Stoma indication

indications and basics of stoma formation

1. Indications and Construction of Stoma Dr Prabha Om Senior Professor & Unit Head Department of General Surgery SMS Medical College and Hospital Executive member ASI (Rajasthan)

2. 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

3. Types of stoma • Duration (Temporary or Permanent ) • Anatomical location: CNS: ventriculostomy Respiratory: tracheostomy GIT: ileostomy, colostomy

4. Indication of Stoma 1. Feeding – Percutaneous endoscopic gastrostomy (PEG) -- Feeding Jejunostomy 2. Lavage – Appendectomy 3. Decompression 4. Diversion – Protection/defunction of distal bowel anastomosis ● Previous contaminated bowel ● Ileorectal anastomosis – Urinary diversion following cystectomy 5. Exteriorization – Perforated or contaminated bowel (distal abscess or fistula) – Permanent stoma (APR of rectum)

5. 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

6. End ileostomy is done in cases where total proctocolectomy is done. 1- Ulcerative colitis. 2- Crohn’s disease. 3- Familial polyposis Coli Loop ileostomy as an alternative of a loop colostomy for Defunctioning (for protection) 1- Low rectal anastomosis following a anterior rectal resection procedure. 2- Ileoanal pouch procedure following Total proctocolectomy.

7. 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.

8. Temparory Colostomy 1- Distal Obstruction. 2- Defunction a low rectal anastomosis after Anterior resection of the rectum. 3- Following traumatic injury to the rectum or colon. 4- During operative treatment of a high fistula in ano . 5- Fulminant Colitis (IBD). 6- Complicated Diverticular disease.

9. Discussion – Discuss the possibility of a stoma with patients undergoing elective or emergency colorectal surgery Assessment – by stoma therapist

10. Stoma site • Flat area of skin – adequate of adhesion of appliance • Pt. should be able to see • To avoid – skin creases, previous scars, umbilicus, bony prominences, at the belt line. • Site should be identified with patient lying, sitting and standing Usual sites • Ileostomies – right iliac fossa • Sigmoid colostomies – Left iliac fossa • Transverse colostomies – right/left upper quadrant

11. Four main aspects to consider before marking the Stome site Physical condition General state of health Current weight and recent weight changes Manual dexterity Eyesight 2. Social activities Occupation (special work positions) Practicing of sports and hobbies Usual clothing Cultural and religious aspects

12. 3. Areas to avoid Bony prominences Skin folds Scars from previous operations Umbilicus Belt line Previous irradiated skin area that has become sensitive (atrophic) 4. Visibility The site is to be in an area that the patient can reach and visualize.

13. Choose an area of 5-7 cm that is relatively flat to locate the ostomy In case of a large abdomen: choose the apex of the mound In case of extreme obesity: choose an area in the upper abdominal quadrants If the person already has an ostomy on the opposite side, mark the new stoma site up or down by 2-3 cm to allow for a belt, if required At the same time it has to be visible to the patient and , if possible, below the belt line to conceal the ostomy appliance

14. Stand up: Is the marking visible to the patient?

15. Sit – again in order to make sure that the location will not interfere with skin folds, scars etc. when sitting down and also to ensure that the stoma will be visible to the patient in this position (to allow for changing the bag when sitting down).

16. Bend: in order to find a location that will not interfere with skin folds, scars etc.

17. Lie down: bony prominences are shown, when the patient is lying down.

18. Basic principles of stoma surgeries • Adequate blood supply on either side(skin and bowel) • Without tension on mesentry or skin • Avoiding pre-existing infection site • Avoiding too small hole at fascial level • No twist

19. 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.

20. Stoma creation – Ileostomy Ileostomy effluent – • Liquid. • Frequently at alkaline pH. • Contains activated digestive enzymes. • Discharge almost continuously. • Excoriates & digests skin. Elevate the ileostomy opening 2-3 cm from skin to ensure that the effluent passes directly into a stoma bag with minimal contact with skin. • Ileum is everted on itself to form a spout .

21. The ileostomy opening should be 5 cm lateral to the umbilicus and brought out through the lateral edges of the rectus abdominus muscle. • It is usually made in the Rt. Iliac fossa. It should be spouted.

22. Conventional vs Brooke’s stomies • Before Brooke, ileostomies were made by exteriorizing the intestine through the abdominal wall and suturing the serosa to skin • Exposure of ileal serosa to alkaline stomal effluent resulted in serositis and ileostomy dysfunction • Brooke introduced technique of eversion of the full thickness of the mucosa and suturing it to the adjacent dermis.

23. Colostomy effluent- • Formed faeces. • Discharged intermittently. • Not directly corrosive to skin. • Usually falls directly into stoma bag. Colostomies are sutured flush with skin . • Allowed to pout slightly to prevent retraction after weight gain.

24. A transverse incision 8-10cm long, with removal of a disc of skin, is made for transverse colon (in the Rt. Upper abdomen midway between the umbilicus and xiphisternum over the rectus abdominus muscle and extending laterally to the lateral border of the rectus muscle), while for the sigmoid colon (in the Lt. iliac fossa with a muscle cutting incision). • # Cut down all layers including the rectus muscle which is divided transversely ligating and dividing the epigastric artery.

25. The most proximal loop of colon is prepared by removing the omentum from its anterior surface (only in Transverse colon), then a small hole is made in the mesocolon through which a rubber tube is passed to fascilitate delivery of the colon through the incision. • # The laparotomy wound should be closed at this stage. • # The colonic loop is held by an underlying glass rod or by a colostomy bar or skin bridge incised initially. The colon is then opened on its antimescolic border longitudinally (along the taenia coli). • # Sutures are used to fix the colonic serosa to the abdominal wall, and colonic mucosa to the surrounding skin. • # The finished loop colostomy should allow one finger to pass down on each side.

26. Pathophysiologic consequences after ileostomy • Colonic diversion – absorptive function of colon is lost • Normal colon absorbs – 1-1.5L of water and 100 mEq /L of sodium and if need be it can increase to 5 liter. • Patients with ileostomy obligatory sodium loss is 30-40mEq/L • A well functioning ileostomies discharges – 500ml to 1.2L of fluid daily • Consequently patients are in state of chronic oliguria • Also they have lower urinary Na/K+ • Changes in urinary composition – increase chances of urolithiasis – calcium and urate crystals • Decreased vitamin B-12 absorption and bile acid reabsorption.

27. Routine care of ostomies • Pouch placement – types • Closed end pouches – needs to be removed and replaced with new pouch every time • Open end pouches – have reusable end that can be opened to drain the content of pouch • Pouch emptying and care – odor and gas common concerns of patient • Assure ostomy bags are odor proof • Empty the pouch when 1/3 rd full prevent pouch seal from excess weight • Changing the pouch 1-2/ wk and sos • For foul odor if at all - Chlorine tabs in bag 1-2 tabs - Bismuth sub gallate 200 – 400mg - Cholorophylline complex can be taken orally

28. Diet – minimal modification needed, avoid unchewed nuts, fruits with skin, popcorns that can obstruct stoma • If gas is bothering patient needs to be given list of gas producing diet, in short to avoid beans, cabbage, cauliflower, brussels, broccoli, asparagus. • Low carb diet with less of potatoes, corn, noodles and wheat products. SOS use of simethicone can be done • Adequate fluid intake – increase by 500ml -750ml even more during high output states like sweating • Should be taught signs of dehydration and fluid electrolyte imbalance –dry mouth, decreased urine, marked fatigue, abdominal cramps.

29. Physical activity – all usual activities can be performed without any restriction, bathing can be done with pouch on or off the stoma,. • Most sports can be performed even with stoma in place except for extreme contact sports. • Sexual activity – does not affect organic function, dysfunction if at all occurs is due to autonomic denervation after proctocolectomy

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