Determination of Colostomy Location

• the location of the colostomy must be

carefully selected preoperatively. It should
avoid any deep folds of fat, scars, and bony
prominences of the abdominal wall.
• If a sigmoid or descending colostomy is
contemplated, the most desirable position is
usually in the left lower quadrant of the
abdomen
 Type by Function
• (1) to provide decompression of the large
intestine,
• (2) to provide diversion of the feces.
 Decompressing colostomy
• A decompressing colostomy is most often
constructed for distal obstructing lesions
causing dilation of the proximal colon without
ischemic necrosis, severe sigmoid diverticulitis
with phlegmon, and for select patients with
toxic megacolon the procedure acts as a
bridge to defenitive operation for toxic
patients with benign diseaseand those with
malignant distal obstruction
 Types of Decompressing Stomas
• there are three types of decompressing
colostomies:
• (1) the so-called “blow-hole” decompressing
colostomy constructed in the cecum or
transverse colon
• (2) tube cecostomy
• (3) loop colostomy
• the tracheostomy tape is replaced by a plastic
rod that frequently has a suture through each
end so that it can be easily repositioned should
it be displaced (Fig. 9-3E).
• The wound is protected, and attention is
directed to the protruding loop of colon, which
is incised either longitudinally or transversely
to allow the best separation of the edges of
the colon (Fig. 9-3F).
• Full thickness of intestine is then sutured to
full thickness of skin with absorbable suture
material (Fig. 9-3G).
Closure of a Temporary Colostomy
• The most important consideration in dealing
with closure of a temporary colostomy is
deciding when it is safe to restore intestinal
continuity
• this can be done by formal manometric and
electromyographic studies or by giving the
patient a 500-mL enema and asking him or her
to hold it until he or she can comfortably walk
to a toilet and expel the enema.
• the closure is begun by making a
circumferential incision around the stoma,
including a small rim of skin (Fig. 9-4A). If the
stoma has been placed in the midline, the
midline incision may be opened on either side
of it to allow adequate mobilization
 DIVERTING COLOSTOMY
• A diverting colostomy is constructed to
provide diversion of intestinal content.
 Choices for Construction
• Although a completely diverting colostomy
can be made only by complete transection of
the colon, a well-constructed loop-transverse
or sigmoid colostomy may provide near
complete fecal diversion.
• If a colostomy is being performed proximal to
an obstructing lesion, to decompress the colon
and divert the flow of stool, it is critical that
the distal limb of the colostomy be vented to
the atmosphere and not closed.
• If the rectum and anus have been completely
resected, an end colostomy is created. If a
partial colectomy/proctectomy has been
performed
Construction of an End Colostomy (Fig. 9-5).

• 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 andm by axing 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 (Fig. 9-5A).
• 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 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.
 Long-Term Colostomy Management

• IRRIGATION
The advantages of irrigating the colostomy
include the absence of need for wearing an
appliance at all times, the provision of a more
regulated lifestyle, the reduced passage of
uncontrolled gas, less leakage of stool between
irrigations, and the general feeling of comfort
that some people experience after irrigating the
colostomy.
 Colostomy Complications
• GENERAL CONSIDERATIONS
• STOMA STRICTURE
• COLOSTOMY NECROSIS
• PARACOLOSTOMY HERNIA
• COLOSTOMY PROLAPSE
• COLOSTOMY PERFORATION
 ILEOSTOMY
Determination of Ileostomy Location

The location of the ileostomy must be carefully

chosen before surgery (Fig. 9-6). It should
avoid any deep folds of fat, scars, bony
prominences of the abdominal wall, the
inguinal folds, and the waistline crease.