Chapter 9. Intestinal Stomas

An intestinal stoma is an opening of the intestinal or urinary tract onto the abdominal wall, constructed surgically or appearing inadvertently. A colostomy is a connection of the colon to the skin of the abdominal wall. An ileostomy involves exteriorization of the ileum on the abdominal skin. In rare instances, the proximal small bowel may be exteriorized as a jejunostomy. A urinary conduit involves a stoma on the abdominal wall that serves to convey urine to an appliance placed on the skin. The conduit may consist of an intestinal segment, or in some cases a direct implantation of the ureter, or even the bladder, on the abdominal wall.

Information about the types and numbers of stomas constructed, complications of stomas, and resultant impairment of an individual's life has been limited because the diseases for which stomas are constructed are not mandated as reportable in the United States. Therefore, the United Ostomy Association of America (UOAA, www.uoaa.org), formerly the United Ostomy Association, a voluntary group of 40,000 members with stomas of various types, undertook the mission of collecting data from patients in the United States and Canada who have an intestinal stoma. A review of 15,000 such entries shows the peak incidence for ileostomy construction owing to ulcerative colitis to occur in persons between 20 and 40 years of age, with a lower peak but in the same age range for patients with Crohn's disease. The second largest peak represents colostomies constructed because of colorectal cancer, and this peak is in patients 60–80 years of age. When complications were analyzed according to original indication for surgery, we found that many patients knew that they had complications but were not aware of the exact nature of the complication. Postoperative intestinal obstruction occurred in all categories of disease, as did retraction of the stoma and abscess formation. There was a preponderance of hernia formation in patients who had surgery for colorectal cancer, whereas abscess, fistula, and stricture formation were the major complications in the patients with Crohn's disease. As new surgical procedures are devised, a justification for their utilization is often the reduction of the level of handicap that exists among patients who have had construction of a conventional ostomy. The UOA survey revealed that patients resumed household activities 90% of the time, vocational activities 73% of the time, social activities 92% of the time, and sexual activities 70% of the time. It is taken into account that patients who have proctectomy for cancer frequently lose their sexual function because of autonomic denervation and not because of the presence of a stoma.

Changes that have improved the quality of life of the patient with a stoma include the development and availability of improved stoma equipment. Specialized surgical techniques, some of which are described in this chapter, have been developed that facilitate the subsequent maintenance of an ostomy. In addition, specialized nursing techniques applied both preoperatively and postoperatively have enhanced the care of the patient with a stoma. The involvement of a Certified Wound Ostomy Continence Nurse (CWOCN) in the care of patients with stomas is critical.

The overall incidence of stoma construction appears to be decreasing and will probably continue to do so. There are now fewer abdominoperineal resections for cancer because of the advent of new surgical techniques, especially the use of stapling devices, as well as an increased use of local treatment for selected rectal tumors. The incidence of permanent ileostomies is decreasing because of the popularization of sphincter-saving procedures for patients with ulcerative colitis and familial polyposis. The surgical procedures that eliminate permanent stomas, however, have resulted in an increasing use of temporary loop ileostomies.

Each type of stoma is associated with a particular spectrum of complications, but some problems are common to all intestinal stomas. The specific ones are dealt with under each category of stoma. A common complication, regardless of the stoma type, is destruction of the peristomal skin, which is usually caused by poor location or construction of the stoma. In addition to the acute maceration and inflammation of the skin, pseudoepitheliomatous hyperplasia may arise at the mucocutaneous border of stomas subjected to chronic malfitting appliances. Appearance of a fistula adjacent to a stoma usually indicates recurrence of Crohn's disease. One of the difficult complications to handle, especially in an obese patient, is improper location of the stoma, which prohibits maintenance of the seal of an appliance. A stoma buried in a skin fold, or a flush stoma, can create devastating peristomal skin problems. A special problem arises in the patient who has portal hypertension because the construction of a stoma results in the creation of a portosystemic shunt, and varices can form in the peristomal skin.

Other common problems include the need for precautions with medications, especially time-released enteric medications, which may pass through a shortened intestinal tract unabsorbed. Laxatives also can be devastating to patients with no colon or with a proximal colostomy. In some cases, the ostomy patient has chronic difficulty maintaining proper fluid and electrolyte balance, and diuretics in these patients can be especially difficult to manage. The usual intestinal preparations prior to diagnostic testing should be altered for the patient with an intestinal stoma.

Many potential stoma complications can be avoided by proper preoperative marking and counseling. The stoma location should be chosen and marked preoperatively, even if there is only a remote possibility of the need for an intestinal stoma during the operative procedure. Surgeons who perform intestinal stomas should be well versed in stoma care and management of stoma complications. The value of collaboration with an enterostomal therapist (CWOCN) cannot be overstated. Patients should meet with the CWOCN preoperatively, and the surgeon and CWOCN should discuss the selection of potential stoma sites together prior to operation.

The most common indication for fashioning a colostomy is cancer of the rectum. Since a colostomy is an opening of the large intestine with no sphincteric control, its location would obviously be better on the abdominal wall than in the perineum, where an appliance cannot be maintained. 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.

Type by Anatomic Location

Traditionally, the type of colostomy has been categorized by the part of the colon used in its construction. The most common type has been called an “end-sigmoid” colostomy. However, if the origin of 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. Therefore, an “end-descending” colostomy is usually preferable to an end-sigmoid colostomy. Other types of colonic stomas include the transverse colostomy and cecostomy. 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.

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. The site is chosen by evaluating the patient in the standing, sitting, and supine positions. Often abdominal skin and fat folds are only noted with the patient in the sitting position. A stoma faceplate is applied to the abdominal wall with its medial margin at the midline; care is taken to not overlay any fold, scar, or prominence; and the stoma site is marked. The inguinal fold and waistline fold should be avoided. If a sigmoid or descending colostomy is contemplated, the most desirable position is usually in the left lower quadrant of the abdomen. However, if the patient is obese, it may be preferable to site the colostomy in the left upper quadrant so that it is visible to the patient and not trapped on the undersurface of a panniculus. If a distal transverse colostomy is planned, the left upper quadrant is usually the preferable site. Please refer to the section on determination of the ileostomy location for more details regarding stoma site selection.

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, and (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. Alternative treatments exist for these conditions: total abdominal colectomy with ileostomy or ileorectal anastomosis; segmental colectomy with construction of end colostomy; segmental colectomy with primary anastomosis; and segmental colectomy with intraoperative colonic lavage and primary anastomosis with temporary diverting loop ileostomy. However, temporary decompressing stomas are still useful and safe. The procedure acts as a bridge to definitive operation for toxic patients with benign disease and those with malignant distal obstruction. The disadvantages of a decompressing stoma is that it does not provide definitive management of the disease process and thus the patient often requires subsequent operation, and it does not necessarily provide complete fecal diversion and thus carries the risk of potentially fatal sepsis if there is distal perforation.

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, and (3) loop colostomy.

Cecostomy and “Blow-Hole” Colostomy.

A cecostomy should be constructed only rarely because it is difficult to manage postoperatively. It should be reserved for the severely, acutely ill patient with massive distention and impending perforation of the colon. This is seen most often with distal obstructing cancer or in some of the pseudo-obstruction syndromes seen in elderly or immuno-compromised patients. Because these operations are done on an urgent basis and the abdomen is usually distorted by intestinal dilation, the choice of site for an incision is over the dilated cecum. The location of this incision or of an intended decompressing transverse colostomy can be selected by placing a marker on the umbilicus when an abdominal film is obtained.

The construction of a blow-hole cecostomy or transverse colostomy (Fig. 9-1) is carried out by making a 4–6 cm transverse incision over the most dilated part of intestine and then placing a series of interrupted, seromuscular, absorbable sutures between the peritoneum and the seromuscular layer of the bowel to be decompressed. This should be done through an incision sufficient to allow subsequent incision of the intestine and suturing of the intestine to the skin. The bowel wall will be very thin, and it is not unusual to have leakage of gas as the sutures are being placed. A disadvantage of a cecostomy or loop colostomy done through a small incision is that one cannot evaluate other parts of the colon for potential ischemic necrosis due to massive dilation.

Once the first layer of sutures has been placed and the intestine is sealed from the remainder of the abdominal cavity, needle decompression of the gas-distended viscus is performed to reduce the tension on the intestinal wall. When this procedure is completed, a second layer of absorbable sutures is placed between the seromuscular layer of the intestine and the fascia of the abdominal wall. Subsequently, the colon is incised, usually with release of a large amount of liquid and gas. The full thickness of intestine then is sutured to the full thickness of skin, again with absorbable sutures, and an appliance is placed over the stoma. Postoperatively, it is not unusual for there to be significant inflammation in the abdominal wall around such a stoma, and after a period of weeks, significant prolapse may occur. Therefore, these stomas should be used for short periods of time, with definitive resection performed as soon as possible.

A tube cecostomy (Fig. 9-2) is constructed by making an incision similar to that used for a “blow hole” colostomy, by formal laparotomy, or by laparoscopy. A purse-string suture is placed in the cecal wall, and a large mushroom-tipped or Malecot catheter is placed in the cecum. The purse-string suture secures the catheter. Usually a second purse-string suture is placed, and the tube is brought through a right lower quadrant incision. The cecum then is sutured to the peritoneum of the abdominal wall. The advantage of this stoma is that there is less chance of prolapse. The major disadvantage is that the tubes usually become blocked with feces, drain poorly, and sometimes leak stool adjacent to the drain. Because of all their disadvantages, tube cecostomy and blowhole colostomies are rarely performed at present.

Loop-Transverse Colostomy.

A loop colostomy using the transverse colon (Fig. 9-3) or left colon can be used as a decompressive stoma, although it will usually completely divert the flow of stool away from the distal colon and can thus be considered a diverting stoma. Occasionally, the posterior wall of the stoma recesses far enough below the wall of the abdomen so that stool can enter the distal loop, although this is uncommon. These stomas are constructed for reasons similar to those described for the blow-hole type stoma and to provide temporary diversion for protection of complicated distal anastomoses. The other advantage is that when properly constructed, a loop colostomy can serve as a long-term stoma. The incidence of prolapse is not prohibitive. Parastomal hernias can occur if the fascia is not closed tightly enough, and these stomas usually cannot be regulated by irrigation techniques.

The site can be chosen for this stoma in an emergency situation as previously described, but it should be marked electively on the abdominal wall in preparation for potential construction in patients who are to have low colorectal anastomoses or in those in whom it is anticipated that an inflammatory reaction will be encountered and will require temporary diversion of intestinal contents as a safeguard against contamination from a leaking anastomosis. This occurs occasionally in patients with severe diverticulitis. In an elective situation, the stoma can be placed through the rectus muscle either on the right or left side, depending on later intentions of closing or resecting the colostomy site in continuity with a cancer operation, or it can be brought through the midline (Fig. 9-3A). If performed in conjunction with a midline incision, a midline colostomy site may be suboptimal because of difficulty with placing the ostomy appliance over the fresh incision.

Construction of loop colostomy requires the colon to be mobile enough to be brought to the level of the abdominal wall (Fig. 9-3B). If this cannot be done or if the colon is so massively dilated that loop colostomy is not safe, one should resort to the use of a blow-hole colostomy as previously described, in which only one wall of the intestine is utilized and tension on the mesentery is avoided. A transverse loop colostomy can be constructed by placing a tracheostomy tape or soft latex drain around the colon at the site chosen for the colostomy. The transverse colon at this site is usually dissected free of the overlying omentum in the embryonic peritoneal fusion planes. The tracheostomy tape and colon are brought through an avascular window in the omentum to allow better sealing between the colon and the abdominal wall (Figs. 9-3B and 9-3C). The fascia is then closed on either side of the loop of colon tightly enough to allow snug passage of one fingertip (Fig. 9-3D).

The skin is then snugly closed, on either side of the loop of colon. 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). If this stoma is properly constructed, the posterior wall will bulge upward, providing the desired diversion as well as decompression. An appliance is applied either over the rod or beneath the rod, depending on the tension of the stoma.

If there is a possibility that the colostomy may become permanent, it may be advantageous to divide the colon with a stapler and create a “divided end-loop” stoma in the manner of Prasad and Abcarian. The proximal colon is matured as an end colostomy, and a corner of the distal limb opened and matured as a mucus fistula in the same stoma incision to vent the distal colon (see Fig. 9-9, construction of separated [divided end-loop] ileostomy). The stoma size is typically smaller than a loop colostomy and the tendencies to prolapse or retract may be lessened.

In the postoperative period, the appliance is emptied or changed as necessary, and the wound is kept clean. The rod is usually left in place for several days and then is easily removed. The colostomy appliance is fashioned as necessary as the contour of the stoma and skin opening change. Patients with this type of stoma usually are not taught to irrigate, because irrigation is infrequently successful. After the immediate postoperative period, the patient usually is instructed to empty the appliance as necessary and to change the entire appliance every 3 to 4 days, depending on the condition of the skin and the ability to maintain an adequate seal of the appliance to the skin.

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. Distal integrity and adequacy of sphincter muscle function must be carefully evaluated before closure of the stoma is undertaken. The reason for constructing the stoma initially must be taken into account, and contrast studies and endoscopy should demonstrate clearly that the original reason for fecal diversion no longer exists.

Adequate function of the anal sphincter must be demonstrated before the temporary colostomy is closed. 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. If the sphincter does not work and cannot be repaired, the patient will be better off with a properly constructed end colostomy than with attempts to preserve a nonfunctional sphincter. Once it is decided that it is safe to close the colostomy, the procedure should be undertaken with the same skill and precaution as that required for a colon anastomosis (Fig. 9-4). The complication rate following colostomy closure is not insignificant, and is cited by some authors as a reason to avoid diverting colostomy construction at all costs. However, as with all issues in medicine, careful consideration of the potential risks and benefits of the procedure in the individual patient should be made prior to deciding on whether or not fecal diversion is indicated.

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. The circumferential incision is deepened until the peritoneal cavity is entered and the colon and surrounding omentum can be separated from the abdominal wall. The colon is then brought through the incision, and the serosal surface is clearly defined circumferentially (Figs. 9-4B and 9-4C). This involves resecting omentum and fibrofatty tissue from the serosal surface. Once this step is completed, the stoma is ready for closure, which can be accomplished by a linear stapling device (Figs. 9-4D and 9-4E), by a hand-sutured closure (Figs. 9-4F and 9-4G), or if the bowel has been compromised in any way, by complete transection of the colon and construction of a formal end-to-end anastomosis. Caution must be taken to ensure that no small intestine has been injured and that no significant bleeding has been left unattended. Once this has been accomplished, the colon is returned to the abdominal cavity and the abdomen is closed. Usually the skin itself is left open for delayed primary closure.

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 (eg, obstructing carcinoma, diverticulitis, leaking anastomosis, or trauma), or because of destruction or infection of the distal colon, rectum, or anus (eg, Crohn's disease or failed anal sphincter reconstruction).

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. Stool and flatus will move preferentially toward the low-pressure side of any pressure gradient, and this usually means that it will flow into the stoma appliance, which is at atmospheric pressure, rather than into the distal bowel. However, patients who have loop stomas must be counseled that if the stoma appliance becomes full, stool and flatus can be forced distally because the pressure gradient now favors passage of intestinal contents into the distal limb of intestine. This discussion should take place prior to discharge from the hospital, as this phenomenon usually occurs late at night after the patient has slept and not emptied their appliance. The first passage of flatus or stool per anus in a patient who was under the impression that their fecal stream was completely diverted can be sufficiently alarming as to prompt an emergent call to the surgeon, usually in the wee hours of the morning.

There are some situations in which the diverting loop colostomy fails to divert the flow of stool because the stoma retracts into the abdomen and stool flows into the distal colon. Patients who are profoundly malnourished may be at increased risk of this complication. In addition, stomas that are constructed under tension may also be prone to retraction.

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 distal limb is closed and there is a complete obstruction distal to the colostomy, this will create a closed loop obstruction, and there is a substantial risk of distention and perforation.

If the rectum and anus have been completely resected, an end colostomy is created. If a partial colectomy/proctectomy has been performed, and an anastomosis is not constructed, an end colostomy is created and the distal bowel is closed (as in a Hartmann resection) or brought to the skin as a mucus fistula. The decision about whether to create a mucus fistula or to close the distal segment will hinge on whether there is concern regarding distal obstruction, the length of the distal segment, and the integrity of the distal segment. For example, in a patient undergoing sigmoid colectomy and colostomy for complicated diverticulitis, it is reasonable to close the rectal stump providing that proctoscopy reveals a normal rectum. Conversely, in a patient undergoing abdominal colectomy and ileostomy for toxic colitis, it may be preferable to bring the distal sigmoid to the skin level as a mucus fistula to avoid rectal stump blowout. A mucus fistula may be constructed as a separate stoma, opening just a corner of the closed end as a small vent. Alternatively, the mucus fistula can be constructed so that the small vent is matured (“mature” means that the colonic wall is sutured primarily to the skin) in a corner of the abdominal wall opening used to create the proximal stoma in the manner of Prasad and Abcarian (the “divided end-loop” stoma). This facilitates care in that the patient has only one stoma appliance, and facilitates stoma closure because both limbs of the bowel are located adjacent to one another. The old operation of the so-called Divine double-barreled colostomy should be abandoned because the adjacent full-diameter stomas make application of an appliance very difficult.

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 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 (Fig. 9-5A).

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 (see Chap. 40). 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 (Fig. 9-5B). 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 incised longitudinally (Fig. 9-5A). The opening is then dilated, and the closed end of the colon is pulled through the abdominal wall (Fig. 9-5C). 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. After the wound is closed and protected, attention is directed to completing the colostomy (Figs. 9-5C, 9-5D, and 9-5E). 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.

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 appliance, which need not be sterile, is held in place with the skin adhesive of the appliance. Tincture of benzoin or other similar adhesives 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 stoma 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 some 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.

Long-Term Colostomy Management

The patient with a properly constructed, well-functioning colostomy may elect to irrigate once a day or every other day and to wear only minimal appliance over the stoma or simply cover it with a gauze in the intervening period, although the patient should be instructed to always carry an appliance should episodes of diarrhea occur. Simple appliances exist to allow absorption of mucus and deodorized passage of gas during the period between irrigations, if the patient elects to irrigate.

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. The disadvantages are that it is a time-consuming ritual and that some people feel discomfort when the bowel is distended during irrigation. Irrigation carries a minimal risk of perforation. Absorption of water during the irrigation process can be significant, and the patient with an irritable bowel syndrome will usually not achieve adequate control by irrigation and may be frustrated by attempting to do so. The principle of irrigation is based on the fact that the distal colon displays a few mass peristaltic motions each day and that these can be stimulated by distention of the intestine. It has been shown that 80% of people who irrigate daily can depend on the discharge from the colostomy being one or two movements per day. Poor results from irrigation can be anticipated if the patient has irritable bowel syndrome, a peristomal hernia, irradiated bowel, inflammatory bowel disease, poor eyesight, reduced manual dexterity, or simply fear of dealing with the intestine at the abdominal wall. A preoperative history of irritable bowel syndrome is most important because these patients must never be promised regular function of their colostomies.

The technique of irrigation, usually performed in the morning, uses a cone tip that fits into the stoma only enough to provide a seal and to allow the instillation of 500–1000 mL of water. It is not necessary to dilate the stoma, and a finger is inserted only periodically to determine the direction for placement of the cone tip. Once the water has been instilled, a drainage bag is applied, and the individual can proceed with morning chores while the colostomy empties in response to the stimulation. Between irrigations the patient usually wears a security pouch, which permits passage of gas through a charcoal filter and provides a small pad to absorb any mucus normally secreted by the colonic mucosa.

Ischemia or infection causing partial loss of the intestinal wall or separation of the stoma from the skin can result in stricture of the colostomy. A tight stricture makes irrigation impossible and frequently causes the patient significant discomfort because of the resulting partial obstruction. Because the stricture is always at skin level, its correction is simple and no patient should suffer because of a colostomy stricture.

Colostomy Complications

General Considerations

A common problem experienced by the patient with a colostomy is irregularity of function, which most often is related to irritable bowel syndrome or irradiation of the intestine. Many problems are related to improper location of the stoma, which allows seepage of mucus and maceration of the skin because an appliance seal cannot be adequately maintained. Parastomal hernia formation is common, and prolapse less so. Patients experience episodes of diarrhea and constipation depending on their underlying disease, dietary habits, and episodic infections. Patients with colostomies can be troubled with gas and odor problems because there is no sphincter around the stoma and gas can be passed uncontrollably. However, most appliances today are odor-proof, making odor only an issue during changing or emptying the appliance. This problem is usually regulated by diet, and in some cases by administering mild antidiarrheal agents when social activity dictates. Minimal bleeding around a stoma is common because the mucosa is exposed to environmental trauma. Of course, prolonged bleeding should be evaluated to be sure that there is not a recurrence of the primary disease process. The same is true of cramps and diarrhea. These can be acceptable occasionally, but anything of a prolonged or severe nature must be evaluated.

Evaluation of the UOA data registry shows that hernia formation is the most common complication of end colostomy, with obstruction, abscess, and fistula presenting less frequently. Of all the complications that occur, few require surgical correction. Fecal impaction can occur with a colostomy and can be managed by irrigation and laxatives. Digital disimpaction is rarely required.

Stoma Stricture

In the past, it was believed unsafe to open the colon and suture the edges to the skin at the time of initial operation and stomas were thus opened in a delayed fashion. Serositis developed because the serosal surface of the exposed colon was irritated by exposure to air. After the exposed end of the colon was opened, it would take some time for the mucosa to eventually anneal to the epidermis. This process was called “maturation” of the colostomy. Strictures were common because the inflammation associated with serositis often led to fibrosis. Surgeons eventually learned to open stomas immediately at the time of initial operation and suture the intestinal wall to the skin. For historical reasons, this maneuver is still referred to as immediate “maturation” of the stoma.

Another cause of colostomy stricture is ischemia, usually as a result of resection of too much mesentery during construction of the stoma, or from inadequate mobilization and tension. Repair may require a simple local procedure if the stricture is focal at the skin level, or revision of the stoma via a transabdominal approach if the stricture involves a longer segment.

Colostomy Necrosis

Ischemia or necrosis of the colostomy results from excessive resection of colonic mesentery, excessive tension on the mesentery leading to the stoma, creation of a fascial opening too small to accommodate the bowel and its mesentery, or poor perfusion due to low-flow states. The blood supply to an end colostomy is unidirectional, without collaterals; therefore, it will be most sensitive to changes in visceral perfusion. If the necrosis is limited to the area of the stoma anterior to the fascia, it may be observed carefully, and stoma revision performed electively at a later date, if necessary. If the necrosis extends into the peritoneal cavity, the abdomen should be explored and the stoma recreated. In some cases it is difficult to ascertain the extent of necrosis. Gentle flexible endoscopy via the stoma is an accurate method to determine the level of necrosis. Occasionally it may be possible to use a glass test tube and light to make this determination, but endoscopy is more reliable.

Paracolostomy Hernia

Paracolostomy hernia is a frequent complication of colostomy creation, even when all is done according to acceptable surgical principles. The creation of an abnormal opening in the abdominal wall that is then subjected on a daily basis to the pressures of Valsalva maneuvers may predispose the patient to suffer a gradual enlargement of the fascial opening. The relative weakness of the posterior rectus sheath in the inferior abdominal wall, with the potential space that exists alongside the rectus muscle, may also predispose the patient to develop a peritonealized sac in the rectus sheath without a large fascial defect. Although it is surgical dogma to create stomas in the rectus sheath to lessen the development of parastomal hernias, there are no definitive data to support this contention.

Asymptomatic parastomal hernias should be observed because the rate of recurrence after repair or relocation of the stoma is high. Patients should be counseled to seek immediate medical attention if they develop symptoms or signs of intestinal incarceration in the hernia. Symptomatic hernias may be relocated or repaired, although no technique has proven to be reliably successful. Local suture repair often fails, and although broad fascial mesh repair appears to be a more rigorous method of repair, there is still a substantial risk of recurrence and the added concern of mesh infection. Laparoscopic repair with intraperitoneal mesh is being used more frequently, although it would appear to offer no advantage over open mesh repair other than a potential reduction in wound complications and short-term postoperative recovery. Some surgeons are placing mesh in the abdominal wall at the time of permanent stoma creation as prophylaxis against hernia formation, but the experience is too preliminary to make definitive assessments of the safety and efficacy of this technique.

Colostomy Prolapse

Prolapse of the colostomy is seen most often with the transverse loop colostomy. This is probably the result of several factors, most prominent being the lack of fixation of the transverse mesocolon to the retroperitoneum, and the size of the fascial opening necessary to bring both limbs of the colon and the mesocolon to the skin level. If the transverse loop colostomy is constructed to decompress a dilated colon, the fascial opening may need to be large initially, and then be excessive once the colon decompresses and thus predispose the colostomy to prolapse later. The surgical treatment of transverse loop colostomy prolapse is difficult, and the best treatment is to rid the patient of the primary disease and restore intestinal continuity. If this is not possible, the loop colostomy should be converted to an end colostomy with mucous fistula, or a divided end-loop colostomy, with concurrent tightening of the fascial defect.

Prolapse of an end colostomy can be managed by a local procedure in which the mucocutaneous junction is disconnected, the redundant colon resected, and the mucocutaneous junction recreated. Concurrent hernia repair can be performed as indicated.

Colostomy Perforation

Perforation of the colon just proximal to the stoma most often occurs during careless irrigation with a catheter or during contrast x-ray studies when a catheter is placed in the colostomy and a balloon is inflated. This occurrence represents a surgical emergency and must be dealt with by laparotomy and reconstruction of the colostomy with adequate drainage, if there is significant fecal or barium contamination. Cases of mild inflammation with extravasation of air can only be managed with antibiotics and localized drainage, and surgery can be avoided.

An ileostomy is an opening constructed between the small intestine and the abdominal wall, usually by using distal ileum, but sometimes more proximal small intestine. The stoma is constructed on a permanent basis for patients who require removal of the entire colon, and usually the rectum, for inflammatory bowel disease, either Crohn's disease or ulcerative colitis. The use of a loop ileostomy is becoming more frequent because of the complex sphincter-preserving operations being performed for ulcerative colitis, familial polyposis, and rectal cancer. For these operations, it is necessary to have complete diversion of intestinal flow while the distal anastomosis and neorectum are allowed to heal and adapt. The loop ileostomy is also useful in cases where multiple or complex anastomoses must be performed distally, usually for Crohn's disease or diverticulitis. As sphincter-preserving operations are used more often, diminishing numbers of permanent ileostomies will be constructed, but similar principles and techniques will be utilized in constructing the temporary loop ileostomies. The same principles used in constructing an ileostomy can be applied to the construction of a urinary conduit.

The surgical construction of an ileostomy must be more precise than that for a colostomy because the content is liquid, high volume, and corrosive to the peristomal skin. Therefore, the stoma must be accurately located preoperatively, and it must have a spigot configuration to allow an appliance to seal effectively and precisely around the stoma.

Various types of ileostomies can be constructed. The most common has been the end ileostomy, using a technique popularized by Brooke and Turnbull. The loop ileostomy is used, as described, to divert stool away from diseased areas or surgical anastomoses distally. The loop-end ileostomy is a stoma that uses the principles of a loop ileostomy but is constructed as a permanent stoma when the mesentery and its blood supply need special protection. The continent ileostomy, a technique devised by the Swedish surgeon, Nils Kock, is an internal pouch that does not require the wearing of an external appliance. The urinary conduit is a stoma constructed of small intestine to provide a conduit to the outside for the urinary tract.

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. The site is chosen by drawing a vertical line through the umbilicus and a transverse line through the inferior margin of the umbilicus and applying a disk the size of a stoma faceplate (approximately 8 cm in diameter) to determine the location. The disk is allowed to abut on both of the lines in the right lower quadrant, and the site is marked with ink. The patient is then brought to an exaggerated sitting position and allowed to turn in various directions to be sure the site is adequate in all positions, and there are no creases or skin folds created by changes of position. If so, the location should be adjusted to bring the stoma to the summit of the infraumbilical fat fold to be sure that there is clearance for fitting of an appliance. When the patient is in the operating room and anesthesia has been administered, the chosen site is scratched with a fine needle before preparation of the abdominal skin is carried out. The majority of complications arising from ileostomies can be avoided by taking these precautions in marking the site for the stoma preoperatively. Even in cases in which the use of a stoma seems remote, the precaution of marking the site preoperatively should be taken. In addition, whenever possible, patients should be seen by a CWOCN and an ostomy visitor so that they can be given information about the stoma and its care. The visit from an ostomate (someone who has done well with a similar stoma) is helpful because it allows the patient to know that the surgery can be survived and that life can be continued productively and normally with the presence of a stoma. The discussion should avoid excessive details about types of equipment and types of stoma problems during the postoperative period, as this information can be overwhelming to a patient facing complex surgery, often life-threatening disease processes, and the concept of having a stoma.

When an ileostomy is anticipated, the choice of abdominal incision is a left paramedian skin incision, slanting the incision to the midline fascia (Fig. 9-6A). This gives the advantage of opening the fascia through the midline to provide a simple, effective closure and at the same time preserve all the right lower quadrant peristomal skin for maintenance of the appliance seal.

End Ileostomy

The construction of the ileostomy begins early in the operative procedure. When the colon is mobilized for colectomy, as is the usual case when an ileostomy is to be constructed, full mobilization of the mesentery of the distal ileum should be carried out (Fig. 9-6D). This is an important and often neglected part of the procedure. There is an embryonic fusion plane of the mesentery of the small intestine to the right posterior abdominal wall. The ileum can be elevated on this mesentery up to the duodenum, allowing extreme mobility of the terminal ileum. The ileocolic artery is then transected as part of the colectomy, and the remaining blood supply to the small intestine is preserved (Fig. 9-6C). It is important to preserve the most distal arcade of vessels and mesenteric tissue on the ileum at the segment of the intended ileostomy. This blood supply is prepared early in the operative procedure so that if there is any question about the vascularity of the distal ileum, it will be known long before the abdomen is closed. The preservation of this distal bit of mesentery and fat on the ileum sometimes appears to cause excess bulk around the ileostomy, but this fat soon atrophies, allowing a well-vascularized stoma of appropriate size. The intestine is transected with a linear-cutting type of stapling instrument so that the end of the ileum can be easily pulled through the abdominal wall without increased risk of contamination. This can, of course, also be accomplished by suturing the end of the ileum.

When the intestinal resection has been completed, an opening is prepared in the right lower quadrant of the abdominal wall at the previously marked site (Fig. 9-6B). It is important to return the abdominal fascia to its natural position prior to making the stoma opening so that the fascia does not impinge upon the stoma when closed. This is of significant concern during situations when a Pfannensteil incision is used to accomplish the colectomy, as is common with hand-assisted laparoscopic colectomy. The round configuration of the stoma is maintained by placing traction clamps on the dermis, fascia, and peritoneum. A 3 cm disk of skin is excised, and a longitudinal incision approximately 3–4 cm long is made through all layers, with each layer being retracted with small retractors as the incision is deepened. If the patient is obese, some fat can be excised, although this is not mandatory. The fascia is incised longitudinally as well, and frequently a small lateral notch is placed on each side. The muscle is separated, and any vessels are coagulated. The posterior fascia and peritoneum are then incised.

The size of the stoma opening should be approximated based on estimates of the diameter of the intestine and mesentery to be brought through, and the thickness of the abdominal wall. The geometric shape of the stoma opening should also be determined by these factors. If the abdominal wall is thin, the opening in the abdominal wall can be cylindrical. If the abdominal wall is thick, the shape of the incision should be pyramidal, with the fascial opening larger than the skin opening to accommodate the amount of mesentery that will be brought through at the fascial level. The oft-used “two finger” rule to gauge the size of the stoma opening is usually not adequate to account for all of the above considerations.

The ileum is brought through the abdominal wall to the intended length, usually about 6 cm (Fig. 9-7B). If the abdominal wall is thick, this maneuver may be difficult to accomplish. It may be helpful to use a small plastic wound protector/retractor through the stoma to facilitate passage of the intestine through the abdominal wall. Alternatively, the fat and skin can be raised off of the fascia as a flap, the intestine brought through the muscle and fascia first, and then subsequently brought through the fat to skin level. The mesentery of the distal ileum may be sutured to the right lateral abdominal wall, although there are no data to prove that this maneuver reduces the incidence of intestinal obstruction, stoma prolapse, or stoma retraction.

The abdomen is then closed. The incision is protected, and attention is directed to the ileostomy where the staple line or suture line is excised, verifying the adequacy of blood supply. If the blood supply of the stoma is questioned, more of the ileum should be resected.

The next objective is to make a protruding, everting stoma. This is accomplished by placing 3-0 chromic catgut sutures through the full thickness of intestine, the seromuscular area of the ileum at the base of the stoma, and the dermis (Fig. 9-7E). Sutures through the skin should be avoided, because any stellate scarring will prevent the maintenance of the required seal of the appliance. Eight of these sutures should be placed, one in and one between each quadrant; and as traction is applied after they are all placed, the stoma should evert nicely.

After the stoma is completed, an ileostomy appliance is applied. A simple appliance in which the skin barrier can be cut to the size of the stoma is best. In the immediate postoperative period, if there is any question about leakage around the appliance or malfitting of the appliance, it should be changed and the skin cleaned immediately. It is important to preserve the integrity of the peristomal skin, and all the nursing staff should be aware of the importance of this. The leaking appliance should not be left for changing by the next shift or for the CWOCN the next morning, because the skin can be damaged during this waiting period.

Loop Ileostomy

The loop ileostomy stoma is constructed when both diversion of the intestinal flow and decompression of the distal intestine are required. The location is chosen exactly as one would choose the site for an end ileostomy. The construction can then follow one of two techniques. The technique popularized by Turnbull at the Cleveland Clinic involves choosing the site in the intestine for the intended loop ileostomy and then placing orienting sutures proximally and distally (Fig. 9-8A). A loose suture with one knot can be placed proximally and one with two groups of knots distally. It is important to maintain this orientation as the stoma is constructed.

The opening in the abdominal wall is made the same as for an end ileostomy (Fig. 9-6B), but the loop of intestine is drawn through this abdominal opening by a tape placed through the mesentery and around the intestine (Fig. 9-8A). Some surgeons recommend orienting the proximal functioning loop in the inferior position, placing a partial twist on the loop of intestine. Although this may help configure the spout of the ileostomy so that ileal effluent is less likely to undermine the appliance, this maneuver may be associated with a higher rate of intestinal obstruction. In massively obese patients with a shortened mesentery, it is necessary to make a pyramidal configuration of the opening in the abdominal wall, with the internal opening being much larger than the external opening at the skin. If this maneuver is used, it is best to place a row of tacking sutures between the peritoneum and the loop of intestine to maintain position and orientation. Once the loop is drawn through the abdominal wall, the abdomen is closed, maintaining the orientation of the loop. It is usually not necessary to fix the mesentery of the ileum to the abdominal wall when constructing a loop ileostomy. The wound is then protected, and attention is directed to the stoma.

The tape is replaced by a small plastic rod, which is commercially available (Fig. 9-8B). It is not sutured to the peristomal skin, but it often has a heavy suture tied around each side so that should the rod dislodge, it can be drawn back through the mesentery rather than being pushed through, with risk of injuring the mesentery. The loop of intestine is opened by making a four-fifths circumferential incision at the distal aspect of the loop, allowing 1 cm of ileum above the skin level in the superior aspect (Fig. 9-8B). The recessive limb thus is formed distally, and sutures are placed between the full thickness of ileum and dermis at this level. As the proximal aspect of the stoma is constructed, sutures are placed as previously described between the full thickness of ileum, the seromuscular area at the base of the stoma, and the dermis. As these sutures are tied, the stoma should assume a spigot configuration supported by the rod. The ileostomy appliance may be placed beneath the rod or over the rod, depending on the tension of the mesentery. The rod is left in place for 1 week, and the same ileostomy care is provided as previously described.

Another technique for constructing a completely diverting ileostomy is to use the divided end-loop method popularized by Abcarian and Prasad (Fig. 9-9). This technique involves transecting the ileum with a linear-cutting stapling instrument. No compromise of the mesentery is involved. The opening in the abdominal wall is made in identical fashion to that previously described, but when the intestine is pulled through, the proximal component is excised, and the stoma is constructed as previously described for an end ileostomy. The recessive limb at the base of the stoma has one corner of the staple line excised, and the full thickness of ileum is sutured to the dermis at the superior aspect of the stoma. This allows a small recessive limb that serves to decompress the distal intestine.

If a loop ileostomy cannot be brought to skin level because of obesity and/or tension on the mesentery (a situation most often encountered following restorative proctocolectomy), it may be helpful to create a divided end ileostomy to achieve more length. The ileum at the site chosen for ileostomy is divided and the proximal end brought out as an end stoma. The distal end is left closed in the peritoneal cavity or abdominal wall. This maneuver will sometimes result in formal laparotomy being required to close the stoma, but is a better alternative than a flush ileostomy.

Closure of Loop Ileostomy

When endoscopic procedures and contrast studies have shown that the pouch is intact or that the distal anastomoses have healed securely, consideration can be given to closing the loop ileostomy. If the primary procedure has involved the anal sphincter mechanism, careful physical examination and manometric studies should verify the adequacy of sphincter function before intestinal continuity is restored.

For closure of the loop ileostomy (Fig. 9-10), a circumferential dissection is carried out, with a minimal rim of skin included, until the peritoneal cavity is entered and clean peritoneal surface of abdominal wall can be palpated circumferentially. Once this is accomplished, the loop of intestine can usually be brought easily through the circular incision in the abdominal wall. Closure is completed by excising the rim of fibrous tissue, with care being taken to preserve as much of the viable intestinal wall as possible (Figs. 9-10B and 9-10C). The choice of closure then varies between hand-sutured transverse closure (Figs. 9-10D and 9-10E), stapled transverse closure (Figs. 9-10F and 9-10G), or formal construction of an anastomosis.

For closure of the separated (divided end-loop) ileostomy (Fig. 9-11), the mobilization is carried out in similar fashion, and a functional end-to-end closure is performed. A linear-cutting stapler is applied and removed, and the enterotomy is closed transversely. The intestine should be rotated so that antimesenteric surfaces are used for the staple line.

After intestinal continuity is restored, the abdominal wall is closed. Because of the risk of skin infection, many surgeons are reluctant to close the skin primarily. Rather, the skin defect can be handled by a number of alternative methods: closure over a drain; partial closure in linear fashion; or partial purse-string closure.

Loop-End Ileostomy

A loop-end ileostomy should be constructed in the rare circumstances in which it is unsafe to resect the mesentery of the distal ileum or when there is tension created on the mesentery as the ileum is brought to the abdominal wall for construction of the ileostomy. This occurs in the patient with a thickened mesentery or a very obese abdominal wall, or in a patient who has had multiple surgical procedures that altered the mesentery. These conditions preclude dealing with the usually pliable mobile tissue. This technique is especially useful in the obese patient who requires construction of a urinary conduit after cystectomy and radiation. The technique is especially helpful because a supporting rod can be placed beneath the stoma for 1 week to help avoid retraction through a thick abdominal wall (Fig. 9-12).

Constructing a loop-end ileostomy involves transecting the ileum as previously described, but the closed end will remain closed (Fig. 9-12A). The staple line is inverted with seromuscular sutures, or if it is to be used for a urinary conduit, only absorbable sutures are used to close the end of the ileum, because stone formation has been reported around staples (Fig. 9-12B). The orienting sutures are then placed as described for construction of a loop ileostomy, and a tracheostomy tape is placed so that when the loop of ileum is pulled through the abdominal wall, the closed recessive end will be superior and just within the abdominal cavity (Fig. 9-12C). The construction of the loop-end stoma then proceeds exactly as that described for the loop ileostomy (Figs. 9-12D, 9-12E, and 9-12F). However, in the case in which the stoma will be permanent, the mesentery of the distal ileum is fixed to the abdominal wall (Fig. 9-12D). If the stoma will be used as a urinary conduit, the loop of the conduit should be brought through the abdominal wall before the ureteral anastomoses have been carried out. It is a disconcerting problem to have the ureters fixed and then find there is an inadequate length of ileum to bring through the abdominal wall. It is also easier to place the ureteral stents when the construction is done in this fashion.

A special problem has been found in patients with a loop-end ileostomy in that there continues to be mucus secretion from the recessive limb, and after a period of several months, this secretion may interfere with the perfect seal of the ileostomy appliance. If interference does occur, it may be necessary to resect the distal limb and convert the stoma to a proper end ileostomy. This is a small price to pay, however, because it is an easy operation to remove the recessive limb, and it can be done without opening the abdominal cavity. Of more importance is the fact that the loop configuration during the initial procedure has allowed maintenance of blood supply and a protruding configuration under circumstances in which this otherwise may have been impossible, and that would have resulted in major complications.

Postoperative Care of Ileostomies

The components of an ileostomy appliance are a skin barrier with a faceplate, and a drainable pouch. Most ileostomy appliances are now commercially available as one-piece or semi-disposable two-piece units. The one in common use has a skin barrier with a fixed plastic flange (ring) so that the stoma opening can be cut precisely, the skin barrier applied, and the pouch snapped directly onto the plastic flange, thus allowing easy drainage and disposal of the pouch part of the appliance. The skin barrier component should need changing only every 4–5 days in a patient with a properly protruding and located stoma. A well-constructed ileostomy should allow the patient to display normal physical vigor, to eat a well-balanced palatable diet, and to engage in normal recreational and sexual activity. There should be no prolapse or retraction, the skin should remain normal, and the appliance should not leak. When first constructed, ileostomy output typically averages 1500 mL per day of liquid effluent, but after adaptation occurs, between 500 mL and 800 mL of thick liquid content should be passed per day.

Ileostomy Complications

Before the concept of stoma eversion was conceived, in approximately 1960, the majority of patients who underwent construction of an ileostomy had serious postoperative complications, usually related to serositis, which caused a partial obstruction at the stoma itself. These patients suffered massive fluid and electrolyte imbalance and often death, which were related to the enormous sequestration of fluid secondary to the small bowel obstruction. This condition was called “ileostomy dysfunction” and was anticipated after the construction of each stoma. This devastating problem essentially has been eliminated, since stomas have been opened and everted immediately at the time of construction. The output of an ileostomy should thus not be excessive, even in the immediate postoperative period.

Patients with ileostomies do have problems, most often related to maintenance of the seal of the appliance because of poor location or defective configuration of the stoma. In some cases, it is necessary either to revise the stoma locally to bring it into a spigot configuration, or to relocate it so an appliance can be securely applied. The most common problem experienced by ileostomy patients is chemical dermatitis. This can be prevented by proper stoma construction techniques, and by obtaining a pouching system that is properly sized and adherent. If the patient has a poorly constructed stoma, or a poorly fitting appliance, destruction of the peristomal skin can be so severe as to require split-thickness skin graft for definitive management. In these cases and in others in which the skin is injured around the stoma, a special ileostomy appliance may be utilized. It is based on maintenance of the seal to the mucosa of the ileum rather than to the peristomal skin. This appliance is used infrequently, when it is the only solution to complicated peristomal skin problems. Its use requires wearing supportive belts to maintain the appliance in place, but the skin can be treated with medicated pads during this period.

Another potential complication of ileostomy is dehydration. In patients with newly constructed ileostomies, the output of intestinal contents is frequently high enough that patients will require intravenous fluid administration until the stoma output decreases and the patient can compensate with adequate oral intake of fluids and electrolytes. One of the early symptoms associated with dehydration is nausea, which further exacerbates the problem as patients are loath to drink fluids. This problem not infrequently results in readmission to the hospital following major intestinal surgery accompanied by ileostomy formation. Patients should be counseled prior to discharge regarding the signs and symptoms of dehydration, and to intervene early with increased oral intake of fluids. Patients with long-term ileostomies are also at risk of becoming dehydrated, which occurs in hot weather and during strenuous physical activity. The individuals should be instructed to maintain adequate intake of fluids and electrolytes. They should routinely have medications on hand for simple diarrhea so that control can be achieved before dehydration occurs.

Some patients with ileostomies will present with acute blockage of the stoma, which is usually related to food indiscretion creating a “food bolus obstruction” just proximal to the level where the intestine exits the abdominal wall. This complication is most common in patients with newly constructed stomas, as there is some residual edema in the tissues which creates a relative narrowing of the ileum as it crosses the abdominal wall. Typically, patients will have ingested some fibrous food with a high residual component and will present with crampy abdominal pain, reduced stoma output, dehydration, and vomiting. These patients should be admitted to the hospital and started on intravenous fluid replacement. The stoma can then be irrigated in an attempt to release the presumed food bolus blockage. A Foley or similar catheter is placed into the stoma, and the stoma is then irrigated gently with warm saline. If food particles are returned from the initial irrigation, the irrigation can be continued until stoma function returns and the blockage is eliminated. If the return is clear, it suggests a more proximal obstruction or an adhesive obstruction, and a water-soluble contrast study should be done for evaluation. If the problem is food blockage, the instillation of the hyperosmolar contrast medium often will prove therapeutic. If there is no evidence of food blockage, it should be dealt with as an adhesive small intestinal obstruction. Figure 9-13 is an algorithm for the alleviation of ileostomy blockage.

Some patients develop a high ileostomy output because of dietary indiscretion, infectious disease, short bowel syndrome, or recurrence of inflammatory bowel disease. The cause must be determined and each problem dealt with individually. It is important to maintain fluid and electrolyte balance as these problems are being resolved. Special care must be provided for the patient with short bowel syndrome to maintain electrolyte balance and to compensate for the vitamin B12, calcium, and fat malabsorption that occurs with absence of the distal ileum.

Another special problem that may occur with an ileostomy is the formation of a paraileostomy fistula. This usually represents recurrence of Crohn's disease and should be dealt with based on the extent of the Crohn's disease. While evaluation and treatment are being carried out, the appliance should be modified so that the fistula is allowed to drain into the appliance, and no attempt should be made to cover the fistula opening. This is usually achieved by modification of the configuration of the skin barrier component of the appliance.

Patients and those individuals aiding in the care of the ileostomy should be in the habit of observing the ileostomy for injury. There are no pain fibers in the ileum, and it is not unusual for a patient to lacerate the stoma with a malfitting appliance without noticing the injury, especially on the inferior aspect of the stoma.

Review of the UOA data registry overall shows a low incidence of complications from ileostomy and an even lower incidence of need for corrective surgery. The vast majority of patients with conventional ileostomies lead normal lives and rarely have a restricted lifestyle because of the stoma. Most patients spend less than 1 hour a day dealing with their stomas.

The continent ileostomy, or Kock pouch, has been used as an alternative to a conventional ileostomy for selected patients with ulcerative colitis or familial polyposis. It involves construction of an internal pouch with a continent nipple valve. The continent ileostomy allows placement of the stoma in an inconspicuous location and avoids the need for wearing an appliance permanently. It does require multiple intubations of the pouch daily to allow emptying. The complication rate for construction of this continent ileostomy has been high because of the difficulty in maintaining continence of the nipple valve and position of the pouch so that intubation can be easily accomplished. This operation should probably be done only in centers where it is performed frequently and where the complications are managed by an experienced team. The continent ileostomy can be constructed as a primary procedure for patients with ulcerative colitis. It may also be considered for patients who have an existing ileostomy that malfunctions, is poorly located, or causes severe injury to the peristomal skin because of allergic reaction to the ostomy equipment. However, the Kock pouch has been used infrequently as primary treatment for patients with familial polyposis and ulcerative colitis since the advent of the restorative proctocolectomy with ileal pouch-anal anastomosis. Most surgeons agree that the continent ileostomy is contraindicated for patients with Crohn's disease because of the significant risk of recurrent disease and the potential for loss of substantial length of intestine should the patient require pouch excision. It is also not to be recommended for patients who have a well-functioning end ileostomy.

The advantages of continent ileostomy are that a patient need not wear an appliance, the patient is continent between intubations, and she or he may experience a better quality of life than if they had a conventional ileostomy. The disadvantages are that not all patients are continent, it does require multiple intubations during the day, there can be difficulty in intubation, and the surgery is prolonged and carries a substantial risk of complications. If the procedure fails, the individual will lose a significant amount of small intestine. Also, psychological factors may have been involved in the original motivation for choosing the internal ileostomy that are not alleviated by the more complicated surgical procedure.

Construction of Continent Ileostomy

The construction of an intestinal reservoir for feces was first described in 1967 by Nils Kock. His original description of a U-shaped pouch was based on the theory that interruption of coordinated peristalsis would enhance capacity. Since then, J- and S-shaped pouches have been used with similar results. An S-shaped pouch is described here.

The construction of a continent ileostomy, or Kock pouch, can be broken into four components: (1) the creation of a pouch, (2) the creation of a nipple valve, which provides continence, (3) the suspension of the pouch from the abdominal wall in such a way as to prevent slippage of the nipple valve, and (4) the creation of a stoma.

The terminal ileum should be transected as close to the cecum as possible (Fig. 9-14A). The S-shaped reservoir is fashioned from a 30 to 45 cm segment of distal ileum, starting 15 cm from the cut end (Fig. 9-14B). The last 15 cm is used for the outlet (5 cm) and nipple valve (10 cm). The intestine is tacked in place in the shape of an S, using interrupted seromuscular sutures of 2-0 polyglycolic acid placed at the edge of the mesentery. Each limb of the S should be 10–15 cm long. The intestine is opened along the entire portion of the S, with the surgeon taking care to incise close to the mesenteric border on the outer limbs of the S and exactly at the antimesenteric surface of the central limb. A single-layer continuous suture line of 2-0 synthetic absorbable suture is first placed between the two walls of the central limb and the inner walls of the two outer limbs (Fig. 9-14C). The sutures that begin on the posterior wall continue onto the anterior wall as the suture line reaches the outer wall of each of the two outer limbs of the S. The anterior wall is completed by continuing the suture from each direction, using an inverting full-thickness technique (either “baseball” or Connell) until the sutures meet in the middle. Before the pouch is closed, the nipple valve must be constructed.

The 15 cm of ileum distal to the pouch will become the nipple valve and stoma. Prior to the completion of the anterior wall suture, with the pouch mostly open, the nipple valve is made by intussuscepting the ileum into the pouch (Figs. 9-14D and 9-14E). A Babcock clamp is passed into the distal ileum from within the pouch and is closed onto the full thickness of the bowel at a point 5 cm from the pouch. The clamp is drawn into the pouch, intussuscepting the bowel on itself to form the nipple valve. The valve is maintained in this position by placing a line of staples on either side of the mesentery and a third row of staples on the antimesenteric aspect (Fig. 9-14F). Occasionally it is possible to place four staple lines equidistant around the circumference of the nipple valve (Fig. 9-14G). A linear-cutting stapling instrument with the cutting blade removed is used to place the staple lines. One arm of the instrument is inserted into the lumen of the nipple from within the pouch before closing and firing the instrument. These staple lines make a serosa-to-serosa fixation of the nipple valve and prevent its unfolding. The anterior wall of the pouch is then completed as previously described (Fig. 9-15A). A 5 cm outlet of distal ileum remains that will pass through the abdominal wall and allow construction of a flush stoma.

The right lower quadrant stoma site is created as described earlier in this chapter, with the opening placed below the belt line and within the rectus muscle. Before the outlet is passed through the abdominal wall opening, a sling of soft synthetic mesh (1 × 10 cm) is passed through a window made in the mesentery of both the pouch and nipple valve under the major vessels as they fold into the nipple valve mesentery (Figs. 9-15B and 9-15C). The strip of mesh maintains the nipple configuration and helps secure the pouch to the abdominal wall. Seromuscular absorbable sutures are used to fix the mesh to the base of the outlet (Fig. 9-15D). The two ends of the sling are left long because they are sutured together at the antimesenteric surface of the outlet. This facilitates delivery of the outlet through the stoma site and allows a securing suture of nonabsorbable material to be placed through the sling into the anterior fascia. As the outlet is readied to be drawn through the abdominal wall, a row of three untied seromuscular sutures is placed on the shoulders of the pouch medial and lateral to the outlet (Fig. 9-15E). These sutures, incorporating the posterior fascia and peritoneum, are used to fix the pouch to the anterior abdominal wall. The outlet is delivered through the stoma site and the pouch is drawn toward the abdominal wall. The sutures are then tied, first laterally and then medially (Fig. 9-15F). A permanent securing suture is placed through the tails of the sling and the anterior fascia, and the ends of the mesh are trimmed.

If possible, the cut edge of the small intestine's mesentery is sutured to the anterior abdominal wall (Fig. 9-15F). A continuous suture is placed from the outlet of the pouch to the falciform ligament. The pouch in its final position should rest at the right pelvic brim, with the antimesenteric surface (anterior wall) of the pouch directed inferiorly.

The terminal ileum at the outlet should be excised at skin level (Fig. 9-15G). The stoma is finally completed by absorbable sutures between the subcuticular layer of the skin and the full thickness of the intestinal wall (Fig. 9-15H). A Medina catheter is passed through the stoma into the pouch and is secured to the skin to prevent slippage of the tube into or out of the pouch (Fig. 9-15I). There should be minimal resistance and no deviation from a straight passage. The pouch should be drained in this manner for 2 weeks before intermittent clamping is begun during the third week. Finally, the pouch should be extubated and reintubated every 4 hours until the intervals gradually increase to 6 or 8 hours.

The nipple valve provides increasing continence as pressure rises in the pouch. Should the nipple valve lose its configuration and prolapse or should it slip through the mesenteric aspect of the pouch (the weakest point), either incontinence or obstruction will result. These two problems, along with “pouchitis,” are the most common complications following the continent ileostomy procedure. As a result, many variations of pouch construction have been used in attempts to prevent or correct these problems.

If a fistula should form from the nipple valve or if the nipple valve should slip, it may be possible to preserve the pouch and construct a new nipple valve (Fig. 9-16). The technique involves resecting the pouch outlet, including the nipple valve, after fully mobilizing the pouch from the abdominal wall and pelvis (Fig. 9-16B). The terminal ileum is transected 15 cm proximal to the pouch (Fig. 9-16C). The pouch is then rotated 180 degrees on its mesentery (Fig. 9-16D). A new nipple valve is created as previously described by intussuscepting the new outlet on itself and placing staple lines along the valve to secure the fold (Figs. 9-16E, 9-16F, and 9-16G). The opening in the pouch wall created when the old outlet was resected serves as the entry to the pouch to perform this maneuver. The proximal ileum's cut edge is then anastomosed to the pouch through a second enterotomy in a position that allows the pouch to lie comfortably in the right lower quadrant as before (Fig. 9-16D). If at all possible, the existing stoma site should be preserved and reused. The pouch then is resuspended by using a mesh sling as described above, and the stoma is constructed (Figs. 9-16H and 9-16I). The pouch should be protected by constant drainage through an indwelling Medina catheter for at least 1 week. Because the pouch will not require expansion and the patient will not need education, the prolonged period of progressive clamping should not be necessary.

The urinary conduit is constructed of a segment of intestine with well-maintained vascularity so that it can be connected to the urinary tract to allow egress of urine through the abdominal wall via a stoma constructed exactly like an ileostomy. It is not intended to have any type of reservoir capacity but merely to provide an open conduit. This urinary conduit is constructed most often after removal of the urinary bladder for invasive cancer. It is also used for management of severe obstructive uropathy, the congenital abnormalities of spina bifida, meningomyelocele, or bladder exstrophy, and for trauma to the spinal cord resulting in a severely neurogenic bladder. The incidence of this surgery for congenital and traumatic disorders is decreasing as other means of emptying the bladder are devised. The cystectomy, construction of the urinary conduit, and ureterointestinal anastomosis are most often carried out by urologists, but the construction of the stoma, as well as restoration of intestinal continuity, may be done by a surgeon more experienced in intestinal and stoma surgery.

The basic principles of construction of the conduit and stoma involve isolation of a segment of intestine, with maintenance of the mesenteric blood supply and enough mobility to allow the distal end to be used as a stoma and the proximal end to serve as the site for ureteral implantation. It is most important to maintain the isoperistaltic direction of the intestine, especially if the conduit is constructed of sigmoid colon. The conduit must not be made of irradiated bowel, even if this requires using either colonic or proximal small intestinal conduits. If the stoma is improperly constructed, there may be a stasis of urine, resulting in reflux and damage to the proximal tract.

The surgical technique consists of choosing a long enough segment of small intestine to allow the stoma to be constructed at the level of the abdominal wall and still allow the proximal end to reach close enough to the retroperitoneum to preclude tension on the ureterointestinal anastomoses (Fig. 9-17). Usually, 18–20 cm of intestine is enough, but this must be modified if there is a shortened mesentery or a massively obese abdominal wall. It is in these latter situations that the loop-end stoma, supported over a small rod, can be advantageous. After the segment of intestine is chosen, the mesentery at the distal point is incised to allow enough mobility for reaching the abdominal wall. The mesentery at the proximal site of transection is incised only in a limited fashion, and care must be taken to preserve a generous blood supply (Fig. 9-17A). Intestinal continuity is restored, with the intended conduit positioned posterior to the restored intestine (Fig. 9-17B). The ileoileal anastomosis may be completed in any fashion that uses sutures or staples. The conduit is then cleaned of intestinal content, and the proximal end is closed. Closure must be done with absorbable sutures, because staples can lead to stone formation. It is then preferable to make the opening in the abdominal wall to construct the stoma as previously described for an ileostomy (Figs. 9-17C and 9-17D). This procedure ensures that the ureteral anastomosis will be completed with the conduit in its final position and without the need for applying tension to bring the intestine through the abdominal wall. The ureteral anastomoses are performed, and stents are placed (Fig. 9-17E). All aspects of the stoma construction are the same as those for an ileostomy except that the appliance must contain a valve to allow emptying since the volume of urine is high and its weight may tend to pull the appliance off. This problem is avoided by the patient emptying the appliance frequently and by sleeping attached to a night drainage system.

Complications of the Urinary Conduit

The most common complication of a urinary conduit is a leaking appliance because of improper placement or construction of a flush rather than a protruding stoma. Although some urologists believe that a flush stoma is less susceptible to injury, most surgeons disagree with this concept and believe that a spigot configuration is best. Sometimes sutures are placed in the skin rather than in the dermis during stoma construction. This leads to a circumferential series of radial scars that preclude maintenance of the seal of the appliance. Because the stoma effluent is thin liquid, the appliance seal must be precise to avoid injury to the peristomal skin. If there is stasis in the conduit, an odor will develop and become the cause of great concern to the patient. Odor, increased mucus production, flank pain, and fever can indicate a urinary tract infection. In order to obtain an accurate urine sample for culture, it is necessary to intubate the stoma rather than sending urine collected from the appliance. It is not unusual to have to revise and sometimes relocate flush urinary conduit stomas. If this is done, care must be taken to ensure that the length of the conduit is adequate. If it is not, it is possible to add a segment of small intestine so that a proper stoma can be constructed without having to revise the ureterointestinal anastomoses.

The patient who does not maintain adequate personal hygiene and acidification of the urine may develop stone formation, with crystal formation around the stoma itself. This development can be alleviated by acidifying the urine or by cleaning and soaking the pouch with white vinegar. The use of Collyseal (Torbot Co.) can also be used to maintain an acidic environment and thus minimize crystal formation at the stoma. If the stoma has been constructed within the field of radiation, the radiation can break down the skin around the stoma. This requires relocation of the stoma to a nonirradiated location on the abdominal wall. Relocation should be done even if the upper quadrants need to be used. Recent advances have employed the principles of Kock pouch construction, previously described, to allow construction of a continent urinary diversion.

The formation of an intestinal fistula is not planned by the surgeon. Therefore, it must be dealt with as it occurs. Applying modern principles of stoma care to maintain the integrity of the peristomal skin until definitive treatment of the fistula can be carried out should prevent damage to the skin from primitive means of preventing severe destruction of the skin and abdominal wall. These stomal care techniques, coupled with intravenous nutritional supplementation, should alleviate uncontrolled intestinal drainage from abdominal wounds.

The most appealing operation early on in the laparoscopic colorectal surgery experience was creation of a diverting intestinal stoma. Laparoscopic loop stoma creation does not require division of the bowel or anastomosis, and the only incision larger than 5 mm required is at the stoma site. Thus, the full benefits of the totally laparoscopic approach can be realized. Surgeons inexperienced in laparoscopic approaches to colorectal disease may find that creation of intestinal stomas is a relatively straightforward and rewarding method to begin their laparoscopic colorectal experience.

Laparoscopic creation of intestinal stomas was reported in the early 1990s and the technique was quickly adopted by many surgeons. Several case series demonstrating the safety and efficacy of the procedure have been reported in the literature. Although there has not been a prospective, randomized trial of laparoscopic versus open stoma creation, case-controlled series have demonstrated reduced duration of postoperative ileus and reduced length of hospital stay with the laparoscopic approach. The benefits of the laparoscopic approach to stoma creation became immediately obvious to surgeons, and thus, it is unlikely that a prospective, randomized trial will ever be performed comparing outcomes of stomas created using laparoscopy versus laparotomy.

Laparoscopic ileostomy and colostomy creation have been performed for a plethora of indications, including obstructing rectal adenocarcinoma, rectal obstruction from extrarectal malignancies, fecal incontinence, penetrating rectal trauma, sacral pressure ulceration, obstructed defecation, perineal Crohn's disease, pelvic fracture, and lumbosacral burns. Virtually any disease process that is an indication for fecal diversion is an indication for consideration of the laparoscopic approach. Laparoscopic creation of diverting loop colostomy is particularly appropriate for patients suffering from symptomatic near-obstructing rectal carcinoma. The technique allows the surgeon to evaluate the liver and peritoneum for the presence of metastases that may be undetected on preoperative imaging studies, and institute fecal diversion without creating adhesions in the abdomen and pelvis that may increase toxicity of neoadjuvant radiotherapy and make future proctectomy more difficult. The absence of a laparotomy incision allows patients to recover rapidly, and allows them to begin neoadjuvant radiotherapy treatments almost immediately.

Some authors have argued that trephine stoma creation is an easier, quicker, and less expensive method of stoma creation than the laparoscopic technique. For the thin patient with a virgin abdomen who will not benefit from abdominal exploration, the trephine method does offer those advantages. However, for patients who are obese, those who have had multiple prior laparotomies, those who would benefit from abdominal exploration, or those who require mobilization of the intestine from its retroperitoneal attachments, the laparoscopic approach offers significant advantages.

In order to save time and expense in the operating room, we have developed an approach to the patient requiring fecal diversion that combines the advantages of both trephine and laparoscopic stoma creation. If the patient is thin and would not necessarily benefit from laparoscopic exploration of the peritoneal cavity, the patient is approached initially with the intention of creating a trephine stoma, with the laparoscopic approach held in reserve. The patient is positioned for a laparoscopic procedure, but the laparoscopic equipment is kept unopened in the operating room. The stoma incision is made, and if the bowel can be delivered in correct orientation to the skin level, the stoma is created and the laparoscopic equipment remains unopened. However, if trephine creation of the stoma is impossible, a Hasson trocar is placed through the stoma incision and the procedure proceeds laparoscopically.

Technique of Laparoscopic Stoma Creation

Patients undergoing diverting colostomy should be placed in the dorsal lithotomy or split leg position in order to have access to the anorectum; patients undergoing ileostomy may be placed in the supine position. The preselected stoma site is opened, a purse-string suture is placed in the posterior rectus sheath, and a Hasson trocar is placed. A 5 mm trocar is placed in the contralateral abdomen and the peritoneal cavity explored. If the bowel to be used for the stoma is sufficiently mobile, no other trocars need to be placed. If mobilization is required, additional 5 mm trocars can be placed to facilitate the dissection. Mobility is usually adequate when the bowel will reach to the peritoneal surface at the stoma site, as the distance to the skin level will decrease when pneumoperitoneum is released. A 5 mm camera is then placed through one of the 5 mm port sites, and the bowel grasped in the correct orientation using an instrument placed through the Hasson trocar at the stoma site. It is occasionally useful to mark the bowel for orientation of the proximal and distal limbs with sutures or clips prior to delivery through the stoma site—this is especially true when creating an ileostomy. The pneumoperitoneum is then released and the posterior rectus sheath opened over the trocar, allowing the bowel to be delivered through the stoma opening.

If the bowel is to be divided and an end stoma fashioned, it is critical that orientation be confirmed. Left-sided colostomy orientation can be confirmed by insufflation of air through a proctoscope, instillation of povidone iodine or dye through a small opening in the distal limb of the stoma with confirmation of dye passage to the rectum via a proctoscope, or passage of a flexible sigmoidoscope to the stoma site. Alternatively, the colon can be divided with a linear-cutting stapler, the distal end is allowed to retract into the peritoneal cavity, and direct visualization with a 5 mm laparoscope is performed to ensure that the distal bowel can be traced in continuity to the rectum.

The rapidity with which postoperative ileus resolves following laparoscopic creation of intestinal stomas may allow patients to return home within 1–2 days. This may create a problem for the patient and the CWOCN, who has little time to perform in-hospital stoma care training. Therefore, it is imperative that the patient meet with the CWOCN preoperatively, not only for stoma site marking, but for stoma care teaching as well.

Laparoscopic Stoma Closure

Laparoscopic techniques are most applicable to patients who have undergone colectomy with construction of a proximal colostomy. Although laparoscopic adhesiolysis is occasionally a beneficial adjunct to loop stoma closure, this is rarely required, as most loop stomas can be closed via a peristomal incision. The most common indication for a laparoscopic approach to the restoration of intestinal continuity is colostomy takedown and construction of coloproctostomy following sigmoid colectomy for complicated diverticular disease (“Hartmann reversal”). This procedure can either be straightforward or complicated, depending on the number and severity of intraperitoneal adhesions and the degree of pelvic fibrosis.

Several methods can be used to perform laparoscopic Hartmann reversal. Some surgeons establish laparoscopic access initially, perform adhesiolysis, mobilize the colon and rectum, take down the colostomy and insert the anvil of the end-to-end stapling device, re-establish pneumoperitoneum, and perform the anastomosis. A more cost-effective method is to take down the colostomy initially, perform as much of the procedure as possible through the colostomy opening, and then decide whether a laparoscopic technique is feasible. A substantial amount of adhesiolysis and mobilization can often be performed through the stoma incision, especially if there is a parastomal hernia present that has enlarged the fascial opening. The proximal colon can be prepared for anastomosis and the anvil of a circular stapling device inserted. If a determination of laparoscopic feasibility can be made prior to establishing pneumoperitoneum, it avoids the need to open any laparoscopic instruments or struggle with fruitless attempts at laparoscopic dissection prior to conversion. However, if it appears that laparoscopic techniques are likely to be successful, pneumoperitoneum is then established, either by closure of the fascia around a port or by insertion of a hand-assist device. The size of the fascial defect will determine which method is more advantageous for the patient and surgeon. The operation is then completed laparoscopically.

Prior to embarking on a laparoscopic reversal of a Hartmann procedure performed for diverticular disease, the surgeon should consider that it may be necessary to resect retained sigmoid colon and mobilize the splenic flexure to allow soft descending colon to reach easily into the pelvis for a colorectal anastomosis. Preoperative evaluation of the proximal colon and distal rectal stump with endoscopy and/or contrast enema will help the surgeon plan the operative procedure and exclude alternative diagnoses.

It is also possible to perform laparoscopic restoration of intestinal continuity following total abdominal or subtotal colectomy and ileostomy. The ileostomy can be taken down, and an end-to-end anastomosis performed laparoscopically using a surgical stapling device.