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118 Cataldo
most aspect of the bowel, it may be observed and allowed to demarcate.
Eventually a skin-level revision should be performed if there is full thick-
ness necrosis. This involves division of the sutures, debridement of the
compromised tissue, and rematuration of the stoma. Circumferential ische-
mia left untended may result in stricture of the colostomy.
Clinically, colostomy retraction is less consequential than ileostomy
retraction. A flat colostomy may be well tolerated by many patients. Still,
a rise of
1
⁄
8
in. is preferred. Retraction of the colostomy is approached simi-
larly to ischemia. If the colostomy retraction approaches the fascia, relapa-
rotomy is called for. Retraction below the skin level will frequently require
surgical attention at some point to avoid stricture and hygiene problems.
Prolapse of an end sigmoid colostomy is a late complication and is
less frequent than with loop sigmoid or loop transverse colostomies [2].
Surgical intervention is usually for psychological reasons or pouching diffi-
culties. Rarely, prolapse may result in obstruction or vascular compromise.
Simple skin-level revision is adequate in uncomplicated cases. For patients
with permanent colostomies, the most common complication is a paracolos-
tomy hernia. Reports vary from 1% to over 60% [5]. The most common
complaint is of pain. Incarceration and strangulation are rare complications.
Mucocutaneous separation may occur secondary to ischemia or retrac-
tion. In their absence, however, separation is due to improper technique or
inadequate closure. Partial separation will be self-limited with time and
wound contraction. Complete separation can easily be managed be debride-
ment and revision. Occasionally but surprisingly rarely, contamination or
infection of a hematoma or seroma results in an infection or abscess within
the trephine. If the infection is limited to the subcutaneous tissue, simple
drainage by dividing the maturation stitches will be adequate. A subcutane-
ous abscess with evidence of cellulitis requires systemic antibiotics. Signs
and symptoms of sepsis should prompt a search for an interabdominal
source. Recurrent infections indicate a fistula. This may be the result of a
full-thickness everting stitch or an amputated diverticulum. Once estab-
lished, colostomy fistulas require stomal revision.
Mortality obviously can occur in association with colostomy creation.
In one review of 126 patients with 130 end colostomies, there were 7 mor-
talities. In all cases, deaths were related to emergent operations or comor-
bid, nonsurgical disease [6].
POSTOPERATIVE CARE AND CONSIDERATIONS
Enterostomal Therapy
If the patient has not had the opportunity to be evaluated preoperatively by
the ET nurse, consultation should be obtained as soon as the first postopera-
tive day. The ET nurse is a resource for the floor nurses for stomal evalua-
End Sigmoid/Descending Colostomy 119
tion and care. For the patient, the ET nurse is the main source of education
and adaptation to this new life change. Often a patient may not be dis-
charged from the hospital until cleared by the ET nurse.
Irrigation Techniques
For some patients with a long-standing end colostomy and with stable
bowel habits, an end sigmoid colostomy can be “trained” to defecate “on
schedule” with routine irrigation. This reduces embarrassment and fears
associated with unscheduled or public functioning of the colostomy. In ad-
dition to simply washing out the distal colon, irrigation stimulates the more
proximal colon to peristalsis and empties the more proximal colon. When
done on a regular basis, the results may be quite reliable. Irrigation is per-
formed as a simple retrograde enema administered via a cone-tipped cathe-
ter held against the stoma. This reduces stomal trauma and leakage around
the catheter. A number of commercial products are available to maintain
cleanliness and facilitate emptying into a toilet. The enema is often admin-
istered with 500–1000 mL of warm tap water. Fluid is instilled slowly until
a sense of fullness occurs. The stoma is allowed to drain and, for approxi-
mately the next half-hour, the colon will continue to evacuate.
SUMMARY
Although the creation of a colostomy is not particularly difficult, its nu-
ances should not be overlooked. A well-functioning colostomy is taken for
granted at its creation. A poorly created colostomy can truly be a life-
ending catastrophe. “Temporary” colostomies will frequently turn out to be
permanent. If all the principles of surgical anastomoses—such as blood
supply and freedom from tension—are observed, stoma creation will re-
main nearly intuitive.
ACKNOWLEDGMENTS
I would like to recognize the efforts and assistance of Linda Gazzarro, RN,
ET, CWOCN. Without her help this chapter would not reflect the true needs
of the patients and their caregivers.
REFERENCES
1. Bass EM, Del Pin A, Tan A, Pearl RK, Orsay CP, Abcarian H. Does preopera-
tive stoma marking and education by the enterostomal therapist affect out-
come? Dis Colon Rectum 1997; 40(4):440–442.
120 Cataldo
2. Park JJ, Del Pin A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, Abcarian H.
Stomal complications: The Cook County Hospital experience. Dis Colon Rec-
tum 1999; 42(12):1575–1580.
3. Shelito PC. Complications of abdominal stoma surgery. Dis Colon Rectum
1998; 41(12):1562–1572.
4. Del Pin A, Cintron JR, Orsay CP, Pearl RK, Tan A, Abcarian H. Enterostomal
complications: Are emergently created enterostomas at greater risk? Am Surg
1997; 63(7):653–656.
5. Fleshman JW. Ostomies. In: Hicks, Beck, Opelka, Timmcke, eds. Complica-
tions in Colon and Rectal Surgery. Baltimore, MD: Williams and Wilkins,
1996:357–381.
6. Porter JA, Salvati EP, Rubin RJ, Eisenstat TE. Complications of colostomies.
Dis Colon Rectum 1989; 32:299–303.
7
Diverting Stomas
Russell K. Pearl
University of Illinois College of Medicine at Chicago
and Cook County Hospital, Chicago, Illinois, U.S.A.
Amir L. Bastawrous
Cook County Hospital, Chicago, Illinois, U.S.A.
Herand Abcarian
University of Illinois at Chicago, Chicago, Illinois, U.S.A.
INTRODUCTION
The construction of diverting stomas is an integral part of many operations
for colorectal tumors, trauma, and inflammatory bowel disease. These sto-
mas are formed by exteriorizing and maturing a segment of small bowel or
colon in which the continuity of the intestinal wall or mesentery is pre-
served, most often resulting in a loop or end-loop configuration. Tradition-
ally they are used in clinical situations in which proximal fecal diversion
must be performed expeditiously and usually on a temporary basis, such as
to protect a low anastomosis, decompress obstructed bowel, or prevent fecal
material from further contaminating an inflammatory mass. The advantages
of diverting stomas include technical ease of construction and, more impor-
tant, ease of closure (because a formal laparotomy is seldom required). For
these reasons diverting stomas, particularly the loop variety, have become
the most frequently used type of ostomy in surgical practice.
Several fundamental questions commonly arise during a discussion of
diverting stomas. Perhaps the most common one is: Do diverting stomas
completely defunctionalize the bowel? The corollary to that question is:
Are diverting stomas necessary? Another important and frequently over-
looked issue is: How often are diverting stomas temporary? In addition,
there has been considerable discussion about which type of diverting
stoma—ileostomy or colostomy—is superior with respect to ease of con-
struction, function, and complications. Finally, what is the role of laparos-
copy in creation and closure of diverting stomas? The aim of this chapter
121
122 Pearl et al.
is to answer these questions and to review the indications, operative tech-
niques, and complications associated with the construction of diverting
stomas.
INDICATIONS
Over the past several years, many of the previously absolute indications for
diverting stomas have been challenged. A loop or end-loop ileostomy was
often created to protect an ileal pouch anal anastomosis in a patient with
chronic ulcerative colitis or familial adenomatous polyposis coli. However,
some centers have recently described comparable results of ileal pouch anal
anastomosis procedures with or without diversion [1–2]. Many surgeons
now take a selective approach to this issue, tailoring the use of an ileostomy
to the individual patient, taking into account body habitus (pelvic shape and
length, mesenteric thickness, or total length of remaining bowel), steroid
use, and anastomotic tension. Diverting ileostomy has also been used as a
temporizing measure in patients with fulminant inflammatory bowel dis-
ease, although most surgeons would probably opt for a more definitive pro-
cedure if the patient’s condition permits.
A diverting colostomy is used most frequently to provide proximal
fecal diversion in patients with a large bowel obstruction or pelvic sepsis
when a malignant tumor, diverticulitis, colorectal trauma, radiation injury,
or a complication of inflammatory bowel disease is present. Recently, such
a colostomy has been used to protect a coloanal anastomosis as part of a
sphincter-saving procedure for midrectal cancer, radiation-induced stricture,
or fistulas. Fecal diversion for colon trauma was initially recognized for
high-velocity military-related penetrating trauma. This was extrapolated to
civilian penetrating colon injuries. Since then, there has been a progressive
trend away from diverting stomas for low-velocity civilian penetrating co-
lon injuries to the point that some surgeons do not divert even left-sided
colon trauma [3].
We would caution against performing a “blind” transverse loop colos-
tomy in cases of large bowel obstruction without manually exploring the
abdomen to ascertain the site and resectability of the obstructing lesion.
This type of diverting stoma has no value in relieving an obstruction at the
ileocecal region or an obstruction due to a sigmoid volvulus.
A tube cecostomy has often been recommended as a convenient and
rapid method of decompressing obstructed large bowel. However, regard-
less of the diameter of the tube’s lumen, a tube cecostomy is relatively
ineffective in diverting the fecal stream. It is also prone to leakage of liquid
stool from around the tube, which may result in wound complications or
intra-abdominal sepsis.
Diverting Stomas 123
OPERATIVE PLANNING AND TECHNIQUE
Whenever possible, an enterostomal therapist should be involved in the
preoperative planning of a stoma, both to provide information about stoma
function and care and to offer support and reassurance to the patient and
family. Proper selection and marking of the ostomy site is an important
consideration in preoperative stoma planning, because many complications
of ostomies are related to improper siting of the stoma. For example, if an
ostomy is brought out too close to a bony prominence, such as the costal
margin or the iliac crest or within skinfolds, scars, or drain sites, it is usu-
ally not possible to obtain an adequate skin seal around the stoma. This
situation will invariably lead to leakage of liquid stool around the ill-fitting
ostomy pouch, which often results in skin irritation.
The patient should be evaluated in the supine, sitting, and (when pos-
sible) standing positions to determine optimal ostomy placement. In emer-
gency situations, the stoma should be brought out through the rectus muscle
in a location surrounded by 2–3 in. of flat skin to allow adequate adherence
of a pouch. In obese individuals, lower abdominal sites should be avoided
because of numerous skinfolds created by the protruding abdomen. Many
obese patients will be unable to manage or even see their stoma in these
locations.
Diverting ileostomies are usually formed in the right lower quadrant,
whereas diverting colostomies are brought out along the course of the trans-
verse or sigmoid colon, depending on the site of injury or obstruction. In a
survey of technical considerations in the construction of intestinal stomas,
28% of surgeons responded that they routinely bring a loop colostomy
through the main laparotomy incision. We believe that this practice makes
it difficult to obtain a leak-free seal around the stoma pouch and produces
a generally unattractive result.
It is always preferable to mature a loop stoma in the operating room,
even in cases of large bowel obstruction. In the past, it was feared that this
procedure would lead to an unacceptable incidence of sepsis, because it
was theorized that stool would re-enter the peritoneal cavity around the
stoma at the mucocutaneous junction. If the distended bowel is carefully
decompressed with a needle attached to the suction tubing to minimize
fecal spillage prior to opening the loop, this fear is unwarranted. The advan-
tages of primary maturation of the loop stoma in the operating room setting
far outweigh the risks of attempting to mature a stoma at the patient’s bed-
side on postoperative day 2 or 3, with suboptimal lighting, equipment, and
anesthesia.
A laparoscopically or endoscopically assisted approach may be con-
sidered for elective or semielective situations where a diverting stoma is
needed. The details of the techniques for laparoscopic ileostomy or colos-
124 Pearl et al.
tomy are described in detail elsewhere in this text. A minimum number of
ports are needed; some have even described loop diverting stomas through
a single port site [4].
Loop Ileostomy
Construction of a loop ileostomy is technically more demanding than con-
struction of most other types of intestinal stomas. In contrast to colonic
content, ileal effluent is liquid and rich in skin irritants, such as bile salts
and proteolytic enzymes. In order to avoid complications, such as ileostomy
dysfunction and skin irritation, the end of the ileum and its mesentery must
be mobilized far enough to form a properly everted protruding ileostomy
without compromising its blood supply.
A circular skin incision about 2 cm in diameter is made at the desig-
nated point and continued through the subcutaneous fat down to the anterior
rectus sheath (Fig. 1). The space created by removing this cylinder of fat
in continuity with the overlying skin provides room for the bowel mesen-
tery in order to minimize vascular compromise. A cruciate incision is made
in the anterior rectus fascia with each limb extending about 3 cm. A curved
hemostat is used to spread the rectus muscle in the direction of its fibers
and to expose the posterior rectus sheath or transversalis fascia. Then a
short transverse incision is made through this layer and the peritoneum. It
is important to ensure that the opening in the rectus muscle is not oblique,
and care should be taken to avoid injury to the inferior epigastric vessels.
As a general rule, the opening in the abdominal wall should admit two
fingers.
When fashioning a traditional loop ileostomy, the surgeon should mo-
bilize the designated loop enough to reach the stoma site on the surface of
the abdominal wall without creating undue tension (Fig. 2). A small open-
ing is made in the mesentery of the loop adjacent to the ileal wall, through
which a small rubber drain or umbilical tape is passed. The ends of the
drain are grasped with a hemostat, and the loop is gently drawn through
the stomal aperture. A small rod or similar device is passed through the
mesenteric opening of the loop in place of the drain; it is sutured in place
to support the ileum on the abdominal wall. In contrast to the situation
with a permanent end ileostomy, the mesentery does not need to be fixed
intraperitoneally. It is useful to mark the distal portion of the loop with a
silk suture at this point to prevent maturing the incorrect or distal end of
the stoma. After the abdominal incision has been closed, the loop is opened
transversely for about two-thirds of its circumference. This incision should
be directed toward the distal end of the loop to ensure enough length to
form a properly everted protruding ileostomy. The ileostomy and the de-
functionalized ileal limb are sutured to the dermis with absorbable sutures
to create a nipple and eversion of the functioning end. Skin protection,
Figure 1 Unplanned loop ileostomy. A. The incision should be placed within the
triangle formed by the anterosuperior iliac spine, the umbilicus, and the pubis overly-
ing the rectus sheath. B. A circular skin incision approximately 2 cm in diameter is
made. C. A cruciate incision is made in the anterior rectus sheath. A clamp is used
to spread the rectus muscle in the direction of its fibers. D. A transverse incision is
made in the posterior rectus sheath or the transversalis fascia. E. The opening in the
abdominal wall should admit two average-size fingers. (After Pearl.) (From Ref. 17.)
126 Pearl et al.
Figure 2 Traditional loop ileostomy. A. A rubber drain is passed through a small
hole in the mesentery of the segment of ileum to be exteriorized as a loop ileos-
tomy. B. A plastic rod is placed through the mesenteric opening to support the
loop on the skin and is sutured in place. The loop is opened transversely for about
two thirds of its circumference toward the distal end. The longer proximal length
of ileum is everted with interrupted absorbable sutures to form a protruding ileos-
tomy. C. Completed loop ileostomy. Note the disparity in size and configuration
between the proximal and distal lumens. (After Pearl.) (From Ref. 17.)
usually in the form of a properly fitted methylcellulose wafer [Stomahesive,
ConvaTec (Bristol-Meyers Squibb), Princeton, NJ] and an ostomy device
are then applied before the patient leaves the operating room. The rod can
usually be removed in 7–10 days. In instances where the stoma has been
created without tension, the ostomy rod may be omitted.
Loop Colostomy
In many ways the construction of a loop colostomy and a loop ileostomy
are similar (Fig. 3). However, because the colon is larger in diameter than
the small bowel, it is sometimes necessary to partially divide some of the
Diverting Stomas 127
Figure 3 Loop colostomy. A. A transverse incision is made in the right upper
quadrant. B. The rectus muscle is often partially divided to allow for more com-
plete eversion of the stoma. A transverse incision is made in the posterior rectus
sheath. C. A supporting rod is placed and then sutured into position. D. The exteri-
orized loop of colon is opened transversely for about two-thirds of its circumfer-
ence. E. The loop colostomy is matured primarily with interrupted absorbable su-
tures. (After Pearl.) (From Ref. 17.)