stoma-200907152929.pdf sdsnls;n.,,dnm,nmv

educational purpose

1. Surg Cdr Chaminda Amarasekara

2. Definition
Classification
Principles of stoma formation
Attachment of the stoma appliance
Stoma care
Complication of intestinal stomas
Dietary advice to ostomates
urostomy

3. “Stoma” is a Greek word –mouth/ opening
Surgically created small opening on the
surface of abdomen in order to divert flow of
faeces/urine
It’s a anastomosis fashioned between
intestine and skin of AAW

4. Intestinal stoma
◦Colostomy
◦Ileostomy

5. Colostomy
Type by anatomic location
1.Sigmoid
2.Transverse
3.Caecostomy

6. Reconstruction
◦End Stoma(Consists of a single intestinal lumen)
◦Loop Stoma
(Gives access to both afferent and efferent limbs)
◦Double barrel
◦Bishop-koop( distal ileostomy with end to side ileas
anastomosis)
◦Santulli(proximal ileostomy with end to side ileas
anastomosis)

7. Type by function
1.Decompression
2.Diversion
Type by duration
Permanent
Temporary

8. Permanent stoma Temporary stoma
Necessary when there
is no distal bowel
segment remaining
after resection
Usually below the belt
line
Permanent colostomy:
LIF
Permanent ileostomy
:RIF
Relieve complete distal
large bowel
obstruction causing
proximal dilatation.

9. Feeding
◦Percutaneous endoscopic gastrostomy(PEG)
Decompression
Diversion
◦Protection/de function of distal bowel anastomosis
Previous contaminated bowel
Iliorectalanastomosis
◦Urinary diversion following cystectomy

10. exteriorization
◦Perforated or contaminated bowel (distal abscess or
fistula)
◦Permanent stoma (APR or Rectum)

12. Pre op counseling
Pre op assessment
Stoma creation

13. Psychological & physical preparation
◦Discuss the possibility of stoma with patients
undergoing elective or emergency colorectal
surgery
Explanation of indications and complications

14. Marking the stoma site
Asses the patient preoperatively
-lying down
-sitting
-standing

16. Mark the best site for stoma
-Area should be easy to see and access
-Avoid bony prominence
-EgIliac crest,ribcage
-Avoid scars, skin creases, anticipated surgical
wounds & belt line.
-The stoma within rectus abdominussheath

18. Stoma creation-ileostomy
Ileostomy effluent

24. Distal obstruction
Ca rectum or sigmoid colon
Usually done as emergency procedure
No time for bowel preparation
Resection anastomosis

25. Blow –hole decompressing stoma
Caecum
Transverse colon
Tube Caecostomy
Loop Transverse Colostomy

27. Advantages
Safe , useful
Subsequent definitive procedures can be performed
Disadvantages
Does not provide complete fecal diversion
May be disruption of continuity distal to the stoma

28. Rarely done now a days
Difficult to manage post operatively
Reserved for
Elderly
Acutely ill
Massive distention of colon with impending rupture

29. Function
Decompression stoma
Diverting stoma
For 06 wks
Then post wall recesses –stool can enter distal loop
Long term stoma
Drawbacks
Irrigation –difficult
Parastomal hernia

32. Aim –for complete diversion of contents
Indications
Breech of continuity of distal bowel
Like –traumatic injury distally
Diverticulitis
Perforated un resectable cancer
Leaked anastomosis
Threatened anastomosis
Disease –destruction of rectum & anus
Crohn’s disease , hidradenitis , multiple sphincter injury ,etc

33. Complete transection
Proximal segment colostomy
Distal segment
Mucous fistula –
Left closed in abdominal cavity
Like –HARTMANN resection
Stoma –same as described earlier

34. Divides the bowel completely ( 2 stoma
beside each other and separate from each
other)
Each opening brought in to the surface as
separate stoma
Proximal end : end stoma
Distal end mucus fistula

38. Safe to restore the continuity of intestine
Evaluate the distal integrity
Evaluate the sphincter muscle function

39. How to evaluate
Endoscopy
Contrast study
Manometry
Circumferential incision around stoma
including small rim of skin
If midline –open either side of mid line &
mobilize the segment

40. Closure –transversely
Stapler
Hand closure
Complete transection colon & construction by end to
end anastomosis
Return to abdominal cavity
Closure of abdomen
Precautions
Haemostasis
Injury to other loops

45. End ileostomy –permanent, for patients who
require removal of complete colon & rectum
Loop ileostomy –temporary, to protect
complex sphincter conserving anastomosis
distally
Ileostomy fluid liquid, high volume, corrosive
to peristomalskin
Ileostomy stoma carefully sited with a nipple

46. Is essential in management of neonates with
certain type of distal intestinal obstruction.
Eg: long segment Hirschsprungdisease
complex meconium ileus
Gastroschisiswith atresia
Ileostomies placed to divert bowel contents in
neonatal necrotizing enterocolitis, ulcerative
colitis, familial polyposis

47. General
◦Stoma diarrhea
Water & electrolyte imbalance
hypokalemia
◦Nutritional disorders
◦Stones
Gallstones
Renal stones
◦Psychosexual
◦Residual disease

48. Specific
◦Skin excoriation
◦Prolapse/gangrene/necrosis of distal end
◦Bleeding
◦ischemia
◦Retraction
◦Parastomal hernia
◦Fistula formation
◦Stenosis of orifice

50. Stenosis
Predisposing causes
Aponeureticopening too small
Stomalischemia
Recurrence –crohn’sdisease
Severe stenosis will cause intestinal obstruction

51. Stomalprolapse
Predisposing factors
Aponeuroticopening too large
Excessive mobilization off redundant
bowel
Raised intra abdominal pressure
Common in loop colostomies

52. Answer
Get rid of disease condition
Maintain continuation of bowel
Convert loop colostomy to end colostomy may be with
mucous fistula

53. Obstruction of small bowel
-occurs particularly in loop stomas
Attributed to intra abdominal adhesions
Hemorrhage
Can be due to
Atrivial bleed from fragile granuloma
Recurrent /novel GI disease
parastomalvarices

54. Diversion colitis
-chronic inflammation of distal bowel left
in situ when faecalstream is diverted away
-may develop bloody discharge from the
rectum

55. Parastomalhernia
If located lateral to rectus

56. Skin manifestations
◦-contact dermatitis from occlusive appliances
◦-Allergic responses to adhesives
◦fungal and bacterial infections

58. Site –proximal to stoma
Following irrigation or contrast study
Treatment
Emergency
Re explore
Re construction

59. Protective skin barrier
Pouch
◦Closed end
◦Drainable

60. Gently clean the stoma & peristomalskin
Dry the peristomalskin & apply filling paste
Cut the center hole of the skin barrier to
match the diameter of the stoma.

61. Remove the sticker of the skin barrier
Fix the skin barrier to the peristomal skin

62. Fix the pouch to the skin barrier
Clip the other end of the pouch
Finally apply plaster around the skin barrier

64. Patients should be advised carefully before
the discharge
Properly fitted appliances should remain in
situ for several days(3-4days)
There are two basic type of pediatric
appliance
◦One piece system
◦Two piece system

65. Candidasis remain a major issue
-Anti fungal cream should be started with
early signs
-Application of silver nitrate may be requried
to control granulation around the mucosa –
skin interface at early stages.

66. Take low fiber food to reduce bulk in stool &
help prevent intestinal obstruction.
Avoid vegetable known to result in offensive
odour
◦Reddish
◦Cabbage
◦Garlic
◦cucumber

67. To reduce flatus avoid
◦Carbonated beverages
◦Chewing gum
◦smoking
Chew food well
Drink adequate amount of water

68. Surgical diversion of urinary system
Indications:
◦Bladder Ca
◦Urinary incontinence
◦Neuropathic bladder

69. Formation of urostomy
◦Needs ileal conduit, a segment of viable ileum made
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 out side the abdomen and
collected by stoma bag

71. THANK YOU