Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_639_Библиотеки_им_академика_М_И_Перельмана.pdf
162 Part II Abdominal Wall
3. Olmi S, Scaini A, Erba L, Guaglio M, Croce E. Quantication of pain
in laparoscopic transabdominal preperitneal (TEP) inguinal hernioplasty
identies marked dierences between prosthesis xation systems. Surgery.
2007;142(1):40–46.
4. Lovisetto F, Zonta S, Rota E, et al. Use of human brin glue (Tissucol)
versus staples for mesh xation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective randomized study. Surg Endosc. 2007
Apr;21(4):646–652. Epub 2006 Nov 14.
5. Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R. Laparoscopic
inguinal hernia repair: gold standard in bilateral hernia repair? Results
of more than 2800 patients in comparison to literature. Surg Endosc.
2010;24(12):3026–3030.
6. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus
laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350(18):
1819–1827.
7. Schafer M, Lauper M, Krahenbuhl L. A nation’s experience of bleeding
complications during laparoscopy. Am J Surg. 2000;180:73.
8. Olsen DO. Laparoscopic cholecystectomy. Am J Surg. 1991;161:339.
INTESTINAL STOMAS
Ira J. Kodner • Thomas E. Read • Donna L. Loehner
9
An intestinal stoma is an opening of the intestinal or urinary
tract onto the abdominal wall, constructed surgically or appearing inadvertently. A colostomy is a connection of the colon
to the skin of the abdominal wall. An ileostomy involves
exteriorization of the ileum on the abdominal skin. In rare
instances, the proximal small bowel may be exteriorized as
a jejunostomy. A urinary conduit involves a stoma on the
abdominal wall that serves to convey urine to an appliance
placed on the skin. e conduit may consist of an intestinal
segment, or in some cases a direct implantation of the ureter,
or even the bladder, on the abdominal wall.
Information about the types and numbers of stomas constructed, complications of stomas, and resultant impairment
of an individual’s life has been limited because the diseases for
which stomas are constructed are not mandated as reportable
in the United States. erefore, the United Ostomy Association of America (UOAA, www.uoaa.org ), formerly the United
Ostomy Association, a voluntary group of 40,000 members
with stomas of various types, undertook the mission of collecting data from patients in the United States and Canada
who have an intestinal stoma. A review of 15,000 such entries
shows the peak incidence for ileostomy construction owing to
ulcerative colitis to occur in persons between 20 and 40 years
of age, with a lower peak but in the same age range for patients
with Crohn’s disease. e second largest peak represents colostomies constructed because of colorectal cancer, and this peak
is in patients 60–80 years of age. When complications were
analyzed according to original indication for surgery, we found
that many patients knew that they had complications but were
not aware of the exact nature of the complication. Postoperative intestinal obstruction occurred in all categories of disease,
as did retraction of the stoma and abscess formation. ere
was a preponderance of hernia formation in patients who had
surgery for colorectal cancer, whereas abscess, stula, and stricture formation were the major complications in the patients
with Crohn’s disease. As new surgical procedures are devised,
a justi cation for their utilization is often the reduction of the
level of handicap that exists among patients who have had construction of a conventional ostomy. e UOA survey revealed
that patients resumed household activities 90% of the time,
vocational activities 73% of the time, social activities 92% of
the time, and sexual activities 70% of the time. It is taken
into account that patients who have proctectomy for cancer
frequently lose their sexual function because of autonomic
denervation and not because of the presence of a stoma.
Changes that have improved the quality of life of the
patient with a stoma include the development and availability
of improved stoma equipment. Specialized surgical techniques,
some of which are described in this chapter, have been
developed that facilitate the subsequent maintenance of an
ostomy. In addition, specialized nursing techniques applied
both preoperatively and postoperatively have enhanced
the care of the patient with a stoma. e involvement of a
Certi ed Wound Ostomy Continence Nurse (CWOCN) in
the care of patients with stomas is critical.
e overall incidence of stoma construction appears to be
decreasing and will probably continue to do so. ere are now
fewer abdominoperineal resections for cancer because of the
advent of new surgical techniques, especially the use of stapling devices, as well as an increased use of local treatment for
selected rectal tumors. e incidence of permanent ileostomies
is decreasing because of the popularization of sphincter-saving
procedures for patients with ulcerative colitis and familial polyposis. e surgical procedures that eliminate permanent stomas,
however, have resulted in an increasing use of temporary loop
ileostomies.
Each type of stoma is associated with a particular spectrum
of complications, but some problems are common to all
intestinal stomas. e speci c ones are dealt with under each
category of stoma. A common complication, regardless of the
stoma type, is destruction of the peristomal skin, which is
usually caused by poor location or construction of the stoma.
In addition to the acute maceration and in ammation of
the skin, pseudoepitheliomatous hyperplasia may arise at
the mucocutaneous border of stomas subjected to chronic
mal tting appliances. Appearance of a stula adjacent to a
stoma usually indicates recurrence of Crohn’s disease. One of
the di cult complications to handle, especially in an obese
patient, is improper location of the stoma, which prohibits
maintenance of the seal of an appliance. A stoma buried in a
skin fold, or a ush stoma, can create devastating peristomal
skin problems. A special problem arises in the patient who
163
164 Part II Abdominal Wall
has portal hypertension because the construction of a stoma
results in the creation of a portosystemic shunt, and varices
can form in the peristomal skin.
Other common problems include the need for precautions
with medications, especially time-released enteric medications, which may pass through a shortened intestinal tract
unabsorbed. Laxatives also can be devastating to patients with
no colon or with a proximal colostomy. In some cases, the
ostomy patient has chronic diculty maintaining proper uid
and electrolyte balance, and diuretics in these patients can
be especially dicult to manage. e usual intestinal preparations prior to diagnostic testing should be altered for the
patient with an intestinal stoma.
Many potential stoma complications can be avoided by
proper preoperative marking and counseling. e stoma
location should be chosen and marked preoperatively, even if
there is only a remote possibility of the need for an intestinal
stoma during the operative procedure. Surgeons who perform
intestinal stomas should be well versed in stoma care and
management of stoma complications. e value of collaboration with an enterostomal therapist (CWOCN) cannot be
overstated. Patients should meet with the CWOCN preoperatively, and the surgeon and CWOCN should discuss the
selection of potential stoma sites together prior to operation.
COLOSTOMY
e most common indication for fashioning a colostomy is
cancer of the rectum. Since a colostomy is an opening of the
large intestine with no sphincteric control, its location would
obviously be better on the abdominal wall than in the perineum,
where an appliance cannot be maintained. A distal colorectal
anastomosis in an elderly patient with a poorly functioning
anal sphincter may result in what is essentially a “perineal colostomy.” In these cases, it often behooves the surgeon to construct
a good colostomy rather than to restore intestinal continuity to
an incontinent anus. Colostomies are also constructed as treatment for obstructing lesions of the distal large intestine and for
actual or potential perforations.
usually expel a liquid content. eleft colon serves as a conduit
and reservoir and has a few mass peristaltic motions per day.
e content is more solid, and in many cases the stoma output can be regulated by irrigation. Proximal colostomies should
be avoided, as they will combine the worst features of both a
colostomy and an ileostomy: liquid, high-volume, foul- smelling
euent. e left colon should be used for a colostomy if possible; the distal transverse colon is also a reasonable choice.
Determination of Colostomy Location
e location of the colostomy must be carefully selected preoperatively. It should avoid any deep folds of fat, scars, and
bony prominences of the abdominal wall. e site is chosen by
evaluating the patient in the standing, sitting, and supine positions. Often abdominal skin and fat folds are only noted with
the patient in the sitting position. A stoma faceplate is applied
to the abdominal wall with its medial margin at the midline;
care is taken to not overlay any fold, scar, or prominence; and
the stoma site is marked. e inguinal fold and waistline fold
should be avoided. If a sigmoid or descending colostomy is contemplated, the most desirable position is usually in the left lower
quadrant of the abdomen. However, if the patient is obese, it
may be preferable to site the colostomy in the left upper quadrant so that it is visible to the patient and not trapped on the
undersurface of a panniculus. If a distal transverse colostomy is
planned, the left upper quadrant is usually the preferable site.
Please refer to the section on determination of the ileostomy
location for more details regarding stoma site selection.
Type by Function
More important than the anatomy of the colon is the function
that the colostomy is intended to perform. ere are two considerations: (1) to provide decompression of the large intestine,
and (2) to provide diversion of the feces.
DECOMPRESSING COLOSTOMY
Type by Anatomic Location
Traditionally, the type of colostomy has been categorized by the
part of the colon used in its construction. e most common
type has been called an “end-sigmoid” colostomy. However, if
the origin of the inferior mesenteric artery is transected during
an operation for cancer of the rectum, the blood supply to the
sigmoid colon is no longer dependable, and it should not be
used for stoma construction. erefore, an “end-descending”
colostomy is usually preferable to an end-sigmoid colostomy.
Other types of colonic stomas include the transverse colostomy
and cecostomy. e physiology of the colon should be taken
into account when considering stoma construction. e right
side of the colon absorbs water and has irregular peristaltic contractions. Stomas made from the proximal half of the colon
A decompressing colostomy is most often constructed for distal
obstructing lesions causing dilation of the proximal colon without ischemic necrosis, severe sigmoid diverticulitis with phlegmon, and for select patients with toxic megacolon. Alternative
treatments exist for these conditions: total abdominal colectomy
with ileostomy or ileorectal anastomosis; segmental colectomy
with construction of end colostomy; segmental colectomy with
primary anastomosis; and segmental colectomy with intraoperative colonic lavage and primary anastomosis with temporary
diverting loop ileostomy. However, temporary decompressing
stomas are still useful and safe. e procedure acts as a bridge
to denitive operation for toxic patients with benign disease
and those with malignant distal obstruction. e disadvantages
of a decompressing stoma is that it does not provide denitive management of the disease process and thus the patient
often requires subsequent operation, and it does not necessarily
Chapter 9 Intestinal Stomas 165
provide complete fecal diversion and thus carries the risk of
potentially fatal sepsis if there is distal perforation.
Types of Decompressing Stomas. ere are three types
of decompressing colostomies: (1) the so-called “blow-hole”
decompressing colostomy constructed in the cecum or
transverse colon, (2) tube cecostomy, and (3) loop colostomy.
Cecostomy and “Blow-Hole” Colostomy. A cecostomy
should be constructed only rarely because it is dicult to
manage postoperatively. It should be reserved for the severely,
acutely ill patient with massive distention and impending
perforation of the colon. is is seen most often with distal
obstructing cancer or in some of the pseudo-obstruction
syndromes seen in elderly or immuno-compromised patients.
Because these operations are done on an urgent basis and the
abdomen is usually distorted by intestinal dilation, the choice
of site for an incision is over the dilated cecum. e location
of this incision or of an intended decompressing transverse
colostomy can be selected by placing a marker on the umbilicus when an abdominal lm is obtained.
e construction of a blow-hole cecostomy or transverse
colostomy (Fig. 9-1) is carried out by making a 4–6 cm transverse incision over the most dilated part of intestine and
then placing a series of interrupted, seromuscular, absorbable sutures between the peritoneum and the seromuscular
layer of the bowel to be decompressed. is should be done
through an incision sucient to allow subsequent incision
of the intestine and suturing of the intestine to the skin. e
bowel wall will be very thin, and it is not unusual to have
leakage of gas as the sutures are being placed. A disadvantage
of a cecostomy or loop colostomy done through a small incision is that one cannot evaluate other parts of the colon for
potential ischemic necrosis due to massive dilation.
Once the rst layer of sutures has been placed and the
intestine is sealed from the remainder of the abdominal
cavity, needle decompression of the gas-distended viscus
is performed to reduce the tension on the intestinal wall.
When this procedure is completed, a second layer of absorbable sutures is placed between the seromuscular layer of the
intestine and the fascia of the abdominal wall. Subsequently,
the colon is incised, usually with release of a large amount of
liquid and gas. e full thickness of intestine then is sutured
to the full thickness of skin, again with absorbable sutures,
and an appliance is placed over the stoma. Postoperatively,
it is not unusual for there to be signicant inammation in
the abdominal wall around such a stoma, and after a period
of weeks, signicant prolapse may occur. erefore, these
stomas should be used for short periods of time, with denitive resection performed as soon as possible.
A tube cecostomy (Fig. 9-2) is constructed by making an
incision similar to that used for a “blow hole” colostomy, by
formal laparotomy, or by laparoscopy. A purse-string suture
is placed in the cecal wall, and a large mushroom-tipped or
Malecot catheter is placed in the cecum. e purse-string
suture secures the catheter. Usually a second purse-string
suture is placed, and the tube is brought through a right lower
quadrant incision. e cecum then is sutured to the peritoneum of the abdominal wall. e advantage of this stoma
is that there is less chance of prolapse. e major disadvantage is that the tubes usually become blocked with feces,
drain poorly, and sometimes leak stool adjacent to the drain.
Because of all their disadvantages, tube cecostomy and blowhole colostomies are rarely performed at present.
Loop-Transverse Colostomy. A loop colostomy using
the transverse colon (Fig. 9-3) or left colon can be used as
a decompressive stoma, although it will usually completely
divert the ow of stool away from the distal colon and can
thus be considered a diverting stoma. Occasionally, the
posterior wall of the stoma recesses far enough below the
wall of the abdomen so that stool can enter the distal loop,
although this is uncommon. ese stomas are constructed
for reasons similar to those described for the blow-hole type
stoma and to provide temporary diversion for protection of
complicated distal anastomoses. e other advantage is that
when properly constructed, a loop colostomy can serve as a
long-term stoma. e incidence of prolapse is not prohibitive. Parastomal hernias can occur if the fascia is not closed
tightly enough, and these stomas usually cannot be regulated
by irrigation techniques.
e site can be chosen for this stoma in an emergency situation as previously described, but it should be marked electively
on the abdominal wall in preparation for potential construction
in patients who are to have low colorectal anastomoses or in
those in whom it is anticipated that an inammatory reaction
will be encountered and will require temporary diversion of
intestinal contents as a safeguard against contamination from a
leaking anastomosis. is occurs occasionally in patients with
severe diverticulitis. In an elective situation, the stoma can be
placed through the rectus muscle either on the right or left side,
depending on later intentions of closing or resecting the colostomy site in continuity with a cancer operation, or it can be
brought through the midline (Fig. 9-3A). If performed in conjunction with a midline incision, a midline colostomy site may
be suboptimal because of diculty with placing the ostomy
appliance over the fresh incision.
Construction of loop colostomy requires the colon to be
mobile enough to be brought to the level of the abdominal
wall (Fig. 9-3B). If this cannot be done or if the colon is so
massively dilated that loop colostomy is not safe, one should
resort to the use of a blow-hole colostomy as previously
described, in which only one wall of the intestine is utilized
and tension on the mesentery is avoided. A transverse loop
colostomy can be constructed by placing a tracheostomy
tape or soft latex drain around the colon at the site chosen
for the colostomy. e transverse colon at this site is usually
dissected free of the overlying omentum in the embryonic
peritoneal fusion planes. e tracheostomy tape and colon
are brought through an avascular window in the omentum
to allow better sealing between the colon and the abdominal wall (Figs. 9-3B and 9-3C). e fascia is then closed on
either side of the loop of colon tightly enough to allow snug
passage of one ngertip (Fig. 9-3D).
First suture layer
(Peritoneum-seromuscular)
Line of incision
Obstructing
lesion
C
B
A
Seromuscular
peritoneal suture
Second suture layer
(Fascia-seromuscular)
D
Bowel incision
Fascia-seromuscular
suture
E
F
Stoma
Skin-bowel suture
Lesion
G
H
FIGURE 9-1 Construction of blow-hole cecostomy or colostomy. A. e incision is located over the most dilated aspect of the intestine.
B. After the peritoneum is quarantined, gas is allowed to escape, decompressing the bowel. C. Placement of the quarantine sutures. D. e colon
is opened, and more adequate aspiration is eected. E. Details of the second level of quarantine sutures between the fascia and seromuscular layer
of the colonic wall (this should be completed before the bowel is opened). F, G. e stoma is completed by placement of sutures between skin
and colonic wall. H. Completed blow-hole stoma.
166
Chapter 9 Intestinal Stomas 167
Osteotomy
site
Dilated
colon
Abdominal
incision
Obstructing
lesion
Mushroom
BA
Malecot
C
D
F
E
FIGURE 9-2 Construction of a tube cecostomy. A. e cecostomy is constructed over the most dilated aspect of the cecum. B. A very large
Malecot or mushroom-tipped catheter is used. C, D. e catheter is secured within the cecum by two purse-string sutures. E. e cecum is sutured
to the abdominal wall at the entry site of the catheter. F. Cross section of the completed tube cecostomy.
168 Part II Abdominal Wall
RUQ
A
Fascia
Upper
midline
Abdominal
incision
Periton
B
Site of
bowel
incision
Fascial closure
C D
Skin
closure
E
Skin-full
thickness
bowel sutures
F
G
FIGURE 9-3 Construction of a loop-transverse colostomy. A. Choice of stomal location. B, C. Tracheostomy tape is used to pull the loop of
colon through the incision. D. e fascia is closed tightly around the loop of intestine. E, F, G. e loop of colon is opened over a supporting rod
and is sutured to the skin of the abdominal wall.
Chapter 9 Intestinal Stomas 169
e skin is then snugly closed, on either side of the loop
of colon. e tracheostomy tape is replaced by a plastic rod
that frequently has a suture through each end so that it can
be easily repositioned should it be displaced (Fig. 9-3E).
e wound is protected, and attention is directed to the
protruding loop of colon, which is incised either longitudinally or transversely to allow the best separation of the
edges of the colon (Fig. 9-3F). Full thickness of intestine is
then sutured to full thickness of skin with absorbable suture
material (Fig. 9-3G). If this stoma is properly constructed,
the posterior wall will bulge upward, providing the desired
diversion as well as decompression. An appliance is applied
either over the rod or beneath the rod, depending on the
tension of the stoma.
If there is a possibility that the colostomy may become
permanent, it may be advantageous to divide the colon with
a stapler and create a “divided end-loop” stoma in the manner of Prasad and Abcarian. e proximal colon is matured
as an end colostomy, and a corner of the distal limb opened
and matured as a mucus stula in the same stoma incision to
vent the distal colon (see Fig. 9-9, construction of separated
[divided end-loop] ileostomy). e stoma size is typically
smaller than a loop colostomy and the tendencies to prolapse
or retract may be lessened.
In the postoperative period, the appliance is emptied
or changed as necessary, and the wound is kept clean. e
rod is usually left in place for several days and then is easily
removed. e colostomy appliance is fashioned as necessary
as the contour of the stoma and skin opening change. Patients
with this type of stoma usually are not taught to irrigate,
because irrigation is infrequently successful. After the immediate postoperative period, the patient usually is instructed
to empty the appliance as necessary and to change the entire
appliance every 3 to 4 days, depending on the condition of
the skin and the ability to maintain an adequate seal of the
appliance to the skin.
Closure of a Temporary Colostomy. e most impor-
tant consideration in dealing with closure of a temporary
colostomy is deciding when it is safe to restore intestinal
continuity. Distal integrity and adequacy of sphincter muscle
function must be carefully evaluated before closure of the
stoma is undertaken. e reason for constructing the stoma
initially must be taken into account, and contrast studies and
endoscopy should demonstrate clearly that the original reason
for fecal diversion no longer exists.
Adequate function of the anal sphincter must be demonstrated before the temporary colostomy is closed. is
can be done by formal manometric and electromyographic
studies or by giving the patient a 500-mL enema and asking himor her to hold it until he or she can comfortably
walk to a toilet and expel the enema. If the sphincter does
not work and cannot be repaired, the patient will be better o with a properly constructed end colostomy than with
attempts to preserve a nonfunctional sphincter. Once it is
decided that it is safe to close the colostomy, the procedure
should be undertaken with the same skill and precaution as
that required for a colon anastomosis (Fig. 9-4). e complication rate following colostomy closure is not insignicant,
and is cited by some authors as a reason to avoid diverting colostomy construction at all costs. However, as with
all issues in medicine, careful consideration of the potential
risks and benets of the procedure in the individual patient
should be made prior to deciding on whether or not fecal
diversion is indicated.
e closure is begun by making a circumferential incision
around the stoma, including a small rim of skin (Fig. 9-4A).
If the stoma has been placed in the midline, the midline
incision may be opened on either side of it to allow adequate mobilization. e circumferential incision is deepened until the peritoneal cavity is entered and the colon and
surrounding omentum can be separated from the abdominal wall. e colon is then brought through the incision,
and the serosal surface is clearly dened circumferentially
(Figs. 9-4B and 9-4C). is involves resecting omentum
and brofatty tissue from the serosal surface. Once this step
is completed, the stoma is ready for closure, which can be
accomplished by a linear stapling device (Figs. 9-4D and
9-4E), by a hand-sutured closure (Figs. 9-4F and 9-4G),
or if the bowel has been compromised in any way, by complete transection of the colon and construction of a formal
end-to-end anastomosis. Caution must be taken to ensure
that no small intestine has been injured and that no signicant bleeding has been left unattended. Once this has been
accomplished, the colon is returned to the abdominal cavity and the abdomen is closed. Usually the skin itself is left
open for delayed primary closure.
DIVERTING COLOSTOMY
A diverting colostomy is constructed to provide diversion
of intestinal content. It is performed because the distal
segment of bowel has been completely resected (as during
abdominoperineal resection), because of known or suspected
perforation or obstruction of the distal bowel (eg, obstructing
carcinoma, diverticulitis, leaking anastomosis, or trauma),
or because of destruction or infection of the distal colon,
rectum, or anus (eg, Crohn’s disease or failed anal sphincter
reconstruction).
Choices for Construction. Although a completely divert-
ing colostomy can be made only by complete transection
of the colon, a well-constructed loop-transverse or sigmoid
colostomy may provide near complete fecal diversion. Stool
and atus will move preferentially toward the low-pressure
side of any pressure gradient, and this usually means that
it will ow into the stoma appliance, which is at atmospheric pressure, rather than into the distal bowel. However, patients who have loop stomas must be counseled that
if the stoma appliance becomes full, stool and atus can
be forced distally because the pressure gradient now favors
passage of intestinal contents into the distal limb of intestine. is discussion should take place prior to discharge
from the hospital, as this phenomenon usually occurs late
170 Part II Abdominal Wall
A
D
B C
E F
G
FIGURE 9-4 Closure of a loop-transverse colostomy. A. A circumferential incision is made around the stoma, with reopening of the midline
incision if needed. B, C. e colon is mobilized adequately. D, E. Staple closure of the colostomy. F, G. Suture closure of the colostomy.
at night after the patient has slept and not emptied their
appliance. e rst passage of atus or stool per anus in a
patient who was under the impression that their fecal stream
was completely diverted can be suciently alarming as to
prompt an emergent call to the surgeon, usually in the wee
hours of the morning.
ere are some situations in which the diverting loop
colostomy fails to divert the ow of stool because the stoma
retracts into the abdomen and stool ows into the distal
colon. Patients who are profoundly malnourished may be at
increased risk of this complication. In addition, stomas that
are constructed under tension may also be prone to retraction.
Chapter 9 Intestinal Stomas 171
If a colostomy is being performed proximal to an obstructing lesion, to decompress the colon and divert the ow of
stool, it is critical that the distal limb of the colostomy be
vented to the atmosphere and not closed. If the distal limb is
closed and there is a complete obstruction distal to the colostomy, this will create a closed loop obstruction, and there is a
substantial risk of distention and perforation.
If the rectum and anus have been completely resected, an
end colostomy is created. If a partial colectomy/proctectomy
has been performed, and an anastomosis is not constructed,
an end colostomy is created and the distal bowel is closed
(as in a Hartmann resection) or brought to the skin as a
mucus stula. e decision about whether to create a mucus
stula or to close the distal segment will hinge on whether
there is concern regarding distal obstruction, the length of
the distal segment, and the integrity of the distal segment.
For example, in a patient undergoing sigmoid colectomy
and colostomy for complicated diverticulitis, it is reasonable to close the rectal stump providing that proctoscopy
reveals a normal rectum. Conversely, in a patient undergoing
abdominal colectomy and ileostomy for toxic colitis, it may
be preferable to bring the distal sigmoid to the skin level
as a mucus stula to avoid rectal stump blowout. A mucus
stula may be constructed as a separate stoma, opening just
a corner of the closed end as a small vent. Alternatively, the
mucus stula can be constructed so that the small vent is
matured (“mature” means that the colonic wall is sutured
primarily to the skin) in a corner of the abdominal wall
opening used to create the proximal stoma in the manner
of Prasad and Abcarian (the “divided end-loop” stoma). is
facilitates care in that the patient has only one stoma appliance, and facilitates stoma closure because both limbs of the
bowel are located adjacent to one another. e old operation
of the so-called Divine double-barreled colostomy should be
abandoned because the adjacent full-diameter stomas make
application of an appliance very dicult.
Construction of an End Colostomy (Fig. 9-5). An end,
completely diverting, colostomy usually is located in the left
lower quadrant, where the site is chosen preoperatively by
placing a vertical line through the umbilicus and another line
transversely through the inferior margin of the umbilicus and
by axing a disk, the size of a stoma faceplate to designate the
stoma opening through the rectus muscle and on the summit
of the infraumbilical fan fold (Fig. 9-5A).
Once a site is chosen, the patient should be evaluated
in multiple body congurations to verify the adequacy of
the stoma site. A common mistake is to choose the site
with the patient supine and then nd when the patient
rises to a standing or sitting position that the chosen site
is completely obscured by fat folds, scar tissue, or a protruding skeletal structure. e location should be adjusted
up or down, even considering the use of upper quadrants
of the abdomen if necessary, to allow proper xation of
an appliance and easy access by the patient. e site usually is marked with ink in the patient’s room and then is
scratched into the skin with a needle in the operating room
after induction of anesthesia. is is totally painless for
the patient and does not leave a permanent tattoo should
colostomy not be needed.
An end colostomy most often is constructed after removal
of the rectum for low-lying malignancy (see Chap. 40). e
entire left colon is mobilized on its mesentery, and depending
on mobility of the colon and thickness of the abdominal wall,
may require mobilization of the splenic exure (Fig. 9-5B).
If the patient has received neoadjuvant pelvic radiotherapy
and/or the inferior mesenteric artery is transected at its origin at the aorta, the entire sigmoid colon should be removed
because of concerns regarding ischemia and a descending
colostomy created.
If the colostomy is to be brought through the left lower
quadrant, an opening in the abdominal wall is made at the
previously marked site by excising a 3 cm disk of skin. e
undesirable oval conguration of a stoma is avoided by
placing traction clamps in the dermis, the fascia, and the
peritoneum. ese clamps are held in alignment whenthe
opening is made through the abdominal wall. is duplicates the conguration of the abdominal wall when the
abdomen is closed and should allow construction of a desirable circular stoma.
e fat, fascia, muscle, and posterior peritoneum are
incised longitudinally (Fig. 9-5A). e opening is then
dilated, and the closed end of the colon is pulled through
the abdominal wall (Fig. 9-5C). e mesentery of the colon
can be sutured to the lateral abdominal wall with a running
suture, although the complication of small bowel obstruction due to torsion of the small bowel mesentery around the
colon mesentery has not been proven to be reduced by this
maneuver. After the wound is closed and protected, attention is directed to completing the colostomy (Figs. 9-5C,
9-5D, and 9-5E). e stoma is completed by excising the
staple or suture line and by placing chromic catgut sutures
between the full thickness of colon and skin. If the stoma is
constructed because of inammatory bowel disease or radiated bowel, a spigot conguration is utilized by applying
principles similar to those for ileostomy construction. is
facilitates a good appliance seal for anticipated high-volume,
liquid euents.
Once the stoma construction is complete, an appliance is
applied in the operating room. e simplest is a one-piece
appliance with a skin barrier that can be cut to the appropriate size of the stoma. is same appliance can be used for
colostomy and ileostomy. e appliance, which need not be
sterile, is held in place with the skin adhesive of the appliance. Tincture of benzoin or other similar adhesives should
never be used to maintain adhesion of an appliance to the
skin because it has a high risk of initiating contact dermatitis. If colostomy function does not begin within 4 or 5 days,
the stoma can be irrigated with small volumes (250 mL) of
normal saline to initiate stoma function. e stoma nurses
are involved early in the care of the stoma and in teaching
the patient and family to provide long-term care of the colostomy. In some cases, the patient is taught the technique of
stoma irrigation, and then each individual decides in the