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471
32 Rectovaginal Endometriosis
Table 32.4 Complications from laparoscopic anterior resection for rectovaginal endometriosis
Authors Year Operations Number Complications
Redwine and Wright [
9 ] 2001 Lap segmental resection 7
None
Kavallaris et al. [
6 ] 2003 Lap TV segmental resection 50 2 anastomotic leaks
Campagnacci et al. [
20 ] 2005 Lap segmental resection 7 None
Keckstein and Wiesinger [
21 ] 2005 Lap segmental resection 142 6 anastomotic leaks
2 abscesses
1 bleed
6 anastomotic stenosis
Abrao et al. [
22 ] 2005 Lap TV segmental resection 8 None
Mohr et al. [
23 ] 2005 Lap segmental resection 48 1 anastomotic leak
1 bleed
1 urinary leak
Darai et al. [
24 ] 2007 Lap segmental resection 71 6 rectovaginal fi stulae
3 pelvic abscesses
1 bleed
Seracchioli et al. [
25 ] 2007 Lap segmental resection 22 1 anastomotic leak
1 bleed
Brouwer and Woods [
11 ] 2007 Lap segmental resection 137 1 anastomotic leak
1 anastomotic stricture
Maytham et al. [
4 ] 2008 Lap segmental resection 27 3 anastomotic leaks
1 pelvic abscess
2 ureteric injuries
5 anastomotic stenosis
Ruffo et al. [
26 ] 2010 Lap segmental resection 436 9 anastomotic leaks
14 fi stulae
9 bleeds
3 abscesses
16 strictures
472
I.J. Adam
32.8 The Future
The role of colorectal surgeons in the management of rectovaginal endometriotic
nodules seems set to increase. The reported incidence of complications is however
of some concern. Given such complications, there has been a call for the establish-
ment of endometriosis centers that specialize in the multidisciplinary management
of such cases [
4 ] . No formal process for the development of such centers so far
exists, although the British Society of Gynaecological Endoscopy has taken a lead
in this matter by initiating a national audit [ 27 ] . Those interested in developing their
practice into this developing and often challenging aspect of coloproctology are
encouraged to participate.
Key Points
Approximately one in ten women of reproductive age have endometriosis •
In approximately one in ten women with endometriosis, the lesions invade •
³ 5 mm causing a deep nodule
The great majority of such nodules are deep in the pouch of Douglas •
Symptoms of rectovaginal endometriotic nodules include:•
Cyclical and noncyclical pelvic pain –
Dysmenorrhea –
Dyspareunia –
Periodic change of bowel habit –
Periodic rectal bleeding –
Dyschesia –
Patients failing medical treatment or with fertility problems should be con-•
sidered for surgery
Best practice is for colorectal and gynecological surgeons to assess cases •
in a multidisciplinary setting before joint operation
In addition to digital evaluation and a staging laparoscopy, better preopera-•
tive information will be provided by one of the following:
Transrectal ultrasound –
Transvaginal ultrasound –
MRI –
Barium enema –
Rectovaginal nodules may be excised with either a rectal shave technique, •
disk excision, or segmental bowel resection
Much of the recent literature has concentrated on laparoscopic anterior •
resection for an increasing proportion of cases
The complication rates from surgery are comparable with rectal surgery •
for other conditions
Outcomes from surgery are favorable, with perhaps 80% of women pain •
free a year after excisional surgery
473
32 Rectovaginal Endometriosis
References
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Sci. 1991;36:353–64.
2. Li TC, Lashen H, Adam I, Wong YM. The management of rectovaginal endometriosis. In: Li
TC, Ledger WL, editors. Chronic pelvic pain. London: Taylor & Francis; 2005. p. 61–73.
3. Garry R. Laparoscopic excision of endometriosis: treatment of choice? Br J Obstet Gynaecol.
1997;104:513–5.
4. Maytham GD, Dowson HM, Levy B, et al. Laparoscopic excision of rectovaginal endometriosis:
report of a prospective study and review of the literature. Colorectal Dis. 2010;12:1105–12.
5. Batt RE, Udgawa SM, Wheeler JM. Endometriosis: microconservative surgery. In: Hunt RB,
editor. Atlas of female infertility surgery. 2nd ed. St. Louis: Mosby Year Book; 1992. p.
454–81.
6. Kavallaris A, Kohler C, Kuhne-Heid R, et al. Histopathological extent of rectal invasion by
rectovaginal endometriosis. Hum Reprod. 2003;18:1323–7.
7. Donnez J, Nisolle M, Gillerot S, et al. Rectovaginal septum adenomyotic nodules: a series of
500 cases. Br J Obstet Gynaecol. 1997;104:1014–8.
8. Bailey HR, Ott MT, Hartendorp P, et al. Aggressive surgical management for advanced col-
orectal endometriosis. Dis Colon Rectum. 1994;37:747–53.
9. Redwine DB, Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac
associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril.
2001;76:358–65.
10. Brouwer R, Woods RJ. Rectal endometriosis: results of radical excision and review of pub-
lished work. Aust N Z J Surg. 2007;77:562–71.
11. De Cicco C, Corona R, Schonman R, et al. Bowel resection for deep endometriosis: a system-
atic review. Br J Obstet Gynaecol. 2011;118:285–91.
12. Ford J, English J, Miles W, et al. Pain, quality of life and complications following the radical
resection of rectovaginal endometriosis. Br J Obstet Gynaecol. 2004;111:353–6.
13. Garry R, Clayton R, Haew J. The effect of endometriosis and its radical laparoscopic excision
on quality of life indicators. Br J Obstet Gynaecol. 2000;107:44–54.
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bowel of bladder involvement – long-term results. Eur J Obstet Gynecol Reprod Biol.
2005;123:224–9.
15. Bazot M, Lafont C, Rouzier R, et al. Diagnostic accuracy of physical examination, transvagi-
nal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose
deep infi ltrating endometriosis. Fertil Steril. 2009;92:1825–33.
16. Landi S, Barbieri F, Fiaccavento A, et al. Preoperative double-contrast barium enema in
patients with suspected intestinal endometriosis. J Am Assoc Gynecol Laparosc.
2004;11:223–8.
17. Woods RJ, Heriot AG, Chen FC. Anterior rectal wall excision for endometriosis using the
circular stapler. Aust N Z J Surg. 2003;73:647–8.
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endometriotic lesions? A prospective surgical and histological study. Hum Reprod.
2005;20:2317–20.
19. Donnez J, Squiffl et J. Complications, pregnancy and recurrence in a prospective series of 500
patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.
Hum Reprod. 2010;25:1949–58.
20. Campagnacci R, Perretta S, Guerrieri M, et al. Laparoscopic colorectal resection for endo-
metriosis. Surg Endosc. 2005;19:662–4.
21. Keckstein J, Weisniger H. Deep endometriosis, including intestinal involvement – the interdis-
ciplinary approach. Minim Invasive Ther Allied Technol. 2005;14:160–6.
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23. Mohr C, Nezhat FR, Nezhat CH, et al. Fertility considerations in laparoscopic treatment of
infi ltrative bowel endometriosis. JSLS. 2005;9:16–24.
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laparoscopic rectosigmoid resection in women with deep infi ltrating endometriosis. Br J Obstet
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475
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_33, © Springer-Verlag London Limited 2012
33.1 Introduction
The earliest stomas were almost certainly the result of battlefi eld trauma leading to a
colocutaneous fi stula. It was only late in the eighteenth century that surgeons attempted
to create a stoma deliberately. Stomas were used only to palliate an obstructing cancer
of the sigmoid or rectum. While this was effective in relieving the obstruction, the lack
of useful stoma appliances meant that quality of life for these patients was often poor.
It was not until comparatively late in the twentieth century that advances in surgical
technique and stoma appliances improved the outlook for patients with stomas.
In modern times, a stoma is in routine use in a number of situations in colorectal
surgery (see Box 33.1 ) .
M. Cheetham , M.B.Ch.B., FRCS
Department of General Surgery , Royal Shrewsbury Hospital ,
Mytton Oak Road , Shrewsbury, Shropshire SY3 8QX , UK
e-mail: mark.cheetham@sath.nhs.uk
Chapter 33
Stomas
Mark Cheetham
Box 33.1: Indications for a Stoma
1. To “protect” a distal anastomosis
e.g., after a low anterior resection or restorative proctocolectomy
2. Following resection when an anastomosis is not safe
e.g., Hartmann’s procedure for fecal peritonitis
3. To relieve obstruction when resection is not feasible
e.g., locally advanced rectal cancer
476
M. Cheetham
33.2 Preoperative Counseling and Siting
In most elective cases, preoperative stoma counseling and siting is performed by a
trained stoma nurse. There is good evidence that stomas sited preoperatively by a
trained stoma therapist have a reduced risk of complications. In a study of 593
patients having planned stomas, the rate of early stoma-related complications was
23.3% if the patient was marked by a stoma nurse and 43.5% if the patient was not
marked preoperatively [ 1 ] .
The patient should be examined lying, standing, and sitting to determine the
optimal site for a stoma. The stoma should be sited away from scars, skin creases,
and bony prominences. In obese patients, it is important to site the stoma more
cephalad so that the stoma is visible to the patient. When siting a stoma it is impor-
tant to also consider the patient’s clothing preference and any disabilities (see
Box 33.2 ). In an emergency, stomas are, by necessity, sited by the operating sur-
geon. All surgeons who perform emergency colorectal surgery should have a work-
ing knowledge of how to site a stoma (see Box 33.2 ). It should be acknowledged
that it can be diffi cult to site a stoma in a sick, immobile patient with a distended
abdomen.
There is evidence from a randomized controlled trial that starting stoma training
prior to admission for surgery results in a shorter length of stay, shorter time to
stoma profi ciency, and lower in-hospital cost [ 2 ] .
4. To reduce distal disease activity
e.g., anal Crohn’s disease
5. Anal sphincter failure
e.g., following abdominoperineal excision of the rectum, refractory fecal
incontinence
Box 33.2: Factors to Consider When Siting a Stoma
Type of stoma
Body habitus
Skin creases
Bony prominences
Previous scars
Patient’s clothing preference
Eyesight and hand function
477
33 Stomas
33.3 End Ileostomy
An end ileostomy is usually formed in the context of a subtotal colectomy or proc-
tocolectomy for infl ammatory bowel disease.
The stoma trephine should be as small as possible to allow delivery of the bowel
without any vascular compromise. The trephine may be made by elevating the skin
with a tissue forceps and using a scalpel to excise a disk of skin. Alternatively, a
cruciate incision can be made at the site of the stoma, excising the corners to make
a circular trephine. Conventionally, the external oblique aponeurosis is incised in a
cruciform manner, and the underlying rectus abdominis is split in the line of its
fi bers. The posterior rectus sheath and peritoneum are elevated between two clips
and incised to enter the abdominal cavity. The ileum to be used for the stoma is
grasped with an atraumatic clip inserted through the stoma trephine and delivered
outside. Maturation of the stoma is performed after any other wound have been
closed and dressed.
An ileostomy should be spouted to facilitated collection of liquid effl uent. The
spout can be created by inserting a Babcock clip into the lumen, grasping the mucosa,
and pulling to create the spout. Alternatively, three everting sutures are placed
though the serosa about 4–5 cm from the opened bowel. These sutures are held in
clips until all are placed and then tightened to spout the ileostomy. If these sutures
are placed carefully, it is possible to create a slight downward tilt to the ileostomy
spout [ 3 ] . If the patient is obese or the small-bowel mesentery is short, it may be
extremely diffi cult to form a spouted ileostomy without any tension. In these cir-
cumstances, it may be useful to close the end of the ileum with a linear cutting sta-
pled and form a loop ileostomy just proximal to this (an “end-loop ileostomy”)
(Fig . 33.1 ). A loop ileostomy is formed in a similar manner with the proximal end
everted to form a spout. It is crucial that the correct (i.e., proximal) limb of the ileos-
tomy is everted, as an alternative both proximal and distal limbs can be spouted [ 4 ] .
Fig. 33.1 End-loop
colostomy: the distal part
of the ileum is closed with
a linear stapler and a loop
of ileum just proximal to
the closed end is brought
through the abdominal
wall and opened as for a
traditional loop ileostomy.
The closed, distal end, lies
just below the level of the
fascia of the abdominal
wall
478
M. Cheetham
33.4 End Colostomy
An end colostomy is usually formed during an abdominoperineal excision of the
rectum or Hartmann’s procedure. An end colostomy may also be useful for selected
patients with fecal incontinence. The sigmoid colon is most often used to construct
an end colostomy, although the extent of the resection may determine that a more
proximal segment of colon is used. Conventionally, an end colostomy is sited in the
left iliac fossa. A colostomy is formed in a similar manner to an end ileostomy
although a colostomy is usually constructed fl ush with the skin. In practice, a “mini-
mally raised colostomy” may allow the stoma to be managed more easily [
5 ] .
33.5 Loop Stomas
Loop stomas are most commonly used to temporarily divert the fecal stream to
allow healing of a low anastomosis. A loop stoma may also be used to relieve
obstruction caused by a distal tumor. The most common types of loop stoma are a
loop ileostomy, a transverse loop colostomy, and a sigmoid loop colostomy. A stoma
rod is often placed under a loop stoma to prevent retraction of the loop in the early
postoperative period. The stoma rod is then removed during the early postoperative
period. Placing a rod may cause diffi culties with stoma care and may delay stoma
training. A randomized controlled trial of the use of rod in loop ileostomies found
no difference in the rates of stoma retraction [ 6 ] . However, a rod may be helpful
when constructing a transverse loop colostomy particularly when the colon is dis-
tended and fecally loaded.
33.6 Defunctioning Stomas After Low Pelvic Anastomosis
It is common practice to perform a proximal “defunctioning” stoma after a low pelvic
anastomosis (low anterior resection of the rectum or restorative proctocolectomy).
The aim is to reduce the consequences of a leaking anastomosis. A diverting stoma
probably does not reduce the incidence of anastomotic leak, but it does reduce the
chance that the leak will become symptomatic or require reoperation [ 7 ] . The reported
risk of an anastomotic leak after anterior resection varies, but a large population study
in Holland demonstrated an overall rate of anastomotic leak of 11.6% [ 8 ] . Surgeons
vary in their use of fecal diversion after rectal cancer surgery, although most will
divert a low rectal anastomoses. Most surgeons will consider a number of factors
when deciding whether or not to perform proximal diversion (see Box 33.3 ) and then
make an individual judgment. It is important also to consider the morbidity related to
the stoma and its subsequent closure when deciding whether or not to perform a
proximal stoma.
479
33 Stomas
Two different approaches are used, either a loop ileostomy or a transverse loop
colostomy. Several randomized trials have compared the two approaches with rather
disparate results (Box 33.4 ). The Cochrane Collaboration has performed a meta-
analysis of these trials and concluded that apart from a higher rate of stoma prolapse
seen with transverse loop colostomies, the results were comparable [ 9 ] . The overall
anastomotic leak rate was 9% in the ileostomy group compared to 12% in the loop
colostomy group, relative risk 0.72, 95%, and confi dence intervals 0.36–1.47 (non-
signifi cant). Three percent of patients with loop ileostomy required reoperation
compared to 2% of the patients with loop colostomy (not signifi cant).
33.7 Diversion After Pouch Surgery
In the initial series of patients undergoing restorative proctocolectomy, all patients
had a temporary loop ileostomy which was closed a few months after the initial oper-
ation [ 10 ] . Since then several centers have published series of patients undergoing
Box 33.4: Pros and Cons of Loop Ileostomy Versus Transverse
Loop Colostomy
Loop ileostomy Transverse loop colostomy
Pros
Easy to close
Reduced risk of dehydration
Lower risk of parasto-
mal hernia and
prolapse
Easy to manage
Cons Risk of dehydration
and renal
impairment
Increased risk of parastomal hernia
Increased risk of prolapse
Higher risk of wound infection at
closure
Box 33.3: Factors to Take into Account When Considering
a Proximal Stoma After Anterior Resection
Height of anastomosis
Degree of intraoperative bleeding
Smoking status
Sex (higher rate of anastomotic failure in men)
Preoperative radiotherapy (What is the risk of a leak?)
Body habitus of the patient (Would you notice a leak?)
Comorbidity (Would the patient survive a leak?)
Hand-eye coordination (Would the patient cope with a stoma?)
480
M. Cheetham
ileoanal pouch surgery without a temporary loop ileostomy [ 11– 13 ] . These studies
suggest that in suitable patients (fi t and not on systemic steroids), it may be safe to
perform ileoanal pouch surgery without a loop ileostomy. A small randomized con-
trolled trial of the use of loop ileostomy in patients undergoing pouch surgery found
no difference in the rate of anastomotic leak between the two groups [
14 ] . Despite
these fi ndings, the majority of surgeons continue to use a temporary loop ileostomy
during restorative proctocolectomy.
33.8 Closing a Defunctioning Stoma
There is some debate about the timing of surgery to close a temporary diverting
stoma. In general, most units would aim to close a diverting stoma within 6–12 weeks
of the initial operation. However, in the UK this time frame is often missed because
the patient is undergoing adjuvant chemotherapy or because of waiting lists.
Although not standard practice, it is possible to close a loop ileostomy much earlier.
Approximately 25% of “temporary” diverting stomas are never closed [ 15 ] , either
because of anastomotic leak, stricturing, or changes in medical comorbidity.
Conventionally, a water-soluble contrast enema is performed by some to assess
healing of the pelvic anastomosis. When the surgeon is satisfi ed on the basis of the
water-soluble contrast enema and clinical examination, the stoma is then closed at a
convenient time.
In closing a loop ileostomy, the operating surgeon has the option of simply clos-
ing the defect in the small bowel with sutures or of resecting the ileostomy and
performing a stapled side-to-side anastomosis. Several small trials have assessed
stapled or sutured closure of loop ileostomies [ 16, 17 ] . There is no clear difference
between the two techniques, although stapling is slightly quicker and may have a
trend towards a reduction in postoperative small-bowel obstruction [ 18 ] . Infi ltrating
the wound with long-acting local anesthetic does not reduce postoperative pain or
opiate usage [ 19 ] . A small randomized trial has shown a reduction in wound infec-
tion rates after closure of loop ileostomy when a subcuticular purse-string closure is
used, compared to linear closure of the skin wound [ 20 ] .
33.9 Trephine or Laparoscopic Stoma for Fecal Diversion
On occasion, it is desirable to form a stoma without performing a laparotomy (e.g.,
when making a stoma for fecal incontinence or prior to chemoradiotherapy). In these
situations, the options are either to perform a trephine stoma [ 21 ] or to use a laparoscopic
technique [ 22 ] . The trephine technique is simple and cheap, but if there are signifi cant
intra-abdominal adhesions or the patient is obese, this procedure may be technically dif-
fi cult. The laparoscopic approach is more involved but does allow the facility to mobi-
lize the colon more easily and may avoid the temptation to create an overlarge stoma
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