COLOSTOMY

DR.MATHISEKARAN.T

TMCH,Thanjavur

Introduction
Stoma (Greek) = Mouth stoma is a surgical bypass of a natural conduit Intestinal Stoma An opening of the intestinal tract onto the abdominal wall, connected surgically or appearing inadvertently.

HISTORY
In 1710; Alexis Littre of Paris first performed colostomy through the anterior abdominal wall 1776 H.Pillore a surgeon from Rouen(FRANCE), also performed cecostomy on a patient with ca rectum. Px died after 28days.

HISTORY

HISTORY
First successful colostomy was done by Duret of Brest(FRANCE), on a 3day old child with imperforate anus and lived to 45yr.

HISTORY
Amussat studied all 29 colostomies done since Pillore, 21 being kids with imperforate anus. Noted that 20 died within a matter of days. Only 4 infants survived, all treated at Brest(remind Duret) Of 8 adults, 5 survived. Concluded that their deaths were due to peritonitis and therefore

Anatomy

Large intestine 1.5 m. (5ft.) Cecum; 7.5cm diameter, 10cm in length. Appendix; 3cm below ICV, variable length and positioning of tip. Colon; identified by taeniae coli, Sacculations (haustra) & appendices epiploicae. Ascending 15cm. Transverse 45cm,fixed b/n hepatic and splenic

Sigmoid; 15 to 50 cm (average 38 cm) and is very mobile , has the narrowest diameter. Rectum; is 12 to 15 cm in length lacks taeniae coli or appendices epiploicae. Along with the sigmoid colon serves as a fecal reservoir. anal canal

Classification is normally based on; Duration Anatomic part of bowel used Loop, End, Double barrel colostomy Retro or transperitoneal

Colostomy

Types

End colostomy Loop colostomy Types By Function Decompressing colostomy Diversion colostomy By Anatomy End-sigmoid colostomy End-descending colostomy Transverse colostomy Caecostomy

Types
Colostomy End left iliac fossa ( common ) Loop
Based on duration: Temporary Permanent

Incidence
Overall incidence of stomas decreasing New surgical techniques Stapling devises Local treatment for selected rectal tumours Sphincter saving procedures for UC, Familial polyposis

Colostomy Colo-rectal cancer Diverticular disease fistula Anal incontinence Ileostomy Crohns disease Ulcerative disease

Indications

TYPES
Colostomy End left iliac fossa Loop Ileostomy End right iliac fossa Loop Loop-End Split Continent (Kockspouch)

TYPES
Colostomy End left iliac fossa Loop Ileostomy End right iliac fossa Loop Loop-End Split Continent (Kockspouch)

TYPES
Colostomy End left iliac fossa Loop Ileostomy End right iliac fossa Loop Loop-End Split Continent (Kockspouch)

TYPES
Colostomy End left iliac fossa Loop Ileostomy End right iliac fossa Loop Loop-End Split Continent (Kockspouch)

Selection of stoma site:

A flat area of skin - for adequate adhesion of appliance. The patient should be able to see the stoma. Skin creases, folds, previous scars, Umbilicus, and bony prominences should be avoided. The stoma site should not be located at the beltline. The site should be identified with the patient lying, sitting, and standing. Preexisting disabilities should be taken into account.

Ileostomies right iliac fossa Sigmoid colostomy left iliac fossa Transverse colostomy right/left upper quadrant

Loop Ileostomy vs colostomy: Randomized controlled trails Ileostomy superior low incidence of complications in stoma formation/ closure (high incidence of intestinal obstruction). Principles of Stoma Surgery: Midline vertical incision Adequate blood supply on either side (skin & bowel) Without tension Avoid pre-existing infection Avoid too small hole at fascial level No twist Stoma hole made at the end of the surgery.

Procedure
Circular skin excise adequate ( 2.5 cm diameter) Subcutaneous fat should not excised supports stoma Cruciate incision in rectus sheath Muscle split in fibre direction Posterior sheath identified and incised Size-depends on the bowel Bowel brought out and secured Brookes technique of fixation Mucocutaneous jn is sutured cirumficially with interrupted absorbable suture

BROOKES TECHNIQUE

 Four suture incorporating the cut end, seromuscular layer at the level of the anterior rectus fascia and subcuticular edge of the skin are placed at 90* to each other. The sutures are tied to produce stomal eversion Simple sutures from cut edge of the bowel to the subcuticular tissue complete maturation of the colostomy.

Quality of Life
Development & availability of stoma equipment Good surgical technique Specialized nursing techniques, Counseling Pre-operative Post-operative

Preoperative Preparation
Investigations CBC, RBS & RFT, Urinalysis. Appropriate X rays. USG abdomen/CT abdomen Correction of fluid and electrolyte imbalance and blood volume deficits. Antibiotics .

Pre-operative assessment must be carefully done identifying some specific factors.

1.Physical, psychological, mental and emotional status. 2.Cultural, social and philosophic background. 3.Sensory capabilities. 4.Past experiences relevant to the present situation. 5.Interest, pre-occupations, pre-conceptions and motivational levels. 6.Knowledge of situation. 7.Environmental conditions and distractions. Ostomates are very much concerned because of changes in lifestyle like toilet habits (urinary/bowel) sexual and economical issues, social acceptance because of odour, noise and appearance of the appliance / pouch under the clothing.

8.Stoma siting The selection of the stoma-site is of paramount importance. The site varies for different people. The major concern is, that the patient should be able to see and to take care of the stoma. Furthermore, skinfolds, surgical scars and bony prominence should not interfere with the stoma because in order to prevent leakage, the collection device must be fixed flatly to normal skin. Improperly placed stomas will cause much distress to the patient. The day before the operation, the stoma-site should be determined after observation of the patient in lying, sitting and standing positions. Special considerations should be taken while marking the stoma-site for children, patients wearing orthopaedic braces or who are in wheelchair or for a handicapped person.

Distal

obstructive lesions causing massive proximal colon dilatation Severe sigmoid diverticulitis with phlegmonToxic megacolon
Phlegmon is a spreading diffuse inflammatory process with formation of suppurative/purulent exudate or pus.

Decompressing colostomy

Types Blow-hole stoma constructed in the caecum/ transverse colon Tube type cecostomy Loop - transverse

Rarely performed Reserved for severely acutely ill with massive distension and impending perforation of colon Elderly Immunocompromised patients Disadvantage: cannot evaluate other parts of the colon for potential ischemic necrosis due to massive dilatation

Blowhole

Blow-hole

Tube caecostomy
Malecot/ Mushroom catheter placed in the caecum Advantage: Less chance of prolapse Disadvantage: Tubes usually blocked with feces Drain poorly leak stool adjacent to the drain

Tube caecostomy

Diversion of intestinal content Distal segment of bowel completely resected APR Known/suspected perforation of distal bowel obstructing carcinoma diverticulitis leaking anastomosis trauma Crohns disease Failed/ reconstruction of anal sphincter

Diverting colostomy

 Left iliac fossa Sigmoid/ descending colon Should not protrude > 1.5 cm to 2cm To avoid herniation & prolapse #fixation of colon to the abdominal wall #extra-peritoneal tunnelling of colon difficult for reversal & revision.

End colostomy

Interrupted Absorbable Sutures Full thickness bite at the end

Sero-muscular bite at skin level

Quick & temporary method. Acute colonic obstruction/ for diversion RUQ proximal transverse colon LIF left colon Disadvantages Large holewhere colon is greatly dilated Para-stomal hernia, prolapse Appliance leakage Risk of damage to marginal artery

Loop Colostomy

Loop colostomy

Double barrel colostomy

This vogue has passed. Still has place In colo-rectal trauma. After resection of damaged colon Proximal & distal ends of colon tracked together along anti-mesenteric surfaces with interrupted absorbable sutures Easier to close

Post-operative stomal assessment should be done which includes the following factors : 1.Type and the segment of bowel. 2.Viability - colour and turgor 3.Stomal height or degree of protrusion. 4.Construction of stoma. 5.Abdominal location. 6.Size of stoma. 7.Oedema 8.Peristomal sutures. A stoma care is a clean procedure which does not require aseptic technique unless absolutely necessary.

Post-opperative care

Extra efforts for the effective pouch management should be made because the main advantage of pouching is: 1.Protection of the surrounding skin. 2.The appliance can be left in position for 7 to 10 days. 3.Accurate measurement and collection of effluent of discharge with odour control measures. 4.Easier mobilization of patient, which will result in, improved patient comfort and security with odour proof leak proof, drainable or closed end pouch. 5.The stoma should be measured from the base before selection of perfect pouch. The enterostomal therapist is responsible for selecting appropriate appliances and training the ostomy patient in their use so that he can return to normal meaningful life.

The patients with ileostomy, urinary diversion and transverse colostomies have to wear a pouch all the time but sigmoid colostomate with AP resection or permanent stoma can be taught how to perform irrigations or self enema through the stoma and only a small dressing is required and not a big pouch. The selection of pouches should be done according to types of ostomies which also depends upon, The ability of the output to cause skin irritation. The nature of the output (liquid, pasty or solid) The output is infrequently, frequently or continuously. Odour of the output. Bed-ridden or ambulatory. Dependent (with physical or mental deformities or independent.)

A meticulous skin care is mandatory, but in case of skin excoriation a skin-barrier wafer, paste, or powder may be very helpful. Home going instruction are given to all the ostomates on discharge like: 1.Nutrition 2.Personal and appliance hygiene 3.Bathing 4.Skin-care 5.Clothing 6.Job 7.Marriage, sex, or pregnancy 8.Exercise (hard body contact games should be avoided) 9.Social gathering

10.Possible complications like bleeding, prolapse, hernia or skin excoriation etc. and immediate solutions. 11.Availability of ostomy appliances and ostomy associations 12.Importance of follow-up For sexual problems a plissit model may be helpful. P : Permission to open the topic LI : Limited information about disease, prognosis and importance to life or sex. SS : Specific suggestions, fulfilling sexual needs (creativity, intimacy, closeness, love making by changing positions, lubricants, music and lights) IT : Intensive therapy, counseling by ET, or sex therapist.

Colostomy-complications
Stoma stricture Colostomy necrosis Para-colostomy hernia Colostomy prolapse Colostomy perforation

Stomal stricture and perforation

Quality of life

Famous personalities with colostomy

#Dwight Eisenhower - Former US President #Napoleon Bonaparte - world leader and military conqueror #Elizabeth Angela Marguerite Bowes-Lyon -wife of King George IV
and the mother of Queen Elizabeth II (colostomy since 1966)

#Tip ONeil - US Speaker of the House and Ambassador to Ireland

THANK YOU