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COMPLICATIONS 471
Urologic Complications
Ureteral injury is the most common urologic injury during laparoscopic colorectal surgery. Knowledge of retroperitoneal and pelvic
anatomy is vital. e ureters should be identied during dissection.
In the event of surrounding inammation, ureteral stents may be
placed intraoperatively to aid in identication. e thin, avascular,
alveolar tissue between the colon and the retroperitoneum should be
used to guide dissection and avoid accidental injury. Care should be
taken to li tissue up and away from the ureters before applying electrocautery to prevent thermal injury.
In the event of recognized injury to the ureter, urologic consultation is advised. Small injuries that do not transect the ureter may be
repaired primarily over a stent. Transections and larger injuries are
dicult to repair laparoscopically and oen require a laparotomy. If
any doubt exists with regard to whether an injury is present, intravenous indigo carmine or methylene blue material should be administered to investigate ureteral integrity.
Bladder injuries are most commonly caused by suprapubic trocar
placement. is type of injury is best prevented by adequate bladder
decompression through catheterization. Lacerations to the bladder
should be repaired primarily in two layers with prolonged postoperative catheter drainage. Urine leaks discovered postoperatively should
be managed in the same manner as those occurring in open surgery.
CONCLUSIONS
Laparoscopic colorectal surgery can be performed safely in the
majority of cases. When intraoperative complication occurs, the
decision to convert to an open operation depends on the severity of
the complication and the skill of the surgeon. Good judgment is the
surgeon’s best tool.
S u g g e S t e d R e a d i n g
Ahmad G, O’Flynn H, Duy JM, et al. Laparoscopic entry techniques.
Cochrane Database Syst Rev. 2012;2:CD006583.
Callery M, Strasberg S, Soper N. Complications of laparoscopic general sur-
gery. Gastro Endosc Clin North Am. 1996;6(2):423–444.
Henny CP, Hoand J. Laparoscopic surgery: pitfalls due to anesthesia, po-
sitioning, and pneumoperitoneum. Surg Endosc. 2005;19(9):1163–1171.
Joshi GP. Complications of laparoscopy. Anesth Clin North Am. 2001;19(1):
89–105.
Lacy A, Garcia-Valdecasas J, Delgado S, etal. Postoperative complications of
laparoscopic-assisted colectomy. Surg Endosc. 1996;11:119–122.
Monson J, Darzi A. Laparoscopic Colorectal Surgery. Oxford: Isis Medical
Media; 1995.
Ramos R. Complications in laparoscopic colon surgery: prevention and man-
agement. Semin Colon Rectal Surg. 1994;5(4):239–243.
Regadas FS, Rodrigues LV, Nicodemo AM, etal. Complications in laparo-
scopic colorectal resection: main types and prevention. Surg Laparosc
Endosc. 1998;8(3):189–192.
Weeks JC, Nelson H, Gelber S, etal. Clinical Outcomes of Surgical era-
py (COST) study group: short-term quality-of-life outcomes following
laparoscopic-assisted colectomy vs. open colectomy for colon cancer: a
randomized trial. JAMA. 2002;287:321–328.
Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM. Wound complications
of laparoscopic vs open colectomy. Surg Endosc. 2002;16(10):1420–1425.
P
M
O C
Victor W. Fazio
†
INTRODUCTION
The term ostomy originates from the Latin word stoma, meaning
“opening” or “origin,” and from the Greek word stomat, meaning
“mouth.” Historically it is unclear when and how the first ostomies were created, although evidence suggests that the earliest use
of fecal diversion was probably related to traumatic fecal fistulas.
The first mention of stomas in the surgical literature is by Littre
in the early eighteenth century, yet stomas did not become part of
surgical practice until decades later, with the creation of ventral
and lumbar colostomies for the treatment of imperforate anus and
obstructing cancers.
Ileostomies have their origins in the late nineteenth century,
when they were used as a means of managing ulcerative colitis.
Although the ileostomy was potentially life saving in the treatment
of advanced disease, it was soon discovered that the same principles of maturation that were applied to colostomies could not be
applied to ileostomies. Early ileostomies that were le to mature
spontaneously caused signicant morbidity and mortality as a
result of serositis, with subsequent development of strictures of the
stoma and uid and electrolyte losses. is constellation of symptoms later became known as “ileostomy dysfunction.” e work of
Turnbull and Brooke in the early 1950s was instrumental in resolving these complications. e key was recognition of the causal role
of serositis; the cure was to cover the serosa, either with a skin gra
(Turnbull) or primary eversion of the bowel (Brooke). e Brooke
technique continues to be the standard technique for the creation
of ileostomies.
In addition to the many clinicians who have greatly contributed to
the development of ostomy surgery and care over the years, enterostomal therapists have contributed hugely to the eld. e rst school
of enterostomal therapists was established in 1961 as a collaboration
between Turnbull and one of his former patients, Mrs. Norma Gill.
Seven wound, ostomy, and continence nursing accredited programs
currently exist throughout the United States, and their contributions
to the care of patients with stomas and the management of ostomy
complications are invaluable.
e temptation exists for surgeons to regard stoma construction
as part of wound closure, which may mean that it is performed by
residents. In reality, stoma construction is an important determinant of outcome because an improperly constructed stoma can lead
to unnecessary inconvenience, stress, and nancial expenditures
for the patient. Although ostomy complications are relatively common, in most cases, further surgery is not required for correction.
is chapter describes important principles in minimizing the incidence of ostomy complications and covers the specic complications
themselves.
OSTOMY CREATION
Prevention of ostomy complications starts before they are created.
Complications are less frequent when stomas are performed electively
(37%) than in an emergency (55%). is dierence can be explained
not only by the diculties posed by an emergency operation, such as
peritonitis/contamination and a dilated bowel, but also by the lack
of appropriate preoperative planning. Despite the indication for the
stoma or the type of stoma, certain basic steps in the process should
always be followed.
Preoperative Discussion and Consent
Appropriate informed consent and preoperative education is very
important. As with any procedure, a full discussion of risks and
benets should be undertaken preoperatively. is step is especially
important for ostomy surgery because of the psychological hurdles
involved. Many resources are available to patients through the American College of Surgeons and the United Ostomy Associations of
America.
Siting the Stoma
Many complications of a dysfunctional ostomy originate in poor
placement. A poorly located stoma is prone to hernia, prolapse,
skin excoriation from leakage, bleeding from appliance trauma, and
parastomal sepsis. Preoperative marking is usually performed by
the enterostomal therapist, but any surgeon operating on the bowel
should be able to do it himself or herself. e standard locations are
within the connes of the rectus abdominis muscle on either side of
the midline, at a height that is visible to and accessible by the patient,
in a at area of skin without scars or dimples. is site usually ends
up being just lateral and most oen inferior but in some cases superior to the umbilicus (Fig. 90-1). Initially the location is chosen with
the patient supine, but it is also essential to evaluate the site with the
patient standing and sitting.
Although various unique situations can lead to diculty in
proper siting of a stoma (Box 90-1), the most common situation
encountered is obesity. Extreme care must be taken in assessing the
site to avoid placement within a crease or an area where the patient
is unable to see or properly care for the stoma. In an obese abdomen, the ostomy is generally placed slightly on the upside of a fold.
A more superior location provides better accessibility. Ideally there
should be 2 inches of at skin around the stoma to allow the appliance to adhere properly.
†
Deceased.
472
Faceplate
Peritoneum
Post. rectus sheath
Infraumbilical
fat fold
COMPLICATIONS 473
Rectus abdominis m.
FIGURE 90-1 Location of ostomy. Ant., Anterior; m., muscle; Post., posterior. (From Fleshman JW. Ostomies.
In: Hicks TC, Beck DE, Opelka FG, et al, eds. Complications of Colon and Rectal Surgery. Baltimore: Williams &
Wilkins; 1996:357-381.)
BOX 90-1: Obstacles to Appropriate Stoma Marking
Obese patients
Bilateral paramedian incisions
Pelvic exenteration requiring both fecal and urinary diversions
Radiation of skin-graed abdominal wall
Disturbed or absent rectus muscles (e.g., transverse rectus ab-
dominis myocutaneous/vertical rectus abdominis myocutaneous aps and bladder exstrophy)
Creating and Maturing the Stoma
To set up for the stoma construction, Kocher clamps should be clipped
onto the cut edge of the anterior rectus sheath as it is displayed in the
incision, and on the dermis. e clamps should be vertically aligned
one over the other and kept in line so that the aperture is straight. A
folded gauze pack is placed immediately under the site of the intended
stoma and held there by the surgeon’s nondominant hand.
e diameter of the stoma aperture is a key to constructing an
eective stoma. An ileostomy should protrude about an inch from
the abdominal skin as a bud, which means that at least 2 inches of
bowel should protrude, tension free, before maturation. To assist in
stabilizing the bud, the skin aperture must not be too loose. It should
just grip the bowel without narrowing it. erefore, the diameter
depends on the diameter of the bowel itself. A colostomy need not
protrude more than 5 mm, and because the bowel is larger than the
ileum, the aperture can be more generous. A stoma aperture that is
too tight can produce a postoperative bowel obstruction that may
appear to be an ileus.
e following steps should be performed:
n Incise the subcutaneous fat vertically in the middle of the ap-
erture, using small retractors to deepen the wound to the fascia. Do not remove fat, which is needed to support the stoma.
n Incise the anterior rectus sheath vertically. If the bowel is big,
small cruciate incisions can be made on either side (Fig. 90-2).
n Using a Kelly clamp, separate the rectus bers in the middle of
the wound. Make sure the posterior fascia/peritoneum is visible for the entire length of the incision (Fig. 90-3).
n Incise the posterior sheath/peritoneum, pushing up from un-
derneath with the folded sponge. Be careful around the deep
epigastric vessels.
n Pass a Kelly clamp through the aperture onto the sponge and
then into the abdomen. Holding up on the end of the clamp,
inspect the inside of the abdominal wall for bleeding (Fig. 90-4).
n Pass one or two ngers into the aperture and check for diam-
eter. e aperture should match the size of the bowel and its
Ant. rectus sheath
FIGURE 90-2 Exposure and incision of the anterior rectus sheath.
(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography copyright 2009-2016. All Rights Reserved.)
FIGURE 90-3 Spreading of the rectus fibers to reveal the posterior
sheath. (Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography copyright 2009-2016. All Rights Reserved.)
attached mesentery. For an ileostomy, a two-nger aperture is
a good size, whereas for a colostomy, a three-nger aperture is
usually required (Fig. 90-5).
For an ileostomy, the choice of an end stoma versus a loop end
is determined prior to making the aperture and is based on the
Prevention and ManageMent of ostoMy CoMPliCations474
FIGURE 90-4 Lining up the fascial and skin edges with Kocher clamps
and placement of a lap sponge to protect the bowel. (Reprinted with
permission, Cleveland Clinic Center for Medical Art & Photography copyright
2009-2016. All Rights Reserved.)
mesenteric border to the other. The full thickness of the downstream (diverted) bowel is then sewn to the dermis. No suture
that is used to mature an ileostomy should traverse the epidermis
because of the risk of the development of mucosal implants, which
can produce mucus and encourage lifting of an appliance. The
upstream bowel maturation sutures are then placed and tightened
while the stoma is gently everted. Sutures are then tied.
If the stoma aperture is too large (i.e., it is not gently gripping
the bowel), supporting 0 chromic sutures can be placed between
subcutaneous fat and the serosa of the bowel, laterally, and the
antimesenteric edge. Alternatively, these sutures can be incorporated into the maturation stitch (“Brooking”). With maturation,
subcuticular sutures are used for ileostomies to avoid mucosal
implants.
An end ileostomy is a fixed point around which loops of bowel
can volve. This can be avoided by sewing the terminal ileal mesentery to the anterior abdominal wall and falciform ligament.
COMPLICATIONS
Stoma-specic complication rates of up to 70% have been reported.
Complications can be classied as early (less than 1 month aer surgery) and late.
Early Complications
FIGURE 90-5 Testing the aperture size. (Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography copyright 2009-2016.
All Rights Reserved.)
thickness of the abdominal wall and the conguration of the mesentery of the bowel—that is, whether it will allow the end of the ileum
to protrude enough to make a satisfactory bud. A trial pull through is
part of the decision-making process.
End Ileostomy
For an end ileostomy, bulky mesenteric fat can be carefully debrided.
e bowel is pulled through with the mesenteric edge cephalad. At
least 5 to 6 cm should protrude. If the skin aperture is too large it
can be narrowed, or supporting sutures can be used (described in the
next section).
Loop Ileostomy
For a loop ileostomy, pass a tonsil clamp adjacent to the mesenteric margin of the bowel at the apex of the chosen site for the
stoma and then bring an umbilical tape through the mesentery,
which is used to pull the loop through the abdominal wall. Tag
afferent and efferent ileum with different colored sutures. At maturation, the incision in the bowel is just above skin level in the
downstream (efferent) limb. This incision needs to be from one
Appliance Issues/Skin Irritation
Peristomal skin irritation is one of the most commonly encountered
postoperative complications, with an overall incidence of up to 42%.
is complication is oen a result of chemical dermatitis from the
ostomy euent and is seen more frequently in persons with ileostomies. Although surgical technique and stoma siting play a signicant
role in preventing leakage or predisposing to leakage, the size of the
aperture and frequency of changing oen are the true underlying
causes of leakage. Involvement of an enterostomal therapist in the
immediate postoperative period to help with education and choice
of the most suitable pouching system for the patient is important.
Postoperative follow-up is also crucial because pouching systems
must adapt to changing conditions as stomas lose their postoperative
edema and patients lose or gain weight. In addition, further education
is usually needed to supplement the initial postoperative instruction.
e key component of t is an exact match of the aperture of the
appliance to the outer diameter of the ostomy, exposing as little skin
as possible. Ostomy pastes and Eakin rings oen are used to ll in
any gaps.
An adequately constructed ostomy requires an appliance change
every 3 to 7 days. When high output or ostomy retraction occurs,
more frequent changes may be required, which leads to more skin
irritation. Revision or re-siting of the ostomy may be necessary.
Another cause of peristomal skin irritation is an allergic reaction to
the stoma appliance or paste, which usually manifests as a dermatitis
that conforms exactly to the outline of the stoma appliance. Infections, usually fungal, also can cause skin irritation. ese infections
are usually easily treated with antifungal powders, which generally
do not alter the adherence of the appliance. Bacterial infections of the
skin are rare and tend to manifest as peristomal abscesses.
Ischemia
An ischemic stoma has several potential causes. Early ischemia occurs
in 1% to 10% of colostomies and in 1% to 5% of ileostomies, and if it
is seen in the operating room, it should be xed. Sometimes ischemia
is due to hypotension, and the patient needs resuscitation. Sometimes
the vessels supplying the stoma have been divided or cauterized and
the bowel must be cut back until active bleeding occurs from its cut
COMPLICATIONS 475
edge. If the stoma is matured and its blood supply is in question, the
tightness of the aperture and tension on the arterial supply should be
assessed. Later ischemia is oen associated with venous congestion
and the use of vasopressors.
In obese patients, a particular concern is having a longer segment
of bowel traverse a thick abdominal wall while at the same time maintaining adequate blood supply. e mesentery tends to tether the
bowel, and depriving more than 5 cm of small bowel from its mesenteric attachments or the colon from its marginal artery inevitably will
lead to ischemia. A solution to this problem is an end-loop stoma.
Enlarging the aperture also may be helpful, although it increases the
risk of the later development of a parastomal hernia.
Assessment of the vascular integrity of a dusky ostomy is usually
fairly straightforward. Transillumination of the bowel will dierentiate between mucosal injury and full-thickness ischemia or necrosis.
Should the viability of the bowel below the level of the skin be in
question, a clear test tube can be placed within the stoma to the level
of the fascia. If the mucosa is viable above the level of the fascia, a
nonoperative approach can be pursued, but if ischemia reaches below
the level of the fascia, a laparotomy and revision are required.
Stoma Stenosis
Newly created stomas are edematous and swollen. If the aperture in
the abdominal wall is small and tight, the postoperative edema may
cause a bowel obstruction, which oen presents as an “ileus” because
the obstruction is so distal. It is manifested when intestinal activity
resumes aer the normal postoperative ileus. is problem can be
treated by intubating the stoma with a Foley catheter that stays in
place until the stoma edema resolves.
Retraction
Most oen, retraction in the early setting is due to excess tension
on the ostomy from inadequate mobilization of the bowel. However, nonhealing as a result of malnutrition, obesity, or prolonged
corticosteroid therapy also can produce retraction. Mucocutaneous
separation is common but usually partial; it tends to have more dire
consequences in patients with an ileostomy as opposed to a colostomy given the volume and consistency of the euent. Early correction usually can be accomplished by means of local revision with
complete separation of the mucocutaneous junction, advancement of
the bowel, resection of any devitalized bowel, and rematuration. If the
bowel does not advance, re-siting is required.
Late Complications
results but still is not an ideal repair. Relocation of the ostomy may be
a better option but sometimes results in two hernias. e preferred
option is now intra-abdominal mesh repair (keyhole or Sugarbaker),
most oen via a laparoscopic approach. Early recurrence rates range
from 4% to 15%, but long-term data have yet to be collected.
Some recent randomized controlled trials have suggested that
prevention of parastomal hernias by prophylactic placement of mesh
in either a preperitoneal or sublay position during the creation of
permanent ostomies is promising. Large multi-institutional studies
that are currently underway should assist in providing more denitive recommendations.
Prolapse
Prolapse is one of the more common late complications of ostomy
construction, with an overall incidence of up to 16%. Prolapse is
more common with colostomies than with ileostomies and with loop
stomas as opposed to end stomas. Location also makes a dierence
because transverse loop colostomies have the highest reported incidence (up to 30%). Prolapse oen is associated with a parastomal
hernia, and repair is usually elective because prolapse rarely aects
stoma function. In cases in which incarceration is a concern, initial
attempts at manual reduction should be attempted with gentle steady
pressure to the prolapsing segment. If this approach is ineective,
placing the patient in the Trendelenburg position can help reduce
edema. Another trick to reducing edema is to sprinkle the stoma with
sugar, which exerts an osmotic eect.
If the ostomy is temporary, closure is the ultimate x. If the
ostomy is permanent, repair is indicated. Options include resection
and reanastomosis of the prolapsing segment or conversion of a loop
ostomy to an end ostomy, along with resection of the redundant
bowel. In prolapsing end colostomies, relocating the proximal colon
in a retroperitoneal tunnel can control the prolapse. It has been suggested that xation of either the bowel itself or the mesentery can play
a role in preventing prolapse, but this suggestion is not supported in
the literature.
Stricture
A stricture is usually a sequel of previous complications, namely
ischemia, infection, or retraction, although the dierential diagnosis includes malignancy and Crohn disease. e overall reported
incidence is 2% to 11%. Dilation provides temporary relief, but a
recurrent stricture usually leads to ostomy revision. Scar excision,
mobilization of the bowel, and rematuring of the mucocutaneous
junction are usually necessary with ileostomies. A colostomy stricture oen can be managed with dietary alterations and irrigation.
Parastomal Hernia
A parastomal hernia occurs in more than 50% of patients with a
stoma. A stoma is a weak point in the abdominal wall, and the high
intra-abdominal pressures generated by straining, coughing, or liing work at this weak point and oen expand it. is symptom oen
presents rst as a symmetrical prominence of the abdominal wall
with the stoma at its apex. However, when intra-abdominal contents,
such as bowel or fat, leave the peritoneal cavity beside the stoma, a
hernia has formed.
It has been suggested that multiple factors contribute to hernia development, including age, obesity, perioperative steroid use,
chronic obstructive pulmonary disease, and emergency ostomy creation, but the two most important factors remain siting outside of the
rectus abdominis and poor surgical technique.
Approximately 20% to 30% of parastomal hernias require some
type of repair, and the options have evolved over time. Local repair
alone with reapproximation of the fascia around the ostomy has
recurrence rates of 30% to 76%. In patients with very limited reserve,
the addition of an onlay or underlay mesh has demonstrated better
Peristomal Pyoderma
In patients with inammatory bowel disease, pyoderma gangrenosum can be seen as a large parastomal ulcer with undermined edges.
In most cases it is a sign of active inammatory bowel disease elsewhere aer a colectomy. e lesions are typically extremely painful
and oen require debridement for complete resolution. Protection
of the diseased skin under an appliance is usually achieved through
placement of calcium alginate and Telfa cutouts. Some improvement also has been noted with intralesional corticosteroid injections.
Treatment or resection of residual active disease is indicated, and as a
last resort, the ostomy may need to be relocated.
Parastomal Ulcer
Ulcers sometimes develop adjacent to a stoma; they cause diculty
with pouching, and the ulcers themselves are painful. Although pyoderma is suggested by the context of inammatory bowel disease,
many parastomal ulcers are not related to pyoderma. Sometimes they
develop because of the pressure of tight-tting clothes or an appliance
Prevention and ManageMent of ostoMy CoMPliCations476
belt. Treatment consists of careful debridement with use of a local
anesthetic. e edges must be shelved and any overhang excised. Silver nitrate can be used to control bleeding, and the ulcers should be
dressed as described for pyoderma. Most ulcers heal spontaneously.
Abscess and Fistula
Peristomal abscesses and stulas are relatively uncommon. As with
any abscess, treatment consists of drainage, which can be accomplished via an incision at the mucocutaneous junction or in an area
beyond the stoma faceplate, with a drain oen le in place. Whatever
the location of drainage, care should be taken to avoid interference
with adherence of the appliance.
Aer initial drainage of the abscess, further workup should
include some type of endoscopic evaluation to assess for the presence
of a stula and active disease of the bowel above the stoma. is step
is especially important in a patient with inammatory bowel disease,
but stulas also have been reported aer overly aggressive colostomy
irrigation. If a supercial stula is present, the ostomy usually can be
revised. Deeper stulae that are intraperitoneal or near the level of
the fascia generally require a laparotomy and revision.
SUMMARY
For all the complications presented in this chapter, prevention is a
better option than treatment. Prevention of ostomy complications
begins with proper siting and engagement of an enterostomal therapist, involves sound surgical technique, and ends with adequate postoperative education and support.
S u g g e S t e d R e a d i n g
Bass EM, Del Pino A, Tan A, Pearl RK, etal. Does preoperative stoma mark-
ing and education by the enterostomal therapist aect outcome? Dis Colon
Rectum. 1997;40:440–442.
Brooke BN. e management of an ileostomy including its complications.
Lancet. 1952;2:102–104.
Fazio VW, Church JM, Wu JS, eds. Atlas of Intestinal Stomas. New York:
Springer; 2012.
Husain SG, Cataldo TE. Late stoma complications. Clin Colon Rectal Surg.
2008;21(1):31–40.
Kann BR. Early stomal complications. Clin Colon Rectal Surg. 2008;21:23–30.
Park JJ, Del Peno A, Orsay CP, etal. Stomal complications: the Cook County
experience. Dis Colon Rectum. 1999;42:1575–1580.
Turnbull RB, Weakley FL, eds. Atlas of Intestinal Stomas. Saint Louis: C.V.
Mosby; 1967.
Wijeyekoon SP, Gurusamy K, et al. Prevention of parastomal herniation
with biologic/composite prosthetic mesh: a systematic review and meta-
analysis of randomized controlled trials. J Am Coll Surg. 2010;211(5):
637–645.
S W
C:
N M
ehabilitation of the patient with a stoma or complicated wound
is the responsibility of the entire health care team, and thus it
R
is important that all members understand the principles and techniques of ostomy and wound management. As Dr. Rupert B. Turnbull, Jr., discovered in the 1950s, collaboration between the surgeon,
the oor and clinic nurse, and the wound, ostomy, and continence
nurse (previously known as the enterostomal therapy nurse) can
facilitate this goal.
PREOPERATIVE PREPARATION
When an ostomy is a planned procedure, the opportunity exists
for preoperative counseling and education that ideally involves the
patient and his or her family, and stoma-site marking can be performed. However, every bowel surgery carries a risk of involving
a stoma, even if it is extremely unlikely. is eventuality should
be discussed preoperatively so that if it happens, the patient is not
completely taken aback. In cases of an unexpected stoma, all the
counseling and education takes place postoperatively.
Preoperative Counseling
Successful rehabilitation begins with the initial interaction with the
patient. e patient and family must have a thorough understanding
of the surgical procedure and likely changes to lifestyle it will cause.
e alterations in anatomy and bowel and bladder function, the need
for pouching, and the impact of a stoma on activities of daily living
should be discussed.
Stoma Site Marking
Regardless of whether a stoma is to be temporary or permanent,
stoma site marking is a key to optimizing the patient’s experience. A
poorly sited and constructed stoma can be a nightmare for the patient,
causing frequent leakage with skin erosion and pain, pouching diculties, and social isolation. e best sites are usually located in the
right or le lower quadrants, in the middle of rectus abdominus, away
from any scars, creases, or dimples, and on the apex of the natural
roll of the abdominal wall. e likely site should be checked with the
patient supine, sitting, standing, and bending. e site should be visible to the patient when he or she is sitting. Some patients with pendulous abdomens or those who require constant use of a wheelchair
may require a site in the upper quadrant. e procedure for selecting
and marking the stoma site is provided in Box 91-1.
Preoperative stoma site selection for the patient undergoing an
ileal pouch–anal anastomosis needs to take into account the mesenteric tension created by the anastomosis, which oen forces the
Paula Erwin-Toth and Barbara J. Hocevar
segment of ileum used for the stoma to be relatively proximal, especially in obese persons. Stomas made under these conditions have
high output that is dicult to control. It is essential that such ileostomies have a good spout to prevent undermining of the skin protection by the watery stool. It is a good idea to mark two sites, one in
the upper and one in the lower abdomen, so that any eventuality is
covered.
Stoma marking for patients undergoing a continent ileostomy
may be lower on the abdomen, and adjacent scars and folds are less of
an issue, because the stoma is ush and continent. e site must still
be visible to a standing or sitting patient so that the drainage catheter
can be inserted.
POSTOPERATIVE MANAGEMENT
An ideal ileostomy is matured primarily and budded; a colostomy can
be ush, but a small eversion of a centimeter makes pouching easier.
A ush, retracted, or excessively elongated stoma can pose pouching
diculties. A clear pouch with a skin barrier should be applied in
the operating room to permit the stoma to be adequately assessed
postoperatively. e aperture in the adhesive skin barrier should be
approximately 1/8-inch larger than the base of the stoma. e skin
should be cleansed with nonlotion soap and dried prior to pouch
application. e procedure for the application of a one-piece pouch is
included in Table 91-1. If a rod is present, a at exible pouching sys-
tem should be tted over, not under, the rod, and the pouch should
be labeled “rod underneath” to prevent accidental dislodgement and
mucosal trauma.
e pouch should be changed on the rst postoperative day
aer conventional open surgery, with rod removal from day 3 to 5,
depending on tension. For laparoscopic stomas, if the pouching system is adhering well, a pouch change is performed on postoperative
day 2, when the rod is removed, depending on the tension. With each
pouch change, the stoma, mucocutaneous junction, and peristomal
skin are assessed. Postoperative stoma and peristomal skin complications and their management are described in Tables 91-2 and 91-3.
Stomas that are retracted or ush, as well as patients with a so abdomen, may benet from a convex pouching system. Principles of tting are highlighted in Table 91-4.
e need to minimize length of hospital stay provides the impetus
to begin patient and family education as soon as possible. Learner
readiness, considered essential for eective patient education, is not
always realistic. All patients should be able to empty their bag and
close it prior to discharge. If the patient is unable to independently
change the pouch, a family member or friend is taught or home care
or posthospital care stays are arranged. Although generally the pouch
change procedure is not complex, learning can be complicated by the
eects of pain medications, anesthesia, and the emotional adjustment
to the stoma.
477
Stoma and Wound ConSiderationS: nurSing management478
BOX 91-1: Criterion Checklist for Stoma Site Marking
1. Gather equipment
2. Explain procedure to patient
3. Wash hands
4. Apply nonsterile gloves
5. With the patient supine, locate the borders of the rectus abdominus muscle
A. Ask the patient to li his or her head from the bed (i.e.,
perform a modied sit-up), cough, or laugh
B. Palpate the abdomen to identify the borders of the rectus
muscle
6. With the patient in the supine position, locate a possible stoma
site in the following manner:
A. Place a stoma-marking disk on the abdomen within the
anatomically appropriate quadrant for the type of stoma
B. Position a stoma-marking disk on an area of smooth skin
surface within the quadrant, avoiding the umbilicus, bony
prominences (e.g., the iliac crest, symphysis pubis), creases/
folds, wrinkles, scars, the belt line, and areas of previous
radiation treatment
C. Using a water-soluble pen, mark the possible stoma site
with an “x” or circle in the center opening of the marking
disk
7. Use a marking disk as needed to assess the initial stoma site
with the patient sitting, standing, and bending; relocate the site
if necessary to avoid creases, wrinkles, and irregular contours
that become apparent with change of patient’s position; mark
the relocated site with a water-soluble pen
8. With the patient sitting and standing, determine that the site is
located on the summit (apex) of the infraumbilical fat mound
9. Assess the patient’s ability to see and reach the stoma site by
asking the patient to touch the stoma site while in the sitting
and standing positions
10. With the patient in the supine position, tattoo or indelibly
mark the selected stoma site
A. Tattoo Method
a. Cleanse the site with alcohol and allow to dry
b. Drop a small amount of India ink on the site
c. Using a sterile 25-gauge needle, puncture the skin three
times through a drop of ink
d. Spread the skin
e. Cleanse residual ink from the skin with dry gauze fol-
lowed by an alcohol wipe
f. If necessary, circle the tattoo with indelible ink with a
contrasting color
g. Apply a small adhesive bandage as needed
B. Indelible Marker Method
a. Using an indelible pen, mark the preferred stoma site
with an “x” or circle
b. Cover the mark with a transparent lm dressing
11. Remove gloves
12. Wipe the pen and marking disk with alcohol wipes
13. Discard waste in the appropriate container
14. Wash hands
15. Document the procedure in the electronic medical record
SPECIAL CONSIDERATIONS
Continent ileostomy
To maintain the patency of the catheter, gentle irrigation with 30 mL
of normal saline solution every 2 hours is advisable in the immediate
postoperative period. is interval can be modied based on individual patient needs. Patients with continent diversions will be discharged wearing a catheter and leg bag with a bedside drainage bag
available at night. One convenient way to stabilize the catheter is to
use a stoma plate and baby bottle nipple.
Intubation instructions are provided approximately 3 to 4 weeks aer
surgery in the ambulatory care setting. Patients are asked to perform
and repeat intubation; they are given written instructions to reinforce
the information regarding technique and frequency of intubation. e
frequency of intubation is generally every 2 hours the rst week, and the
interval is increased an hour per week up to every 4 to 5 hours. Patients
may elect to maintain constant drainage at night or set an alarm to
awaken them. Patients with stomas, but especially those with continent
diversions, should be urged to wear a medical identication bracelet or
necklace to alert emergency care personnel to their medical status.
Detailed written information regarding pouch and wound care
procedures, frequency of change, specic ordering information for
supplies—including product names and stock numbers—and sources
of supplies should be provided. Dietary guidelines and other information relating to activities of daily living are also included (Box
91-2). Patients are generally sent home with minimal supplies, and
thus establishing a source of supply soon aer discharge is imperative. A listing of patient resources should be made available.
e goals in managing most types of wounds are the same: removal
of necrotic tissue; prevention, elimination or control of infection; absorption of exudate; maintenance of a moist wound environment; protection
of the wound from trauma; and protection of the skin around the wound.
When a draining wound or stula is present, creative combination of
pouching and wound care products can result in cost-eective, comfortable systems. Patients with these complex conditions will benet from
the expertise of a wound, ostomy, and continence nurse.
Wound care dressings can be categorized as transparent adhesive lms, hydrocolloids, hydrogels, exudate absorbers, foams, antimicrobial agents, lubricating sprays or emollients, and nonadherent
and gauze dressings. Appropriate use of these products can promote
healing and enhance patient comfort (Table 91-5). Adjunctive tech-
nology, such as negative pressure wound therapy, may prove useful
in promoting healing of wounds and improve control of drainage in
select patients. Hyperbaric oxygen therapy is useful for wounds in
which local oxygen concentration is likely to be low, which is particularly the case in patients who have had radiation therapy and an
unhealed wound in the radiated tissue.
POSTDISCHARGE FOLLOW-UP
Patients returning for postdischarge care should have a thorough
examination and evaluation of stoma, wound, skin, and management
methods. Repeat measurement and retting of the pouching system,
modication of wound care regimen, and treatment of stoma and
peristomal skin problems are performed (see Tables 91-2, 91-3, and
91-4). Recommendations for basic ostomy and wound care supplies,
examples of which the surgeon should have available in the oce, are
provided (Box 91-3).
WOUND MANAGEMENT
A patient who experiences a stula, mucocutaneous separation, a parastomal ulcer, or complex abdominal or perineal wounds will benet
from the advances in wound management made in recent years.
COLOSTOMY IRRIGATION
Colostomy irrigation may be appropriate for patients with established descending or sigmoid colostomies. Irrigation is performed
TABLE 91-1: Procedures for Changing Pouches
How to Change a Disposable One-Piece, Cut-to-Fit Pouch with an
Attached Skin Barrier
1. Gather the following supplies:
Washcloths or paper towels
Non-oily soap (Ivory and Dial are recommended brands)
Scissors
Plastic bag or newspaper
New pouch
Accessory products
2. Prepare the new pouch
Trace the pattern (sized to t within 1/8 inch of stoma) onto the
cover paper of the skin barrier
Cut out the skin barrier; be careful not to cut through the front of
the pouch
Remove the cover papers from the skin barrier and the adhesive
surface of the pouch
If used, apply skin barrier paste or skin barrier ring around the
opening of the skin barrier
Set the pouch aside, sticky side up
3. Remove the worn pouch
Holding the pouch upright, remove the clip from the end of the
pouch
Empty the waste from the pouch into the toilet
Remove the worn pouch by:
— Applying light pressure on the skin with one hand
— Gently pulling the pouch from the skin with the other hand
Wrap the worn pouch in newspaper, or place in a plastic bag and
discard
4. Cleanse the skin around the stoma
Wash the area around the stoma with non-oily soap and warm water
Rinse o any soap with warm water
Pat the skin dry with a washcloth or paper towel
5. Apply the new pouch
Center the pouch opening over the stoma and press into place
Smooth the adhesive surface of the pouch onto the skin
Hold the pouch rmly in place for approximately 30 sec to warm
the adhesive
6. Close the pouch end securely following the manufacturer’s instruction
COMPLICATIONS 479
How to Change a Disposable Two-Piece Pouch with a Cut-to-Fit
Skin Barrier Flange
1. Gather the following supplies:
Washcloths or paper towels
Non-oily soap (Ivory and Dial are recommended brands)
Scissors
Plastic bag or newspaper
New pouch
Accessory products
2. Prepare the new pouch
Trace the pattern (sized to t within 1/8 inch of stoma) onto the
cover paper of the skin barrier ange
Cut out the skin barrier ange
Remove the cover papers from the skin barrier and the adhesive
surface of the ange
If used, apply skin barrier paste or skin barrier ring around the
opening in the skin barrier ange
Set the skin barrier ange aside, sticky side up
3. Remove the worn pouch
Holding the pouch upright, open the bottom of the pouch
Empty the waste from the pouch into the toilet
Remove the worn pouch by:
— Applying light pressure on the skin with one hand
— Gently pulling the pouch from the skin with the other hand
Wrap the worn pouch in newspaper or place it in a plastic bag
and discard
4. Cleanse the skin around the stoma
Wash the area around the stoma with non-oily soap and warm water
Rinse o any soap with warm water
Pat the skin dry with a washcloth or paper towel
5. Apply the prepared pouch
Center the skin barrier ange opening over the stoma and press
into place
Smooth the adhesive surface of the skin barrier ange onto the skin
Apply the pouch securely onto the skin barrier ange
Hold the skin barrier ange/pouch rmly in place for approxi-
mately 30 sec to warm the adhesive
6. Close the pouch end securely following the manufacturer’s instruction
TABLE 91-2: Selected Stomal Complications
Problem Characteristics Interventions
Mucocutane-
ous separation
Separation of the suture line at the junc-
tion of stomal mucosa and skin
Erythema around the area of separation;
may have drainage or pain at site
Can be partial or circumferential; shal-
low or deep
Necrosis Mucosal color dark red, maroon, purple,
gray, brown, or black; stoma is dry,
hard, or accid
Assess depth of separation: if peritoneal contamination is a concern, resuture
stoma to skin
Shallow separation: use skin barrier powder to ll the defect, and pouch
Deep separation: gentle packing with gauze may be necessary; cover with thin
hydrocolloid or other appropriate dressing, and pouch
If infection is a concern, use an antimicrobial dressing and antibiotics as needed
If a large volume of uid is draining from the separation, include the area in the
pouch opening
Use a clear pouch in the postoperative period to allow for ongoing mucosal as-
sessment
Assess depth of necrosis
If below the fascial level, perform a repeat operation with reconstruction of the
stoma
For supercial necrosis, provide conservative management with the tissue al-
lowed to slough with debridement as needed
Continued
Stoma and Wound ConSiderationS: nurSing management480
TABLE 91-2: Selected Stomal Complications—cont’d
Problem Characteristics Interventions
Parastomal
abscess or
stula
Abscess adjacent to stoma
Fistula may be present
Administer systemic antibiotics
Perform incision and drainage of the abscess site, which is best done with a
mushroom-tipped catheter
Perform contrast studies to dene the extent of the stula
Perform surgical intervention as needed
Modify the pouching system based on the location and extent of the stula or
abscess
Food bolus
obstruction
Severe, crampy abdominal pain with
nausea, vomiting
Output may cease or become watery and
odorous
Stomal edema is common
Patient relates recent history of ingest-
ing high-ber foods such as peanuts,
popcorn, or string vegetables
Hernia Hernia around stoma presents as a bulge
that can interfere with pouch seal,
causing mechanical or irritant contact
dermatitis
Prolapse Telescoping of the bowel through the
stoma; length and diameter of mucosa
increases with potential for laceration
Retraction Stoma recedes below skin level, causing
a variety of pouching and peristomal
skin diculties
If a loop stoma recedes, it will not divert
completely
Stenosis Narrowing of the lumen of the stoma,
which can lead to partial stomal
obstruction
Conservative management: warm bath, peristomal massage, and liquids
Supportive measures: intravenous uid replacement, pain medications, and
nasogastric tube
Ileal lavage
Use of support belt
Perform pouch modication to accommodate change in contour
Consider discontinuing routine colostomy irrigation
Surgical repair plus or minus relocation
Conservative: Manually reduce prolapse; apply binder with prolapse overbelt
while the person is supine; reassess pouching system for proper aperture size
Surgical management
Assess for recurrent disease such as Crohn disease
Ret pouching system oen by increasing degree of convexity
Perform surgical revision if pouching modication is not successful
Preventive measures such as an appropriate pouching system, prompt treatment
of pseudoverrucous lesions; avoid routine dilation of stoma
Stool soeners and laxatives as needed
Surgical revision
Trauma Laceration or bruising of mucosa
Lacerations are seen as yellow to white
linear marks in the mucosa
Identify and eliminate causative factor for the trauma, e.g., correct aperture,
clothing alterations
Use measures to control bleeding as needed
TABLE 91-3: Selected Peristomal Skin Conditions
Condition Characteristics Interventions
Allergic contact
dermatitis
Candidiasis or
fungal rash
Allergic response caused by patient sensitivity to a particu-
lar product
Area of response generally conforms to exposed area
Skin appears erythematous, edematous, eroded, weepy, or
bleeding
Patient may report bleeding
Generally diuse erythematous papules
Papules oen coalese to form a plaque with characteristic
advancing border with satellite lesions
Proliferation of fungus is fostered by a warm, dark, moist
environment
Pruritus is common
Remove oending product, avoid other irritants, and
protect the skin
Modify pouching system as needed, possible use of nonad-
herent system; patch test with other products as needed
Use of corticosteroid agents as needed
Eliminate moisture; use pouch covers; dry tapes with blow
dryer on cool setting
Assess pouching system for leakage and modify as needed
Apply topical antifungal preparations
May require systemic antifungal medications if rash recaci-
trant or severe