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. 2. Assessment – by stoma therapist
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.
10. Principles of stoma formation
3. Stoma creation – 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.
12. Principles of stoma formation
3. Stoma creation – Colostomy
Colostomy effluent-
• Formed faeces.
• Discharged intermittently.
• Not directly corrosive to skin.
• Usually falls directly into stoma bag.
13. Principles of stoma formation
3. Stoma creation – Colostomy
• Colostomies are sutured flush with skin.
• Allowed to pout slightly to prevent retraction after
weight gain.
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
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.
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
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. • Cut the central hole of the
skin barrier to match the
diameter of the stoma.
Attachment of the stoma appliance
• Gently clean the stoma & peristomal skin.
• Dry the peristomal skin & apply filling paste
on it.
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.
34. Complications of intestinal stomas
Early
1. Ischaemia
2. Retraction
Late
1. Stenosis
2. Prolapse
3. Parastomal
herniation
4. Obstruction of small
bowel
5. Haemorrhage
6. Diversion colitis
7. Dermatitis
8. Psychological
35. • Ischaemia
Stoma should be pink & moist.
When ischaemic grey / black & dry
Complications of intestinal stomas
36. Complications of intestinal stomas
Complete retraction into
peritoneal cavity
Peritonitis
Partial retraction
Subcutaneous tissue is
exposed to faecal
contents
Peristomal cellulitis,
abscesses & fistulae
• Retraction
37. Complications of intestinal stomas
Predisposing causes:
►Aponeurotic opening
too small
►Stomal ischaemia
►Recurrence – Crohn’s
disease
Severe stenosis
Intestinal obstruction
• Stenosis
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.
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
