Abdominal Stomas – Overview

Abdominal stomas are openings into the abdominal cavity. These stomas are surgically sited during abdominal surgical procedures to serve different purposes which are discussed below.

Selection of the type of stoma is highly influenced by the indication of stoma and its content.

Proper selection of the site of stoma carries an immense value.


Selection Of The Site Of Stoma

  • Easily accessible 
  • Good visibility
  • Should no overlie skin creases or waist line – To avoid interference with clothing 
  • Avoid….
    • Wound sites
    • Bony prominences
    • Existing scars
    • Umbilicus – At least 5 cm away from the umbilicus 
  • Patient factors 
    • Psychological state
    • Allergies
    • Obese
    • Bed bound 
 
Preoperative Preparation For An Elective Stoma
  • Bowel preparation
    • Laxatives
    • Enemas 
  • Antibiotic prophylaxis
  • Deep vein thrombosis prophylaxis
  • Marking stoma site
  • Counselling 



Types Of Stomas

Gastrostomy

  • Indications
    • Feeding 
  • Common site
    • Epigastrium 
  • Method
    • Percutaneous endoscopic gastrostomy (PEG) 
 
Jejunostomy
  • Percutaneous jejunostomy 
    • Indications
      • Feeding
    • Common site
      • Usually left upper quadrant 
    • Method
      • Witzel jejunostomy
  • Loop jejunostomy
    • Not usually performed because of its’ high output
Jejunostomy feeding


Ileostomy

  • Loop ileostomy
    • Indications
      • Defunctioning of colon – Following rectal cancer to protect the anastomosis
      • Persistent low intestinal fistula
    • Common site
      • Right iliac fossa
  • End ileostomy 
    • Indications
      • Following planned proctocolectomy in ulcerative colitis, crohn’s disease, familial adenomatous polyposis coli
    • Common site
      • Right iliac fossa
  • Important facts
    • Ileostomy has an output of 500 ml/day 
    • High enzyme content in the fluid
    • Leads to dehydration and electrolyte imbalance 
    • A sprout is kept avoid contact of fecal materials with the skin, to prevent skin excoriation 
 
Caecostomy
  • Indications
    • On table lavage
    • To decompress distal segment of bowel following colonic diversion or resection
    • To protect lower anastomoses
  • Common site
    • Right iliac fossa
  • Method
    • Performed with a large-bore catheter through a stab incision in the caecum, protected by a purse string
  • Important facts
    • Considered as the last resort when colostomy is not possible
Colostomy
  • Loop colostomy
    • Indications
      • To protect the distal anastomoses
      • To defunction a diseased segment – Crohn’s disease, severe proctitis
    • Common site
      • Left iliac fossa
  • End colostomy
    • Indications
      • Following abdominoperineal resection in lower rectal cancers
    • Common site
      • Left iliac fossa
  • Important facts
    • Output is about 100 ml/day 
    • No enzyme content in the fluid
    • No sprout present 
 
Hartmann’s Procedure (End Colostomy And Rectal Stump)
  • Indications
    • Used as a damage control procedure – Impending bowel rupture
    • Done if primary anastomosis is contraindicated 
  • Common site
    • According to the involved bowel
  • Method
    • After resection the colostomy is brought out using the proximal end of colon
    • Distal rectal stump is over-sewn and left in the abdomen
    • Laparotomy is performed later to reanastomose the bowel 
    



End Colostomy And Mucous Fistula

  • Indications
    • It is an alternative to Hartmann’s procedure
  • Common site
    • According to the involved bowel
  • Method 
    •  After resection the colostomy is brought out using the proximal end of colon
    • Distal bowel is brought out as a separate stoma – It produces only mucus
    • Reanastomosis is easier than Hartmann’s procedure
 

Complications Of Stomas
  • Immediate complications
    • Bleeding 
    • Ischaemia
    • Necrosis
    • Suture detachment
  • Late complications
    • Stenosis
    • Prolapse
    • Retraction
    • Intussusception 
    • Parastomal hernia
    • Fistula formation 
    • Skin excoriation
    • Bowel content spill over the efferent loop 
    • Stoma diarrhoea
      • Lead to dehydration and electrolyte imbalance
      • Common in ileostomy 
    • Nutritional disorders
      • Megaloblastic anaemia
    • Short gut syndrome
      • Lead to dehydration and electrolyte imbalance
    • Psychological problems
Practical Problems Of Stomas And How To Overcome These Problems
  • Odour
    • Proper hygiene
    • Diet
    • Deodorant sprays
  • Flatus
    • Diet 
    • Special filters (Charcol)
  • Leakage
    • Methylcellulose paste is helpful
  • Skin excoriation
    • Barrier creams
    • Two piece appliance  
  • Parastomal hernia
    • Flexible pouch, supporting belt and filler paste is helpful
    • Resiting may be necessary
  • Stomal prolapse 
    • Surgical correction 
 
complications of stoma



Stomal Appliances And Pouches
Appliances
  • One piece
  • Two piece


Pouches

  • Drainable 
    • Used immediately following surgery, when the output is large and stools are poorly formed
  • Closed 
    • Charcoal filter is present – To prevent the odour of flatus
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