Stoma

Stoma

1. Definition Greek: ‘ mouth’ Stoma =  an artificial opening in the abdominal wall , which connects a hollow viscus(bowel, urinary tract) to the outside environment/ to divert faeces or urine to the exterior which is collected in an external appliance. Natural openings: Nostrils, mouth , anus. Intestinal stoma = opening of the intestinal tract onto abdominal wall Viscus:  large interior organ in any of the great body cavities, especially those in the abdomen. STOMA

2. Types of stoma Duration (Temporary or Permanent ) Anatomical location: CNS: ventriculostomy Respiratory : tracheostomy GIT : ileostomy, colostomy Reconstruction : End Loop Double Barrel( Mickulicz ) Bishop-Koop(distal ileostomy with end to side ileas anatomosis ) Santulli (proximal ileostomy with end-to-side anastomosis)

3. Permanent stoma Necessary when there is no distal bowel segment remaining after resection or when for some reason the bowel cannot be re-joined Usually below the belt line Permanent colostomy: left iliac fossa (LIF) Permanent ileostomy: right iliac fossa (RIF) Temporary stoma Relieve complete distal large bowel obstruction causing proximal dilatation

4. Indication of Stoma Feeding Percutaneous endoscopic gastrostmoy (PEG) Lavage Appendectomy Decompression Diversion Protection/ defunction of distal bowel anastomosis Previous contaminated bowel Iliorectal anastomosis Urinary diversion following cytectomy Exteriorization Perforated or contaminated bowel (distal abscess or fistula) Permanent stoma (APR of rectum)

5. S ite of abdominal Stoma

6. Preparation of patient undergoing Stoma Psychosocial and physical preparation Explanation if indication and complication Request help of Clinical Nurse Specialist in Stoma care pre-operatively, who w ill mark the site. Marking the stoma site (Pt standing up) Pt able to see the stoma well 5 cm from the umbilicus ( spino -umbilical line away from all bony prominence) Away from scar & skin creases Away from bony points or waistline of clothes Easily accessible to Pt (not under a large fold of fat ) The stoma within rectus abdominis sheath

7. Examination of Stoma Inspection Site Types of stoma Surrounding skin Covering of surrounding skin Loop Stoma functioning Stoma discharge Colour Type Amaount Palpation General abdominal palpation Stoma ? Percussion Shifting dullness Auscultation Bowel sound End examination PR exam

8. Complication of Stoma General(d/t u/l dz ) Stoma diarrhea Water&electrolyte imbalance Hypokalemia Nutritional disorders Stones Gallstone Renal stone Psychosexual Residual disease Crohn’s disease Parastomal fistula Specific Skin excoriation Prolapse /gangrene/ necrosis of distal end Bleeding Retraction Parastomal hernia Fistula formation Stenosis of orifice Cause constipation 1.Local: skin excoriation, dermatitis, candidiatis , ischaemia , 2.Structural: retracted, prolapse, stenosis, parastomal hernia (support corset) 3.Systemic:dehydration,electrolyte imbalance, malabsorption

9. INTESTINAL STOMA PERMANENT End colostomy End ileostomy Hartsmann’s procedure(End colostomy + rectal stump) TEMPORARY Loop transverse colostomy emergency procedure: large bowel obstruction defunctioning stoma b owel rest: pericolic abscess, anorectal fistula

10. ILEOSTOMY essential in the management of neonates with certain types of distal intestinal obstruction e.g : long segment Hirschsprung disease, complex meconium ileus, gastroschisis with atresia Ileostomies are commonly placed to divert bowel contents in neonatal necrotizing enterocolitis, ulcerative colitis, familial polyposis

11. Ileostomy effluent : Liquid . Contains activated digestive enzymes. Discharged almost continuously. Appearance: sprout of mucosa -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 exerted on itself to form a spout.

12. End Ileostomy

13. Loop Ileostomy

14. Colostomy A colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the exterior, where it can be collected in an external appliance Indication : Imperforate anus, Hirschsprung disease, Abdomino-perineal resection of a low rectal anal canal tumour diverticular disease.

15. Colostomy By anatomy : Transverse colostomy Descending colostomy Sigmoid colostomy By function : Decompressing Diversion By construction : End Loop Double barrel

16. COLOSTOMY Type: Temporary (loop colostomy) Permanent (end colostomy) Indications: Diverticular disease Colorectal cancer Appearance: Flush with the skin (#) Mucosa sutured to skin Location: P ermanent at LIF Temporary at LIF or right hypochondrium Effluent: intermittent and solid

17. Colostomies are sutured flush with skin. Allowed to pout slightly to prevent retraction after weight gain

18. End Colostomy

19. Double-barrel colostomy When creating a double-barrel colostomy, the surgeon divides the bowel completely .(2 stoma besides each other and separate from each other) Each opening is brought to the surface as a separate stoma Proximal-end = end stoma (secrets stool), needs a drainage bag. Distal-end= mucous fistula (secretes mucus) Temporary stoma

20. Hartmann’s Procedure

21. Surgical diversion of urinary system Done for baldder Ca, urinary incontinence and neuropathic bladders Formation of urostomy Needs ileal conduit, a segment of viable ileum mad like a tube where 1 end is open (used as stoma) and another end is closed( used as reserve). Ureters are implanted into this isolated segment of small bowel tube The open-end of conduit is everted to create a similar spout as ileostomy and allows diversion of urine from kidneys to outside the abdomen and collected by stoma bag Urostomy

22. Loop stoma – temporary stoma

23. VASCULAR COMPROMISE Ischaemia due to operative tissue trauma Intestinal necrosis due to ligation of arterial supply/inadequate collateral arterial circulation Venous outflow obstruction > venous congestion >necrosis of stoma

24. Stoma care Parents, as well as older children, must be carefully taught and reassured before leaving the hospital and on subsequent follow-up visits. Properly fitted appliances should remain in situ for several days (change every 3 days ). There are two basic types of pediatric appliances:  the one-piece pouching system in which the adhesive skin barrier is already attached to the pouch  the two-piece system in which the adhesive skin barrier is separate from the pouch. Candidiasis remains a common problem in the parastomal skin, and local antifungal medication should be used at the earliest sign of irritation. With skin excoriation, the area is exposed to air and a synthetic barrier is applied. A hairdryer can be useful . application of silver nitrate may be necessary to control granulation tissue around the mucosa-skin interface in the early stages.

25. Colostomy bags and appliances