Permanent or temporary fecal diversion is necessary for the surgical management of a wide variety of colorectal conditions including bowel obstruction, low pelvic anastomoses, poor sphincter function, difficult bowel regimen in spinal cord injury, rectal cancers and other pelvic malignancies, inflammatory bowel disease, perineal soft tissue infection, decubitus ulcers, and traumatic perineal injury.
Intestinal stomas carry significant social implications, and the prospect of having one commonly engenders very strong reactions from patients and their families. Many are initially filled with a sense of dread over “the bag.” However, for many patients, having an intestinal stoma can dramatically improve quality of life and allow them to regain control over their lives. For example, those with poor bowel function causing frequency, urgency, or incontinence may find themselves spending hours each day in the bathroom, fearful of leaving the house, and anxious when they are not near a bathroom. An intestinal stoma can allow them to reintegrate into normal life. While a well-functioning and well-placed stoma is compatible with an excellent quality of life, a poorly constructed stoma that cannot be reliably pouched can wreak havoc on a patient’s life.
The goal of this chapter is to serve as a resource for surgeons who create and close stomas, so that their patients can have the best possible functional outcome. The chapter discusses preoperative planning and decision-making, technical details of how to create intestinal stomas, and management of stoma complications.
The main technical principles for optimal stoma construction include proper stoma siting on the abdominal wall, adequate mobilization of the bowel, preservation of blood supply, and eversion of the bowel wall during stoma maturation. The important nontechnical considerations include providing education and support for patients with stomas, and knowing how to manage stoma-related complications.
Stoma construction requires attention not only to the bowel anatomy but also the abdominal wall anatomy. The most ideal segment of colon to use for a colostomy is the descending colon or proximal sigmoid colon, as using the distal end of a floppy sigmoid colon increases the risk of prolapse. For ileostomy creation, the most distal segment of small bowel that will reach through the abdominal wall should be used. Often it is necessary to ligate mesenteric vessels for oncologic or mobilization purposes. Ensuring that the marginal artery is intact for colostomies and that the arcade of ileal vessels is intact for ileostomies is critical for preventing stoma ischemia. The length and thickness of the mesentery affect whether the stoma will reach through the abdominal wall adequately to create a stoma that is not under tension. A short, thick mesentery may require more extensive mobilization to create a good stoma. Abdominal wall thickness and contour are important considerations during stoma creation. Thick abdominal walls require more mobilization of the bowel so that the stoma will reach through the abdominal wall without tension. Creases and scars on the abdominal wall ...