Intestinal Stomas general surgery srb.pptx

Stoma ppt

1. By : Dr J L Kumawat Professor and Unit Head Department of General Surgery

2. Definition Intestinal stomas are surgically created openings of small or large intestines onto the anterior abdominal wall.

3. COLOSTOMY INTESTINAL STOMA ILEOSTOMY Classification

4. INTESTINAL STOMA END STOMA Consists of a single intestinal lumen LOOP STOMA Gives access to both afferent & efferent limbs Classification

5. INTESTINAL STOMA Classification PERMANENT TEMPORARY

6. Principles of stoma formation 1. Discussion – Discuss the possibility of a stoma with patients undergoing elective or emergency colorectal surgery. Principles of stoma formation

7. Assessment –  Assess the patient preoperatively – lying down sitting standing  Mark the best site for a stoma. Area should be easy to see and access. Avoid bony prominences (e.g. iliac crest, rib cage), scars, skin creases, anticipated surgical wounds & belt line. Principles of stoma formation

8. Principles of stoma formation 3. Stoma creation  Create an opening (about the width of 2 fingertips) in anterior abdominal wall.  Deliver well- vascularized, tension- free segment of bowel through the rectus abdominis .  Close any other wounds  Open bowel & secure to skin with evenly spaced absorbable sutures.

9. Principles of stoma formation Stoma creation – A. Ileostomy Ileostomy effluent – Liquid. Frequently at alkaline pH . Contains activated digestive enzymes. Discharged almost continuously. Excoriates & digests skin.

10. Principles of stoma formation Stoma creation – A. Ileostomy Elevate the ileostomy opening 2- 3 cm from skin to ensure the effluent passes directly into a stoma bag with minimal contact with skin. Ileum is everted on itself to form a spout .

11. Principles of stoma formation

12. Principles of stoma formation Stoma creation – B. Colostomy Colostomy effluent- Formed faeces. Discharged intermittently. Not directly corrosive to skin. Usually falls directly into stoma bag.

13. Principles of stoma formation Stoma creation – B. Colostomy Colostomies are sutured flush with skin . Allowed to pout slightly to prevent retraction after weight gain.

14. Principles of stoma formation

15. In right iliac fossa Usually a permanent stoma Electively - Proctocolectomy for: inflammatory bowel disease or familial adenomatous polyposis coli END STOMAS - End ileostomy

16. Usually temporary in the emergency setting Subtotal colectomy with end ileostomy- in fulminant or perforated ulcerative colitis. in distal obstruction of large bowel where caecum is non viable or perforated. After a segmental resection of small bowel where primary anastomosis is unsafe. e.g. perforated Crohn’s disease, thromboembolic bowel ischamia END STOMAS - End ileostomy

17. END STOMAS - End ileostomy In temporary end ileostomy: Distal bowel closed & left in abdomen exteriorized as a mucous fistula

18. END STOMAS - End ileostomy In temporary end ileostomy:

19. END STOMAS - End ileostomy In temporary end ileostomy: Relaparotomy to restore intestinal continuity when the patient has recovered (after 3- 4 months).

20. END STOMAS - End colostomy Usually in left iliac fossa . Frequently sigmoid colostomies.

21. END STOMAS - End colostomy Abdominoperineal excision for anorectal tumours a permanent end colostomy an elective surgery

22. END STOMAS - End colostomy

23. END STOMAS - End colostomy Hartmann’s procedure In emergency setting. For ischaemia, perforation or obstruction of distal colon or rectum. Potentially reversible 3- 4 months later. Patients are often elderly & frail. 40% never undergo reversal.

24. END STOMAS - End colostomy Hartmann’s procedure

25. Most common in terminal ileum, transverse colon & sigmoid colon. A loop of bowel is brought to the anterior abdominal wall & held in place by a plastic bridge passed through the mesentery. Bowel wall is incised & edges are sutured to skin. Plastic bridge is removed when mucocutaneous anastomosis has matured (after 5- 7 days). LOOP STOMAS

26. LOOP STOMAS

27. In general, temporary stomas. Can be reversed via the stoma site 2- 3 months after formation. Used to divert faecal stream to protect - a distal anastomosis after low anterior resection. Difficult anal sphincter repairs. Complex perianal fistula procedures. LOOP STOMAS

28. A loop transverse colostomy can be done to defunction an anastomosis after an anterior resection. LOOP STOMAS

29. Stoma appliance Pouch (Bag) Protective skin barrier Closed- end Drainable Remains on the skin between bag changes & needs to be changed every few days.

30. Attachment of the stoma appliance Gently clean the stoma & peristomal skin. Dry the peristomal skin & apply filling paste on it. Cut the central hole of the skin barrier to match the diameter of the stoma.

31. Remove the sticker of the skin barrier. Fix the skin barrier to the peristomal skin. Attachment of the stoma appliance

32. Clip the other end of the pouch. Finally apply plaster around the skin barrier. Attachment of the stoma appliance Fix the pouch to the skin barrier.

33. Attachment of the stoma appliance

34. Complications of intestinal stomas Early Ischaemia Retraction Late Stenosis Prolapse Parastomal herniation Obstruction of small bowel Haemorrhage Diversion colitis Dermatitis Psychological

35. Ischaemia Stoma should be pink & moist. When ischaemic grey / black & dry Complications of intestinal stomas

36. Complications of intestinal stomas Partial retraction Subcutaneous tissue is exposed to faecal contents Peristomal cellulitis, abscesses & fistulae Retraction Complete retraction into peritoneal cavity Peritonitis

37. Complications of intestinal stomas Severe stenosis Intestinal obstruction Stenosis Predisposing causes: Aponeurotic opening too small Stomal ischaemia Recurrence – Crohn’s disease

38. Complications of intestinal stomas Stomal prolapse Predisposing factors: Aponeurotic opening too large Excessive mobilization of redundant bowel Raised intra- abdominal pressure Common in loop colostomies.

39. Complications of intestinal stomas Parastomal herniation  The most common late complication of end colostomies.  Occurs in up to 30% of stomas.  Incidence increases with time.  Predisposing factors – similar to those for prolapse.

40. Complications of intestinal stomas Obstruction of the small bowel  Occur particularly in loop stomas. (10- 15%)  Attributed to intra- abdominal adhesions.

41. Complications of intestinal stomas Haemorrhage Can be due to: A trvial bleed from a fragile granuloma Recurrent / novel gastrointestinal disease Parastomal varices between the veins of mesenteric & anterior abdominal wall – in patients with portal hypertension

42. Complications of intestinal stomas Diversion colitis  Chronic inflammation of the distal bowel left in situ when faecal stream is diverted away.  May develop bloody discharge from rectum.

43. Complications of intestinal stomas Skin manifestations  Faecal irritant dermatitis

44. Complications of intestinal stomas Skin manifestations  Contact dermatitis from occlusive appliances  Allergic responses to adhesives  Fungal & bacterial infections

45. Complications of intestinal stomas Skin manifestations  Peristomal psoriasis in a patient with Crohn's disease.

46. Skin manifestations  Peristomal cutaneous Crohn's disease Complications of intestinal stomas

47. Skin manifestations  Peristomal pyoderma gangrenosum in a patient with ulcerative colitis. Complications of intestinal stomas

48. Dietary advice to ostomates Take low fibre food to reduce bulk in stool & help prevent intestinal obstruction. Avoid vegetables known to result in offensive odour. ×Raddish ×Cabbage ×Garlic ×Cucumber

49. To reduce flatus, avoid: × carbonated beverages × chewing gum × smoking Chew food well. Drink adequate amounts of water. Dietary advice to ostomates

50. THANK YOU