twice as fast as

dry wound healing

1962 Winter - on pigs
1963 Hinman and Maibach confirmed

Winter's work on human beings.