Nurindah D.

Utami
 Colostomy
◦ End colostomy
◦ Loop colostomy

 Ileostomy
◦ End Ileostomy
◦ Loop ileostomy

 End Loop ostomy

 Cecostomy
 Urostomy
 (A) End stoma (inset shows
everting maturation);
(B) double-barrel stoma: End
stoma and mucous hop-Koop
stoma; and
(F) fistula are divided and
brought through the same
incision (inset shows closed
mucus fistula sutured to
abdominal wall);
(C) loop stoma;
(D) decompressing blowhole
stoma;
(E) Bis Santulli stoma
 To provide fecal diversion for both elective
and emergent procedures

◦ Colonic obstruction
◦ Bowel perforation with peritonitis
◦ Trauma
◦ Protection of low colorectal/coloanal anastomosis
◦ Perianal sepsis
◦ Radiation proctitis
◦ Rectovaginal fistula
◦ incontinence
 Preoperative Counseling
◦ Stoma nurse/therapist
◦ Assuage anxiety
◦ Explain post op care

 Stoma site selection

◦ Visibility (pt. able to care for stoma)
◦ Colostomy vs ileostomy
◦ Assess pt supine, sitting, standing and bending forward
◦ Individualized
◦ Obese pts –better located in upper abdomen
◦ Avoid skin creases, bony prominences, scars, drain sites and belt
lines.
◦ Mark site
 Laparoscopic
colostomy/Ileostomy

 3 ports usually, SILS

 Operative time
usually ~ <1 hour
 Better selection of stoma site – as no midline
incision is involved
 Early post operative recovery
 Better pain control
 Short length of hospital stay
 Cosmetics
 20-41% of patients will have complications
 Nearly 50% of these will require a revision

 Ileostomy vs colostomy

 Early complications
◦ Ischemia, hemorrhage, stenosis, fistula and retraction.
Technical

 Late complications
◦ 6% -76% incidence
◦ Prolapse, obstruction, hernia and skin irritation
◦ Complication due to poor technique and poor care and
management.
◦ Could also be due to recurrent disease.
 2.3-17% incidence

 Ranges from harmless mucosal

sloughing to frank Necrosis

 Causes
◦ Aggressive stripping of
mesentery
◦ Stenotic fascia defect
◦ Extensive tension

 Assess depth of necrosis

 Necrosis beyond fascial defect

warrants immediate
reconstruction

 Consider End loop

 Mild hemorrhage common and self limiting.
◦ Usually mucosal.
◦ Apply pressure

 Active bleeding
◦ Implies failure to ligate a mesenteric vessel
◦ Identify and ligate prior to leaving OR
 2-14% incidence

 Could manifest early or late

 Ischemia is usual
underlying factor

 Other causes: -Infection

and retraction

 R/o Crohn’s or recurrent

malignancy

 Treat initially with dilation

 Definitive Stoma revision

 Separation along
mucocutaneous border

 Occurs to some extent in

many patient

 Caused by underlying
tension and or separation
of sutures

 Supportive care usually

resolve problem

 Could lead to eventual

stricture, serositis or
infection
 Incidence of 2-14.8%
 Peristomal abscess
◦ infected hematoma
◦ Stoma revision
◦ Foliculitis for mature stomas
 I &D

 Fistula may form from

Abscess

 Beyond immediate post op,

fistula formation or
infection could be signs of
recurrent Crohn’s disease
 1-6% for colostomy and 3-17% for
ileostomy

 Most common reason for re-

operation

 Tension:
◦ Tension
◦ Obesity
◦ Steroids use. Poor wound healing

 Can lead to leakage and severe

skin problem, more in ileostomy

 Convex stoma plate or use of

protective barrier helps

 Most eventually need revision

 2-26% incidence

 Seen mostly in transverse

loop colostomy (30%)

 May occur with parastomal

hernia

 Managed by reduction and

supportive care until
definitive surgery

 Convert to end colostomy if

need be
 “ It doesn’t matter if God Himself
made your ostomy. If you have it
long enough you have a 100% risk
of a parastomal hernia”
J Byron Gathright, 1996

 50% of patients

 Predisposing factors
◦ Stoma placement lateral to rectus
◦ Large stoma aperture
◦ Obesity
◦ Prior abdominal incisions
◦ Malnutrition
◦ Wound infection

 Minor cases- Abdominal binder

 Symptomatic – Repair with mesh,

Relocation
 Incidence 4.6-13% in early post op

 Causes
◦ Technical
◦ Too large fascial defect

 Rarely seen in mature stomas

 Signs of bowel obstruction

 Repair hernia with mesh

 3-42% Incidence

 Range from mild skin dermatitis to full-

thicknes skin necrosis and ulceration

 More common with illeostomy

 Skin Erosion from constant exposure to

stoma effluent

 Contact dermatitis
Contact Dermatitis
 Fungal infection

 Intervention
◦ Better fitting appliance
◦ Improve cleaning of peristomal skin
◦ Application of desents and skin barriers
◦ Anti fungals and antibiotics
◦ Stoma paste

Effluent Irritation
 Candida albicans infection

Foliculitis
 First described
associated with
Crohn’s in 1970

 Diagnosis mainly by
physical exam (80%)

 “Cookie cutter”
appearance

 Treatment conflicting
◦ Wound debridement
◦ Steroids injection
◦ Systemic therapy
 Granulomas are lumpy
lesions due to
inflammation in the
dermis.

 Stomal granulomas
may be due to:
◦ Granulation tissue (poor
wound healing and
infection)
◦ Bowel metaplasia (stomal
skin morphing into bowel
tissue)
◦ Crohn's disease
 In the last century, there have been
dramatic improvements in surgical
techniques for the creation of stomas

 Life with a stoma has also changed

dramatically

 The development of enterostomal therapy

and the improvement of ostomy
management systems have made life with a
stoma nearly as routine as life with an anus.
 “care and expertise are important in creating
intestinal stomas because some patients
must live with the technical result for the rest
of their lives”
Thank you