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  1. 1. Stomas • A stoma (or ostomy, these 2 words mean the same thing) is a surgically created opening on the abdomen which allows stool or urine to exit the body. There are 3 main types of stoma – colostomy, ileostomy and urostomy.
  2. 2. Caecostomy
  3. 3. Urinary Stomas When a urinary stoma is created, the urine does not go to the bladder. The urine is rerouted through an opening on the abdomen (stoma) created by a surgeon. Vesicostomy: An opening in the bladder created to connect the bladder to an opening on the lower abdomen. Ureterostomy: The ureter (or ureters) is attached to the skin’s surface through a small opening in the abdomen. Ileal conduit: A small section of the ileum (small intestine) is used to create a passage for the urine to exit the body. This section of the small intestine, called a conduit, is attached to the abdominal wall to create a stoma. The urine flows from the kidneys, through the ureters, and out the stoma
  4. 4. Underlay
  5. 5.
  6. 6. (1) Colostomy • A colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the exterior, where it can be collected in an external appliance. Depending on the purpose for which the diversion has been necessary, a colostomy may be : 1) temporary or 2) permanent
  7. 7. Types of colostomy: • Loop colostomy: This type of colostomy is usually used in emergencies and is a temporary and large stoma. A loop of the bowel is pulled out onto the abdomen and held in place with an external device. The bowel is then sutured to the abdomen and two openings are created in the one stoma: one for stool and the other for mucus. • End colostomy: A stoma is created from one end of the bowel. The other portion of the bowel is either removed or sewn shut (Hartmann's procedure). • Double barrel colostomy: The bowel is severed and both ends are brought out onto the abdomen. Only the proximal stoma is functioning.
  8. 8. Some common reasons are: • A section of the colon has been removed, e.g. due to colon cancer requiring a total mesorectal excision, diverticulitis, injury, etc., so that it is no longer possible for feces to exit via the anus. • A portion of the colon (or large intestine) has been operated upon and needs to be 'rested' until it is healed. In this case, the colostomy is often temporary and is usually reversed at a later date, leaving the patient with a small scar in place of the stoma. Children undergoing surgery for extensive pelvic tumors commonly are given a colostomy in preparation for surgery to remove the tumor, followed by reversal of the colostomy. • Fecal incontinence that is non-responsive to other treatments
  9. 9. (1)Temporary Colostomy. Indications: 1- Distal Obstruction. 2- Defunction a low rectal anastomosis after Anterior resection of the rectum. 3- Following traumatic injury to the rectum or colon. 4- During operative treatment of a high fistula in ano. 5- Fulminant Colitis (IBD). 6- Complicated Diverticular disease.
  10. 10. Site of the colon used: A segment which has a mesentery: 1- Transverse colon. (Disease involve Lt. side of the colon) 2- Sigmoid colon. (Disease involve the rectum or rectosigmoid junction)
  11. 11. • A sigmoid colostomy is usually brought out at the Lt. iliac fossa. • A Transverse colostomy is usually brought out in the Rt. Hypochondrium.
  12. 12. • # GA is important since since traction on the mesentery causes pain and nausea. • # A transverse incision 8-10cm long, with removal of a disc of skin, is made for transverse colon (in the Rt. upper abdomen midway between the umbilicus and xiphisternum over the rectus abdominus muscle and extending laterally to the lateral border of the rectus muscle), while for the sigmoid colon (in the Lt. iliac fossa with a muscle cutting incision). • # Cut down all layers including the rectus muscle which is divided transversely ligating and dividing the epigastric artery.
  13. 13. • # The most proximal loop of colon is prepared by removing the omentum from its anterior surface (only in Transverse colon), then a small hole is made in the mesocolon through which a rubber tube is passed to fascilitate delivery of the colon through the incision. • # The laparotomy wound should be closed at this stage. • # The colonic loop is held by an underlying glass rod or by a colostomy bar or skin bridge incised initially. The colon is then opened on its antimescolic border longitudinally (along the taenia coli). • # Sutures are used to fix the colonic serosa to the abdominal wall, and colonic mucosa to the surrounding skin. • # The finished loop colostomy should allow one finger to pass down on each side.
  14. 14. 2- Double Barrelled colostomy: the colon is divided so that both ends can be brought separately to the surface with a skin bridge intervening. • Advantage: ensures that the distal segment (colon, rectum) is completely defunctioned (Absolute Rest).
  15. 15. 3- Hartmann’s Procedure: • This includes a proximal End Colostomy with a distal closed colonic segment. • This procedure can be used when resecting a tumour of the Lt. site of the colon or in Complicated diverticular disease.
  16. 16. (2) Permanent Colostomy Indications: 1- Rectal carcinoma excision ( A-P resection) ----- End colostomy 2- Inoperable rectal or colonic carcinoma ---- Loop colostomy
  17. 17. Complications of colostomies • The following complications can occur to any colostomy but are • more common after poor technique or siting of the stoma: 1) prolapse; 2) retraction; 3) necrosis of the distal end; 4) fistula formation; 5) stenosis of the orifice;
  18. 18. 6) colostomy hernia; 7) bleeding (usually from granulomas around the margin of the colostomy); 8 )colostomy „diarrhoea‟: this is usually an infective enteritis and will respond to oral metronidazole 200 mg three times daily. 9) Many of these complications require revision of the colostomy.
  19. 19. Stoma Complications • Candidiasis= Yeast Related Infection • Folliculitis= hair trauma • Irritant Dermatitis= Inflammation of the skin around the stoma
  20. 20. (2) Ileostomy • Definition: It is an artificial opening made between the ileum and skin of the abdominal wall, to divert intestinal contents to the exterior, without a sphincter to control the timing of its emptying. Effluent is usually liquid.
  21. 21. The Brooke Ileostomy • Adopted worldwide after introduction in 1952 • Revolutionized Stoma surgery Bryan Brooke – My Surgical Idol
  22. 22. (1) End Ileostomy. Indications: In cases where total proctocolectomy is done. 1- Ulcerative colitis. 2- Crohn’s disease. 3- Familial polyposis Coli.
  23. 23. 2) Loop Ileostomy. Indications: as an alternative of a loop colostomy for Defunctioning (for protection) 1- Low rectal anastomosis following a anterior rectal resection procedure. 2- Ileoanal pouch procedure following Total proctocolectomy.
  24. 24. Technique of Ileostomy: • The ileostomy opening should be 5 cm lateral to the umbilicus and brought out through the lateral edges of the rectus abdominus muscle. • It is usually made in the Rt. Iliac fossa. It should be spouted.
  25. 25. Complications of Ileostomy: • • • • • • • 1- Prolapse. 2- Retraction. 3- ParaIleostomy Hernia. 4- Bleeding. 5- Necrosis and gangrene of the distal end. 6- Stenosis of the Ileotomy orifice. 7- Skin reaction around the stoma. (Excoriation, erosion, sloughing) • 8- Fluid and electrolyte imbalance. (Ileostomy Flux).
  26. 26. (3) Caecostomy • Indication: 1- Trauma to the caecum. 2- Closed loop syndrome. (In desperately ill patients with advanced obstruction) Site: Rt. Iliac fossa.
  27. 27. Complications of Stomas
  28. 28. Good stoma Bad stoma
  29. 29. “Is it supposed to be…long?”
  30. 30. • Retracted
  31. 31. “Sunken in…”
  32. 32. “Erythematous skin…”
  33. 33. Skin irritation • Almost entirely due to poor stoma siting • Occurs in 3-60% • Result of Chemical dermatitis or frequent appliance changes. • Fungal irritation by C. Albicans • May be due to abscess or fistula – Fistula common in Crohn’s – Fistula from taking too much bowel wall on seromuscular bites of Brook ileostomy – Abscess often due to retraction of mucocutaneous border
  34. 34. Retraction • Convex appliances are key to avoid reoperation • Can be revised locally – Re-Brooke-ing • May require laparotomy and resiting if severe retraction
  35. 35. Dusky Stoma
  36. 36. Criteria taken into consideration when positioning a stoma: • 1- Away from any bony prominence. (Anterior superior iliac spine , Symphysis pubis) • 2- Away from the umbilicus. • 3- Away from any previous surgical incision. • 4- Visible when the patient stands. • 5- Comfortable for the patient.
  37. 37. Stoma Examination • Introduction • name and role • explain to the patient what you will be doing • explain to the patient why you want to do it • gain full consent from the patient • confirm the patients name and age
  38. 38. Preparation • wash your hands • put on gloves • appropriate patient exposure • ask the patient if they are in any pain before beginning and be sensitive to this • INSPECT from the end of the bed to see if the patient looks well, abdominal contour, scars, swellings and the site of the stoma
  39. 39. • INSPECT the stoma closely noting its colour, number of lumens, presence of a spout or flush with the skin, presence of blood, mucus or leakage of faeces INSPECT the stoma bag noting the colour, consistency and the volume of the contents Stomas should be a healthy,,,how it should be like ??????
  40. 40. • stomas should be a healthy pink/red colour and should be moist and glistening. Darker and matter hues may indicate ischaemia while a pallor may suggest anaemia. The presence of a spout identifies an ileostomy while a stoma flush with the skin is usually a colostomy. • brown fully formed contents suggest a colostomy. Semi-solid or liquid contents dark green in colour suggest and ileostomy
  41. 41. • The volume of the stoma bag contents is extremely important as a common complication of stomas is high output loss and fluid and electrolyte imbalance. Large volumes passed may therefore require adequate fluid management, while reductions in volume may indicate stenosis and therefore an impending obstruction.
  42. 42. • INSPECT the surrounding skin for erythema, rash, ulceration and mucocutaneous junction seperation • PALPATE the surrounding area for tenderness and masses such as parastomal hernias • PERCUSSION abdomenAUSCULTATION to ensure bowel sounds are present and therefore an indication of a working bowel
  43. 43. Psychosocial/Vocational implications • Vocational Implications – Ostomy surgery itself does not present obstacles to most vocational functioning – Changes in body image – Economic costs of living with an ostomy can be considerable when complications from the stoma or disease process develop – Provide information and education to the person in a manner that relays a message of acceptance
  44. 44. “Better to create an ugly stoma in a good location than a pretty stoma in an ugly location.” --Peter Cataldo
  45. 45. Ostomies
  46. 46. Ostomies • Should have an ostomy bag in place • Depending on location of ostomy may produce liquid or solid fecal matter • Digestive enzymes may corrode skin around stoma • Ostomy site should be pink or red • Most pouches can be emptied without removal
  47. 47. “It doesn‟t matter if a good doctor made your ostomy. If you have it long enough, you have a 100% risk of a parastomal hernia.” J Byron Gathright,
  48. 48. Ostomy Care • Wash your Hands • Assemble your Equipment • Wear Gloves • Clean around the stoma • Observe the Stoma • Measure the stoma
  49. 49. • Measure the Stoma • Transfer the Measurement to the Wafer • Cut the Wafer to Fit • Remember to keep the area dry and be ready for drainage
  50. 50. • Peal the Adhesive Backing off and Gently adhere the Wafer to the Patient • You may use Soma Paste to further seal and protect the skin
  51. 51. • Gently attach the Bag to the Ring around the Wafer • Make sure the seal is tight and secure • Make sure the bag is clipped at the bottom
  52. 52. • Prepare for Drainage and Always Document the Procedure
  53. 53. Summary May be colostomy or ileostomy May be temporary or permanent Temporary or defunctioning stomas are usually fashioned as loop stomas An ileostomy is spouted; a colostomy is flush Ileostomy effluent is usually liquid whereas colostomy effluent is usually solid Ileostomy patients are more likely to develop fluid and electrolyte problems
  54. 54. ■ An ileostomy is usually sited in the right iliac fossa ■ A temporary colostomy may be transverse and sited in the right upper quadrant ■ End-colostomy is usually sited in the left iliac fossa ■ All patients should be counselled by a stoma care nurse before operation ■ Complications include skin irritation, prolapse, retraction,necrosis, stenosis, parastomal hernia, bleeding and fistulation
  55. 55. What makes a Stoma Difficult? Poor Planning? Technical errors? Difficult Postoperative Maintenance?
  56. 56. Non-difficult stoma Imperfect location Perfect Stoma
  57. 57. Difficult Stoma
  58. 58. Preoperative considerations LOCATION! LOCATION! LOCATION! • • • • • Does this Person really need this stoma? Quality of life issues Elective vs. Emergent Education Will this be reversed?
  59. 59. How to Properly Site a Stoma* 1. Examine abdomen with patient clothed 2. Examine exposed abdomen with patient supine, standing, sitting, bending over 3. Identify skin creases, folds, skin problems, scars, bony prominences 4. Draw imaginary line where incision will be 5. Choose point 5 cm away from incision with 5-7 cm of flat surface. 6. Identify and mark edge of rectus muscle
  60. 60. 8. Mark site with X Choose an area visible to patient, but below level of belt line
  61. 61. 9. Examine mark with patient supine, standing, sitting, bending over. 10. Mark and cover with tegaderm. Better position Note change in skin fold with sitting!
  62. 62. Ostomy Triangle
  63. 63. Special considerations • • • • • Obesity Ventral hernia Multiple Stomas Prior Stoma Lifestyle
  64. 64. Appropriate lengths for stoma • Ileostomy – Total bowel length above skin = 6-8 cm – Loop = 3 cm at mesenteric apex – Height of spout after Brooke Ileostomy creation > 20 mm decreases skin/wound issues • Colostomy – Total bowel length above skin 2-4 cm – Height of stoma after Colostomy maturation should be > 5mm Persson E, Colorect Dis 2009
  65. 65. A Difficult Situation • • • • • 65 year old man Diabetic with CHF Perforated diverticulitis 5 laparotomies Septic with peritonitis Get the idea???
  66. 66. The Difficult Stoma • Inflamed, thickened, foreshortened mesentery – Prior operations – Inflammatory changes • Obesity – Thick abdominal wall – Poor tissue quality • Distended colon
  67. 67. Obesity and Stoma Creation • Increased depth of skin creases causes pouching difficulties, even in properly constructed, well located ostomies • Difficult to identify the rectus muscles preoperatively • Obese patients cannot see their lower abdomen • Thicker abdominal wall adipose tissue requires increased amount of length of mobilization
  68. 68. Remember Preoperative planning, operative technique, postoperative education are of vital importance Make every stoma as though it were going to be permanent
  69. 69. Go North Young Man • In obese patients Supraumbilical placement of stomas is desirable • Improved Pouching • Decreased skin irritation • Thinner abdominal wall above umbilicus • Patients can see it
  70. 70. How to differentiate a colostomy from ileostomy?
  71. 71. Resources for Ostomates • Baily & love • United Ostomy Associations of America – WWW.OSTOMY.ORG • ASCRS website – • Wound, Ostomy, and Continence Nursing – WWW.WOCN.ORG