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Patients who have planned surgery involving a stoma typically see a
‘bag lady’ (a stoma nurse or enterostomal therapist) prior to operation.
This consultation helps to prepare the patient psychologically and
practicallyfortheirsurgery.Akeypartofthisprocessismarkingthesite
for the planned stoma. The patient is usually examined lying and
standing, and their clothing preferences are taken into account. An
emergencyabdominalsurgeondoesnothavetheluxuryofaccess
toastomanurseat2inthe morning when confronted with a sick
patient with aperforatedcolon (actually,even if you can find one, a
stomanursewilloftentellyouthattheycannotsiteastomainapatient
with a tender distendedabdomen). So you needto have a reasonable
understandingofwheretoplaceyourstoma.
Youshouldaimtoplaceyourstomathroughaflatpartoftheskin
away from scars,bony prominences and skin creases. In practice,
think of an imaginary triangle with points at the umbilicus, anterior
superior iliac skin and the mid-point of the costal margin andthen site
yourstomathroughthistriangle(oneitherside)—thetriangleofstomata
( Figure14.3).
Foramorenuancedversionofthis,youshouldvaryhowhighorlowin
thetriangleyoucutaccordingtotheclinicalsituation.Skinnyyounggirls
withCrohn’sdiseasetendtopreferastomalowdownintheabdomento
fitwiththeirwardrobe.Thissitewould,ofcourse,beadisasterina250lb
beer-swilling man needing a Hartmann’s procedure; for him place the
stomahigher above the beer belly, sohecan see to change hisstoma
pouch.Inpracticewithvisceraloedemaanddistendedbowelloops
you may need to place your stoma where it can reach the skin
without tension, rather than the optimal site. Whatever you do,
bringing the stoma, or even a mucous fistula out through the surgical
wound,isnotsomethingthatIwouldadvise(see Figure14.4).
Figure14.4.Bringingacolostomyoutthroughalaparotomyincisionislikeputtingatoilet
inthekitchen.
Makingastoma—generalprinciples
Consider a stoma as an anastomosis between bowel and skin;
you should aim to bring together well-vascularized tissues with
minimaltensionandpayattentiontosurgicaltechnique(althoughto
befairtheconsequencesofa‘leak’fromastoma areless seriousthan
thosefrom an anastomoticleak — that’swhy youmadea stomainthe
firstplace,wasn’tit?).
Youshouldmakethestomatrephineassmall(orlarge)aspossibleto
allow delivery of the bowel without any vascular compromise. The
trephine may bemade by elevating the skin with a tissue forceps and
using a scalpel to excise a disk of skin. In my hands, this invariably
resultsinamuchtoolarge,raggedskindefect.Soasanalternative,a
cruciateincisioncanbemadeatthesiteofthestoma,excisingthe
corners to make a circular trephine. Conventionally, the external
obliqueaponeurosisisincisedinacruciformmanner,andtheunderlying
rectus abdominis is split in the line of its fibers. The posterior rectus
sheath and peritoneum are elevated between two clips and incised to
enter the abdominal cavity. Be careful not to injure the inferior
epigastricarteryatthispoint— it’sa realpain inthe arsetohave to
fuddleinthedepthsofasmallstomaincisiontostopbleedingattheend
ofalonglaparotomy.
The bowel to be used for the stoma is grasped with an atraumatic
clampinserted throughthe stomatrephine anddelivered outside.If you
aremakinga loopstoma,a nylontapecanbeloopedthroughaholein
themesenteryandusedtoguideoutthebowel.
Maturation of the stoma is performed (after any other wounds
havebeenclosedanddressed)asfollows:
•
An ileostomy should be spouted (known as the ‘Brooke’s
ileostomy’)tofacilitatecollectionofliquideffluent.Thespoutcanbe
createdby inserting aBabcockclamp into thelumen, grasping the
mucosa,andpullingtocreatethespout.Alternatively,threeeverting
suturesareplacedthoughtheserosaabout4-5cmfromtheopened
bowel. These sutures are held in clamps until all are placed and
thentightenedtospouttheileostomy.Becarefulwiththeseeverting
sutures;ifplacedtoodeeplytheycancauseadifficultfistulaatthe
mucocutaneous junction. By varying the height of these everting
sutures,itispossibletocreateaslightdownwardtilttotheileostomy
spoutwhich willmake stomamanagement easier.Ifthepatientis
obese or the small bowel mesentery is short, it may be
extremely difficult to form a spouted ileostomy without any
tension.In these circumstances, it may be useful to close the
end of the ileum with a linear cutting staple and form a loop
ileostomyjust proximal tothis(anend-loop ileostomy).Aloop
ileostomy is formed in a similar manner with the proximal end
evertedtoformaspout.Itis crucial that the correct (i.e. proximal)
limboftheileostomyiseverted;asanalternativebothproximaland
distal limbs can be spouted. A rod is almost always unnecessary
whencreatingaloopileostomy.
•
A colostomy, in contrast, does not need a spout. Although
traditionally a colostomywas formed flush with the skin, there are
some advantages to creating a ‘minimally-raised’ colostomy which
reduces leaking and pancaking (pooling of semi-solid stool under
the stoma appliance). Again, fine absorbable sutures should be
usedtostitchthefullthicknessofthebowel,includingthemucosa,
toskinfollowingwoundclosure.
After an operation to create a stoma, I usually seal the laparotomy
woundwithaliberalapplicationofskinglue,thetheorybeingthatifthere
is an early leak from the stoma appliance it will not contaminate and
infect the wound. Anecdotally this does seem to work, although if the
wound is grossly contaminated at the time of an emergency operation
(e.g. fecal peritonitis) this is probably pointless (under these
circumstances,Ieitherleavetheskinopenorgentlyapproximateitwitha
fewinterruptednylonsutures).
Endcolostomy
In the setting of emergency surgery, an end colostomy is usually
performedduringaHartmann’sproceduretoresectthesigmoidcolonfor
perforation or (perhaps less commonly nowadays) for large bowel
obstruction. The stoma is usually sited in the left iliac fossa. The
challengehereistodeliverasufficientlengthofhealthycolontocreatea
tension-freecolostomy. Itmaybe necessary toformallymobilizethe
splenic flexure and pedicle the colon based on the middle colic
vesselstoachievethis.Ensurethattheendoftheboweltobematured
as the colostomy sits ‘comfortably’ on the surface of the skin before
closing the abdomen. If you are worried that it is too tight, then it
probably is; under these circumstances mobilize the colon now
beforeclosing.
Inaddition to mobilizingthe splenic flexure,high ligation of the inferior mesenteric artery and
veinwould provide additional lengthand a ‘thinner’mesentericpedicle,thus facilitating a leftsidedcolostomyinthemorbidlyobesepatient.Ifinditnecessaryattimes.Jon
Loopcolostomy
Twotypesofloopcolostomyareusefulintheemergencysetting—a
transverseloopcolostomyorasigmoidloopcolostomy:
•
Atransverse loop colostomy isuseful torelieve obstruction ina
patientwhoisunfitforamajorresectionormorerarelyaspartofa
staged procedure (you will then later proceed with a planned
resection). It is possible to perform a loop transverse colostomy
withoutalaparotomybymakingatrephineincisionintherightupper
quadrant; indeed on rare occasions, I have even performed this
underketamineandlocalanaesthetic(althoughthiswasn’tmuchfun
for surgeon or patient!). Distal limb prolapse is a fairly frequent
problemwithatransverseloopcolostomy,butthiscanbedealtwith
later.
•
A sigmoid loop colostomy is easier for a patient to care for;
certainlytherearefewerproblemswithcolostomyprolapsewiththis
stoma. It is useful for ‘defunctioning’ in a patient with a major
perinealwound(anemergencysettingofFournier’sgangreneoran
openfracturedpelviswouldbetypicalexamplesofthis).Itisrarely
possible to create a sigmoid loop colostomy to relieve large
bowel obstruction dueto problems withlength and a grossly
distendedcolon.
Endileostomy
Inthe settingofemergencysurgery,anend ileostomyisusually
performed as part ofasubtotal colectomy forcolitis. Typically it is
sited in the right iliac fossa, although the mobility of the small bowel
mesenterymeansthatitcanbesitedalmostanywhereifnecessary.The
smallbowelmesentery should be trimmed back carefully to pedicle the
bowel leading up to the stoma. Dothis carefully oryou risk completely
devitalizingthestoma.Alsobecarefulwhendeliveringthestomathrough
yourtrephineincision;iftheincisionistoosmalloryouareroughwiththe
tissues,you maystripback themesenteryduring delivery(another way
of devitalizing the stoma). One more important issue isto preserve the
vasculaturefora futureilealpouch—thatwillbe viableandalsoreach
thepelvicfloor.
Loopileostomy
A loop ileostomy has only limited use in emergency surgery.
Perhapsoneexamplewhereitmaybeusedisinamorbidlyobese
patient with acute perforated diverticulitis. An emergency sigmoid
resectioninthissettingisaformidablechallenge;occasionallyitmaybe
better to make a proximal stoma and then later perform an elective
resection. When operating on a morbidly obese patient with a thick
abdominalwallandashortmesocolon,aloopileostomymaybetheonly
feasible stoma. Unfortunately such problems have already spilled from
themotherofthefatties(USA)tous…
Mucousfistula
Amucous fistula isa stomacreated fromthe proximalend ofa
diverted part of bowel. The classic example would be following an
emergencycolectomyforcolitis,whentheendoftherectalstumpwould
bebroughttothesurfaceandmaturedasasecondstoma.Patientsand
their stoma nurses on the whole hate mucous fistulae; they smell and
resultinasecondstomaappliance.Thereisgoodevidencethatinmost
casesofulcerativecolitis,itissafetoclosetherectalstumpandleaveit
intraperitoneally.Veryrarelythecolonissofriablethatitisnotpossibleto
close the stump safely either with sutures or staples. In these
circumstances,Ihaveleftalongstumpandexteriorizeditthroughtheleft
iliacfossa.AsthecolonisfriableitwillnotholdsutureswellandIhave
used a neonatal umbilical clamp to holdthe colon abovethe skin level
(this sloughs off in a few weeks, leaving a neat and secure mucous
fistula).
Ileocolostomy(double-barrel)
Ifyouhaveresectedtherightcolon,butmaintainthatitisunsafe
toperformanileocolicanastomosis,itisworthconsideringcreating
adouble-barrelileocolostomy.Here,both endsof thebowel(terminal
ileumandcolon) arebroughtoutthroughthe sametrephine—youcan
suture the back walls of the two segments together if you wish. The
advantages of this approach are that for the patient there is only one
stomaapplianceneededandforthesurgeonitisthenpossibletoclose
thislaterwithout a formal laparotomy. An ileocolostomy isusefulin two
situations:following a reoperation for a leakingileocolicanastomosis or
attheprimaryprocedurewhentheriskofaleakishigh(classicexamples
ofthisareanemaciated,steroid-dependentpatientwithCrohn’sdisease
orapatientwithfecalperitonitisfromaperforatedcaecum).
Jejunostomy
Rarely will you need to create a jejunostomy. There is often a
reluctance to create a proximal stoma due to the perceived risks of a
high-outputstoma;however,insomesituationsyouwillneedtobalance
this risk against that of an anastomotic leak or uncontrolled abdominal
sepsis. You may need to make a jejunostomy when there is an
unrecognizedenterotomyintheproximalbowelortodiverttheintestinal
contents from acomplex enterocutaneous fistula. This is the ultimate
bailout stoma and usually indicates that the patient has had an
abdominalcatastropheorthatthesurgeonhascockedup.Because
youwillrarelyneedto do this it will be an unfamiliar procedure to you.
Herearesometips:
•
Makeyour stomatrephinewhere therelevant piece ofjejunum will
reach(thisisusuallyintheleftupperquadrant).
•
Pulltheendorloopofjejunumthroughthetrephineasnormal.
•
You will find that it’s much harder to spout a jejunostomy than an
ileostomy due to the thickness of the bowel wall and the short
mesentery; don’t worry too much about that, remember this is a
bailoutstoma!
•
The vascular pattern of thejejunum does not allow youto pedicle
the bowel as you would do for an end ileostomy, so don’t bother
trying;youarelikelytodevascularizeasectionofjejunumifyoudo.
•
Open and mature the stoma as usual with interrupted fine
absorbablesutures.
•
Itislikelytolookawfulcomparedtoyourusualstomata,c’estlavie!
‘Blow-hole’colostomyandcecostomy
Some surgeons think of blow-hole stomata as obsolete, and others
don’t even know what they are. But we think this deserves a brief
mention, for the rare case when it may be the best solution
available.
A blow-hole stoma is constructed using only the anterior bowel wall,
which is opened and sutured to the skin, without mobilizing or
exteriorizing the bowel above the skin level. The sole purpose of this
stoma is decompression, as it does not completely divert the fecal
stream, so it may be useful to alleviatecolonic obstruction when more
complicated solutions are not appropriate due to the patient’s general
condition. Naturally, it is reserved for old, debilitated, high-risk
patients, and its main advantage is the simplicity that makes it
possibletoconstructunderlocalanesthesia.
Theclassicblow-holestomaisasurgicalcecostomy(asopposed
totube-cecostomy, thatrarely functionsas expectedduetoblockageof
thetubeandleakagearoundit).Take,forexample,a90-year-oldpatient
withsevereheartfailureandanobstructingtumoratthesplenicflexure:
hisbestchancetoleavethehospitalwouldbebyperformingtheminimal
proceduretodecompressthebowelbeforeitperforates,withouttryingto
‘cure’himbyheroiccolectomy.Evenatransverseloopcolostomy,which
mandatesgeneral anesthesia,may betoo muchfor him.Sothrougha
McBurneyincision(asforappendectomy)youevisceratethececum
and fix the eviscerated segment to the abdominal wall defect all
around.Then you open thececum, suck the crapout,and you mature
the opening tothe skin. The skin level stoma is not bulky,and usually
easyto manage.Its maincomplications areretraction andstenosis,but
thesecanbepreventedby thesteps Ihave mentionedabove ( Figure
14.5).
Figure14.5.Blow-holestoma.
Makingastomainafatperson
The challenge of making a stoma in the ever too frequent
morbidly obese patient cannot be underestimated. Here are some
tips for when you find yourself in this sorry (reflected by the number of
timestheFwordisutteredduringtheoperation)situation:
•
Sitethestomahigherthanyouwouldnormally(itwillnotbevisible
tothepatientifit’sunderthefatapron).
•
Make the stoma trephine larger (the mesocolon will be thick and
friableandwillnotcomethroughaconventional-sizedhole).
•
Make sure that you fully mobilize the colon before making a
colostomy (the panniculus and its attached colostomy moves
verticallyseveralinchesonstanding).
•
Consideranend-loopstomaifyouarestillstrugglingforlength
(to do this staple off the end of the bowel and then make a loop
stomajustproximaltothis).
•
Go back to your room and open the well-earned bottle of
Glensomething.
Postoperativecareofastoma
Although not quite a window into the soul, a stoma does allow you
direct access to visualize the visceral circulation. You should therefore
look at the stoma directly on the first postoperative day. A transparent
stomapouchusuallyallowsagoodviewofastoma,butifyoucan’tseeit
properlydon’tbelazy;removethestomapouchandmakesurethatyou
have a good view; if the light on the ward is poor then use a torch
(Americanoswouldcallitaflashlight).
Stomaischemia
Stoma ischemia is usually evident early in the postoperative
period.Thismaybecausedbyeitherageneralizedstateofhypotension
or, more commonly, a technical problem during the construction of the
stoma. The severity of ischemia may vary from minor mucosal
hypoperfusion to a black, completely necrotic stoma. Again, all newly
formed stomata should be inspectedthe dayfollowing surgery to
assesstheirviability.Ifacolostomylooksischemic,itcanbeusefulto
useeitheraproctoscopeoratesttubeinsertedintothestomatoassess
theviabilityofthebowelunderthefascia.Useapentorchtoassessthe
viabilityofthemucosa.
Urgentsurgerytoresectandrefashionthestomawillbeneededif
thebowelleadinguptothecolostomyisnecrotic.Conversely,ifthe
bowelimmediatelyunderthestomaispink,thenyoucanaffordtowait.It
islikelythatthemucosawillsloughoffthestomaandthatthelateresult
willbeastenosedstoma.Thiscanbedealtwithonitsownmeritslater,
butthisispreferabletoadifficultrelaparotomyintheearlypostoperative
period. A black ileostomy in contrast should usually be revised
urgently(herelengthisusuallylessofanissue,anditisoftenpossible
toreviseanendileostomylocallywithoutalaparotomy).
Ifthecolostomyappearsblackthenitisblack—donotsuccumb
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