Stoma

Stoma

Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

The formation of a stoma will likely form only part of an operation. It is advisable that a specialist stoma nurse discuss with the patient pre-operatively (when possible) the implications involved and also to aid in the siting. The important points when informing a patient of a potential stoma.

The important points when informing a patient of a potential stoma are:

  • Permanent or temporary: If it is anticipated to be temporary it is important to stress that it may be permanent depending on intra- and postoperative events.
  • Site: An ileostomy is commonly sited in the right iliac fossa.
  • Single- versus double-barrelled.
  • Possibility of a mucous fistula.
Operative techniques

Ileostomy

End: Formed following the complete removal of the colon including the rectum. A mucous fistula may be fashioned in addition, termed a double-barrelled stoma.

Loop: Formed in order to defunction either a distal obstructing colonic lesion or in order to protect a distal anastomosis.

Colostomy

End: Formed in order to defunction a distal segment of bowel. Commonly performed following an anterior resection, APER, or as part of a Hartmann’s operation.  May be indicated in a distal colonic fistula. A mucous fistula may be fashioned in addition to this procedure.

Loop: Formed in order to defunction either a distal obstruction colonic lesion, a distal anastomosis or complex pelvic disease.

Reversal of Ileostomy or Colostomy

Is performed in order to restore the integrity of the intestinal tract. If performed open, involves either a circumferential incision around the stoma or possibly through the previous laparotomy incision. Reversal of loop ileostomies or colostomies can generally be performed through the circumferential incision around the stoma whereas reversal of end-ileostomies or colostomies usually involves opening the old scar in order to safely access the bowel. The anastomosis is performed and the wound is closed. 

The formation of a stoma and indeed the reversal may also be performed either open or laparoscopically.

Additional procedures that may become necessary

Stoma formation can be both the primary procedure or part of a larger sequence of events as a temporary stoma (Defunctioning).

Benefits

Therapeutic: 

  • Diversion stoma – divert faeces away from a segment of bowel that has been removed or away from the perineum in trauma or pathology (i.e. necrotising fasciitis).  Defunctioning stoma – to allow a segment of bowel, distal pathology, or anastomosis to heal.
  • To relieve symptoms, signs and complications of small or large bowel obstruction.
Alternative procedures/conservative measures
  • The patient should be advised of the indications and reasons for stoma formation. If it is feasible to avoid the formation of a stoma (which may result in the increased risk of an anastomotic leak) and the patient is advised of these risks, then the operating surgeon may opt to forego the stoma. This should be appropriately documented on the consent form. 
Serious/frequently occurring risks
  • Formation of a Stoma: Overall complication rates ranging from 13.1% to 69.4%;  bleeding, infection (including intra-abdominal abscess, wound and urinary infection), vascular compromise (ischaemia and infarction of the stoma 2.3 – 17%), retraction, prolapsed, peristomal skin irritation (3-42%), peristomal infection/abscess/fistula formation (2-14.8%), stenosis, alteration of bowel habit, parastomal hernia (early and late presentation 4.6-13%).
  • Reversal of Stoma: Bleeding, infection (intra-abdominal abscess, urinary and wound infection), perforation of bowel, anastomotic leak, enterocutaneous fistula, ileus, stricture at the anastomotic site, reoperation.
Blood transfusion necessary
  • Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions.
  • Cross-match (depending on starting haemoglobin and nature of the primary procedure being performed).
Type of anaesthesia/sedation
  • General anaesthesia.

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