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Chapter 23 Stoma Surgery
that a transverse colostomy may be placed with minimal operative stress for the patient. If necessary, a transverse loop colostomy may be placed under local anesthesia
with an incision just at the stoma site. This type of stoma, therefore, is our preferred
option for the debilitated patient with high general operative risk. In patients who require a stoma as a definitive treatment, a Hartmann procedure with an end-descending colostomy is our preferred operation (Fig. 23.1). An end colostomy in the descending colon will usually allow stoma care by irrigation (Fig. 23.2).This procedure of controlled emptying of the bowel every 2–3 days with the potential to dispense with placing stoma bags is frequently perceived as the optimal stoma care in the trained and fit
patient (Turnbull 2003). It is of note that all mentioned operations may easily be performed with the laparoscopic approach, if the patient has had no extensive previous
abdominal operations (Weiss et al. 1995; Oliveira et al. 1977; Ludwig et al. 1996;
Schwandner et al.1998).
23.2 Preparation
It is almost normal that the patient is somewhat horrified when the possibility of a stoma placement as a cure for severe fecal incontinence is mentioned the first time. Thus,
placement of a stoma for fecal incontinence is basically never a one-visit decision.Except for the emergency situation, when stoma placement may be required in patients
with an anal sphincter destroyed by perineal injury, this operation should only be
undertaken after repeated and extensive discussions with the patient. It is advisable
that not only the surgeon explain why a stoma is believed to be advantageous, but also
the stoma nurse, who will frequently have more detailed information available on aspects of stoma care and special procedures such as irrigation.According to our expe-
327
Fig. 23.1. Hartmann situation. This graph displays the situation after a Hartmann operation with
a closed rectal stump and an end colostomy at the left colon
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328
Martin E. Kreis,Ekkehard C. Jehle
Fig. 23.2. Irrigation. This figure shows the technique of irrigating an end colostomy. With the
help of special appliances,a large enema is given into the colostomy,which allows complete emptying of the proximal colon. In suitable patients, this technique prevents evacuations from the
colostomy for 2–3 days,which enables patients to dispense with the bag that otherwise covers the
stoma for this time period
rience, it is furthermore extremely helpful when the patient who is facing a stoma
placement is given the opportunity to talk to somebody who has already undergone
this procedure previously since the patient’s perspective is certainly different at times
compared to the surgeons’ or nurses’.
Besides carefully familiarizing the patient with stoma care, the position of the stoma requires optimal planning. The marking should be performed in the supine, upright and sitting positions. Special attention is to be given to skin folds and the level of
the pants or belt. It is furthermore mandatory that the patient is able to see the stoma
site. This latter aspect is particularly important in the obese patient (Fig. 23.3).
23.3 Technical Aspects of Stoma Surgery
23.3.1 Operative Access
In suitable patients, we prefer the laparoscopic approach, as it allows the patient to
profit from the advantages of laparoscopic surgery such as reduced postoperative
pain, less frequent postoperative motility disorders and shortened hospital stay
(Robinson and Stiegmann 2004). In general, one trocar is placed close to the umbilicus for the camera and one at the site of the future stoma. This arrangement is usually
sufficient for a loop ileostomy. If a Hartmann procedure is performed with an end colostomy at the level of the descending colon an additional trocar is required for the
dissection and mobilization of the descending colon. If the laparoscopic approach is
Chapter 23 Stoma Surgery
Fig. 23.3. Marking of the stoma site.A good position of the stoma is indispensable for easy stoma
care later on and subsequent good quality of life for the patient. The stoma and the stoma bags
must not interfere with the patients’ belt-line.Furthermore, the patient must see the stoma and
it must not be placed in locations where skin folds build up in different body positions
329
not feasible, a midline laparotomy is performed to avoid any incision at potential future stoma sites, which may be important if the stoma ever has to be replaced subsequent to stoma complications.There are no detailed or conclusive reports on the cost
of laparoscopic vs open stoma surgery (Johnsson and Zethraeus 2000). The laparoscopic procedure is likely to be more expensive because of the special materials that are
necessary for laparoscopic surgery. However, this is probably balanced by the generally shortened hospital stay following laparoscopic surgery.
23.3.2 Loop Ostomies
We perform a loop ileostomy most frequently (Fig. 23.4; Weiss et al. 1995). The pneumoperitoneum is established following a skin incision below the umbilicus either by
use of the Veres needle or a minilaparotomy. Then, a 10-mm trocar is placed and the
camera inserted. The skin at the level of the ileostoma is excised with a diameter of approximately 2–3 cm and an additional trocar inserted. In order to have an adequate
gap at the level of the fascia, we change the initially placed trocar to a 20-mm trocar,
before we grasp the most distal ileal loop that is sufficiently mobile with a Babcock
clamp. Alternatively, the fascia may be incised from above after the loop has been
grasped. This step is facilitated by having the patient in the Trendelenburg position.
The loop is exteriorized and a splint is placed below.Now the position of the proximal
and distal part of the loop needs to be confirmed carefully. The abdomen is deflated,
the camera port is withdrawn and the fascia and skin are closed below the umbilicus.
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Martin E. Kreis,Ekkehard C. Jehle
Fig. 23.4. Laparoscopic ileostomy. The technique for the construction of a laparoscopic ileostomy is shown. Note that only two trocars are necessary, one at the umbilicus for the camera and
one at the future stoma site
Then the loop is incised at the level of the distal loop such that the proximal loop is
fixed to the skin by creating a nipple. The nipple ensures that the stoma appliances can
be positioned so that the contents of the small intestine cannot touch the skin. This is
crucial in order to avoid later skin problems around the stoma.When the procedure is
performed via a midline laparotomy, the fascia is incised at the level of the stoma site
just enough to allow the passage of two fingers. In the case of a loop colostomy at the
level of the transverse colon,a slightly extended transverse incision is performed to directly pull out a loop of the transverse colon. A nipple is not mandatory when placing
a colostomy since the contents of the colon usually do not cause irritations of the skin.
23.3.3 Hartmann Procedure, End Colostomy
of the Descending Colon
The sigmoid and the descending colon is mobilized and the colon transected with a
stapler at the level of the distal sigmoid colon after division of the mesentery. Identification of the ureter prior to the dissection of the mesentery is advisable since it eliminates the risk of injury.A stapling device that cuts and closes the colon with a stapling
line at both ends is most advantageous for this step (e.g., Endostapler, Ethicon,Hamburg, Germany).Caution needs to be used to divide the mesentery away from the part
of the colon that will form the colostomy in order to ensure adequate blood supply to
the stoma. A disc of about 2–3 cm is excised at the level of the skin and the fascia incised before the end of the descending colon is exteriorized.The colon right below the
stoma site should be in a fairly straight position,as a loop or siphon may render intubation of the stoma difficult, potentially precluding a later irrigation procedure. At
Chapter 23 Stoma Surgery
times shortening of the colon after it has been pulled through the stoma site may be
required. Opening and fixation of the stoma at the skin level following withdrawal of
the trocars and closure of the port sites are the final steps of the procedure.In our experience, additional fixation of the stoma at the level of the fascia is unnecessary. The
open operation is performed accordingly through a midline laparotomy.
23.4 Postoperative Complications
The most frequently encountered problems following stoma placement are stoma retraction, prolapse,parastomal hernia and skin problems (Shellito 1998).Stoma retrac-
tion usually is secondary to a technical problem during stoma placement,i.e., tension
on the bowel.In most cases, conservative treatment is possible except when the stoma
completely slips back into the abdomen causing peritonitis.Then an emergency reoperation is indispensable. For the other cases managed conservatively, time will show
whether stenosis or skin problems secondary to difficult stoma care occur with the
subsequent need for replacement of the stoma at a different site.Prolapse and parasto-
mal hernia may also warrant correction either by local excision and shortening of the
redundant intestine at the stoma site or by repositioning the stoma to a different position. As some degree of prolapse and parastomal hernia is physiological after some
time, surgery should only be undertaken in symptomatic patients or when other problems such as bleeding or obstruction occur. Skin problems around the stoma site are
basically always a consequence of difficulties in stoma care. In most cases, a stoma
therapist will manage to solve these problems by modifications of the stoma care
and/or special appliances. If skin irritations are secondary to skin folds at the stoma
site, surgical repositioning of the stoma may ultimately be warranted.
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23.5 Summary
A diverting stoma is an extremely important option for the treatment of fecal incontinence. It should be considered in patients after unsuccessful conservative or surgical
treatment if severe limitations of social activities persist. However,a diverting stoma is
not only a last resort but also a reasonable option for patients who seek the most efficacious,simple and quick relief of fecal incontinence.Furthermore, a loop ostomy may
be useful during extensive reconstructive surgery of the sphincters. Temporary stomas
are usually placed as loop ostomies, while a Hartmann procedure with an end-descending colostomy is our procedure of choice for permanent stoma. Careful marking
of future stoma site and extensive advice to the patient preoperatively are indispensable.In the suitable patient,stoma placement may be performed by minimally invasive
techniques.
References
Edwards DP, Leppington-Clarke A,Sexton R, Heald RJ, Moran BJ (2001) Stoma-related complica-
tions are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg 88: 360–363
Grumann MM, Noack EM,Hoffmann IA, Schlag PM (2001) Comparison of quality of life in pa-
tients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann
Surg 233: 149–156
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Martin E. Kreis,Ekkehard C. Jehle
Jonsson B,Zethraeus N (2000) Costs and benefits of laparoscopic surgery – a review of the liter-
ature.Eur J Surg Suppl 585:48–56
Lehur PA, Roig JV, Duinslaeger M (2000) Artificial anal sphincter: prospective clinical and man-
ometric evaluation.Dis Colon Rectum 43 :1100–1106
Ludwig KA, Milsom JW, Garcia-Ruiz A, Fazio VW (1996) Laparoscopic techniques for fecal diver-
sion. Dis Colon Rectum 39: 285–288
Madoff RD (2004) Surgical treatment options for fecal incontinence. Gastroenterology 126 :
S48–S54
Madoff RD,Rosen HR, Baeten CG,LaFontaine LJ, Cavina E,Devesa M, Rouanet P,Christiansen J,
Faucheron JL,Isbister W, Kohler L, Guelinckx PJ, Pahlman L (1999) Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective,multicenter trial. Gastroenterology 116: 549–556
Matzel KE, Kamm MA, Stosser M, Baeten CG, Christiansen J, Madoff R, Mellgren A, Nicholls RJ,
Rius J, Rosen H (2004) Sacral spinal nerve stimulation for faecal incontinence: multicentre
study. Lancet 363: 1270–1276
Miner PB Jr (2004) Economic and personal impact of fecal and urinary incontinence. Gastroen-
terology 126: S8–S13
Norton C (2004) Behavioral management of fecal incontinence in adults. Gastroenterology 126 :
S64–S70
Oliveira L,Reissmann P, Nogueras J,Wexner SD (1977) Laparoscopic creation of stomas.Surg En-
dosc 11: 19–23
Read M,Read NW, Barber DC, Duthie HL (1982) Effects of loperamide on anal sphincter function
in patients complaining of chronic diarrhea with fecal incontinence and urgency. Dig Dis Sci
27: 807–814
Robinson TN,Stiegmann GV (2004) Minimally invasive surgery. Endoscopy 36: 48–51
Scarlett Y (2004) Medical management of fecal incontinence.Gastroenterology 126 :S55–S63
Schwandner O, Schiedeck THK,Bruch HP (1998) Stoma creation for fecal diversion: is the lapar-
oscopic technique appropriate? Int J Colorect Dis 13 :251–255
Shellito PC (1998) Complications of abdominal stoma surgery. Dis Colon Rectum 41 :1562–1572
Turnbull GB (2003) Managing oversight of colostomy irrigation in long term-care. Ostomy
Wound Manage 49 :13–14
Weiss UL, Jehle E, Becker HD,Buess GF, Starlinger M (1995) Laparoscopic ileostomy. Br J Surg 82
:1648
Zittel TT, Manncke K, Haug S, Schäfer JF, Kreis ME, Becker HD, Jehle EC (2000) Functional re-
sults after laparoscopic rectopexy for rectal prolapse. J Gastrointest Surg 4: 632–641
Part VII
Postoperative Care of Patients
After Pelvic Operations
VII
Chapter 24
Chapter 24 Postoperative Management After Surgery for In-
Postoperative Management After Surgery
for Incontinence and Prolapse
Ursula M.Peschers, Ralf Tunn
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24
Contents
24.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 336
24.2 Immediate Postoperative Phase . . . . . . . . . . . . . . . 336
24.2.1 Medium Term . . . . . . . . . . . . . . . . . . . . . . . . . 336
24.3 Immediate Postoperative Care . . . . . . . . . . . . . . . . 336
24.3.1 Medium Term: . . . . . . . . . . . . . . . . . . . . . . . . 337
336
Ursula M. Peschers, Ralf Tunn
24.1 Introduction
Incontinence and prolapse surgery is intended to restore anatomy and function. Contrary to oncological surgery,which is carried out to save the patient’s life, urogynecological surgery tries to improve the patient’s well-being. Therefore postoperative care
after surgery for incontinence and prolapse presents specific issues.
24.2 Immediate Postoperative Phase
24
쐽 Did side effects occur: voiding disorder, residual urine,
de novo urge incontinence?
24.2.1 Medium Term
쐽 Incontinence surgery: did symptoms improve?
쐽 Prolapse surgery: is anatomy restored and function preserved?
쐽 How can the result of surgery be preserved?
Unfortunately, to our knowledge there are no evidence-based recommendations because no studies have been published that compare different methods of postoperative
care.
24.3 Immediate Postoperative Care
Kidney ultrasound should be performed to exclude hydronephrosis postoperatively.
Proper bladder emptying has to be ensured.Intermittent self catheterization or suprapubic bladder drainage can be used. Patients should void every 2–3 h during the
day and at least once during the night. If residual urine is less than 100 cc catheterization can be stopped.
If the patient complains about residual urine and/or de novo urgency a urinary
tract infection should be excluded and residual urine checked.Cholinergic drugs help
to improve detrusor contraction, alpha-blocking agents additionally decrease the urethral sphincter tonus.Perineal or introital ultrasound can be used to check for bladder
neck position after colposuspension and for tape position after tension-free application of a polypropylene tape (Viereck,Kosczsewski).If the patient complains about urgency urinary tract infections have to be excluded. If she does not have significant residual urine anticholinergic drugs can be tried.
Postmenopausal patients should generally receive vaginal estriol, especially after
mesh implantation,to avoid erosion of the mesh. Estriol might also be helpful after incontinence surgery when a female patient complains of urgency.
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