Colostomy,segmoid

resection and
Hartmann's procedure

By Abayneh
Ayele(IESO STUDENT)
WOLLO UNIVERSITY

seminar
contents
Anatomy and blood
supply of intestine.

Definition and types of

colostomy.

Indications of
colostomy and iliostomy.

Operative techniques

stomal varices/bleeding

Introductio
n.
A colostomy is an opening

made into the large bowel to

divert its contents to the
exterior.
The procedure is often part
of another operation such as
abdominal resection or
subtotal colectomy or may be
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Introducti
on..
Fecal

diversions may be required on

either a temporary or permanent basis for
the management of a variety of
pathologic conditions, including congenital
anomalies, obstructive or inflammatory
disorders, traumatic disruption of the
intestinal tract, or gastrointestinal
malignancy
The number of permanent diversions is
decreasing because of medical and
surgical advances.
8

Introduction
Ileostomies,

cecostomies, and
ascending colostomies
typically produce >500 mL
per day of output containing
digestive enzymes.
descending/sigmoid
colostomies produce stool
that is formed and does not
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Introduction
Loop

stomas are larger and

somewhat more difficult to
manage than end stomas.
Any diversion involving
retention of the distal bowel is
normally accompanied by
intermittent mucoid discharge
from the anus.
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2 main
types

a Colostomy can be Temporary or Permanent

A temporary colostomy can be performed on an
emergency basis to decompress an obstructed or
perforated distal colon.
A temporary "diverting" colostomy can also be
performed electively to permit healing of a
fistulous tract or acute inflammatory process
distal to the colostomy.
In addition, a diverting colostomy is sometimes
created for protection of a distal anastomosis
when delayed healing is anticipated (such as an
anastomosis involving irradiated tissue
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Permanent colostomy
Permanent

colostomy is most
commonly performed for cancer
involving the distal rectum or
anus.
Fortunately, it is now recognized
that a 1 cm margin of resection
is almost always sufficient to
provide clear margins, which has
reduced the number of patients
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1.

standard
sites
Caecostomy

-in(RLQ)/ RIF.
2. Transverse
colostomy - in
right/left
epigastrium.
3. Sigmoid
colostomy in(LLQ)/ LIF.

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5 specific types
1.

Loop colostomy

- Brings a loop of gut out of the

abdomen over a short length of
rubber tube or glass rod.
Easiest to make in emergencies.
can be closed extraperitoneally.
- Suitable for most purposes.
- 2 openings made in one stoma.
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Loop
colostomy
(
a)

b)
c)
d)

e)

A soft catheter or a length of nylon

tape is passed through a small
window made in the mesentery of the
colon, and the prepared loop of colon
is eased through the hole in the
abdominal wall with the aid of the
catheter.
The catheter or tube is replaced by a
supporting colostomy rod.
A transverse incision is made across
the apex of the colon loop.
The cut edges of the colon are
everted and sutured to the skin edge
of the stoma hole with interrupted
absorbable sutures that take fullthickness bites of the colon and
subepidermal bites of the skin.
The rod is left in place for 5 days to
support the loop stoma during the
early phase of healing

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Colostomy: 5 specific types

contd.
Double-barrel colostomy
- A modified loop colostomy.
- Stitching the last few centimeters of
its limbs together inside the abdomen
so that resemble a double-barreled
shotgun.
- The spur/wall b/n the 2 loops is later
crushed to make the colostomy easier
to close with a special crushing clamp.
2.

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Colostomy: 5 specific types

contd.
- Can be closed extraperitoneally, only the
proximal stoma is functioning.
- The 2 ends come out through the same or
different wounds.
3. Spectacle colostomy
- Limbs or stomies are separated by a
small bridge of skin.
- Useful for colostomy of longer duration.
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Colostomy: 5 specific types

contd.
- Useful during the repair of rectovaginal or
vesicovaginal fistula, when work on the rectum
and bladder has to be completed before the
fistula can be closed.
- Closed intraperitonealy with a full anastomosis
b/c of separated loops.
4. End(Hartmans operation) colostomy
A

stoma is created from proximal end of

bowel.
The distal end of the bowel is either
removed or sewn shut.
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End colostomy
1.The end of the colon sits 1 to 2 cm above skin
level.
2. Four absorbable sutures are placed, one in each
quadrant of the stoma.

3.Each suture takes a full-thickness bite of the

end of the colon, a seromuscular bite of the
emerging colon at skin level, and a
subcutaneous bite of the edge of the skin
opening.

The stoma is completed by filling in the

gaps between the four quadrant sutures
with interrupted sutures that take fullthickness bites of the end of the colon
and subepidermal bites of the skin edge.
4.

5.The stoma should have a small

(0.5 to 1 cm) lip, which facilitates

accurate positioning of the
colostomy bag.

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5. Mucus fistula colostomy

This

is the term sometimes

given to the distal
opening(stoma).
A colostomy normally has 2
openings.
The proximal one discharges
feces & the distal mucus.
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Indications of Colostomy
Gangrenous

intestinal

obstruction
Rectal/colonic trauma
Colonic carcinoma
Anal atresia
Imperforate anus
Fecal incontinence nonresponsive to other

21

PREOPERATIVE PREPARATION

If

colostomy is part of an
elective bowel resection,
preparation should be as for
the primary procedure.
The patient should be assessed
preoperatively by the stoma
therapist to be evaluated for
the optimal placement of the
stoma
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Operative Procedure

1.End Colostomy
EXPOSURE AND OPERATIVE
TECHNIQUE
The site of the stoma should be
approximately 10 cm from the
ASIS and obliquely toward the
umbilicus.
Creases should be avoided.
in the presence of a panus, the
stoma is placed higher up .

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the

site of the stoma is

selected.
the skin is grasped with
a Kocher clamp/allis.
The Kocher is lifted and a
circular skin incision is
made.
The dermis is incised with
cutting electrocautery.
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subcutaneous

fat is excised.
using retractors dissection is
continued until the anterior
rectus sheath is visualized.
The anterior rectus sheath is
incised in a cruciate fashion.
the rectus muscle is spread
transversely and
longitudinally to identify the
posterior rectus sheath.
25

A similar cruciate incision is

made on posterior rectus sheath.
The resulting defect in the
anterior abdominal wall should
easily admit 2-3 fingers.
Two Babcock clamps are passed
through the defect to grasp the
colon
colon gently drawn through the
defect.
avoid any twists or constriction
of the mesentery.

26

The

bowel is secured to the

anterior rectus sheath at the
four cardinal points with
seromuscular bites using 3-0
silk sutures.
If there is adequate length of
mucosa, an attempt is made
to rosebud the stoma
otherwise, it is secured flush
to the skin using 3-0
absorbable sutures.

27

To rosebud the stoma

a

bite of the dermis is taken

followed by a seromuscular bite of the
adjacent bowel
the maneuver is completed by passing
the suture through the full thickness of
the edge of the bowel wall.
Four such sutures are placed in the
cardinal points and then tied down to
evert the bowel.
Using 3-0 absorbable sutures,
additional sutures between the skin and
the edge of the bowel are placed to
completely secure the stoma
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To

ensure that there is

no obstruction
secondary to any
twisting of the colon,
the stoma is gently
examined with a
lubricated finger.
The skin around the
stoma is cleansed and

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30

31

32

2.Loop Colostomy
A loop colostomy may be
constructed to divert fecal
stream from an anastomosis.
a loop colostomy can also be
created for a left colon
obstruction on an emergency
basis
permanently for palliating an
unresectable cancer.
33

OPERATIVE TECHNIQUE
An

8- to 10-cm transverse incision is made

approximately 2.5 cm above the umbilicus
over the left half of the rectus sheath.
The anterior rectus sheath and then the
rectus muscle are divided with
electrocautery.
Larger blood vessels are clamped and
ligated with 2-0 silk sutures because they
often retract during electrocautery.
The posterior rectus sheath is

incised, and the peritoneal cavity

is entered.

34

OPERATIVE TECHNIQUE
The

transverse colon is
identified by the teniae coli and
delivered through the wound.
In obese patients, to avoid
retraction, the loop of
transverse colon is suspended
with rubber tubing or a glass
rod/iv set.
35

OPERATIVE TECHNIQUE
A

small opening is made

within the mesentery .
the plastic T-piece is
passed through this
defect.
The colon is secured to
the anterior rectus sheath
at four cardinal points

36

OPERATIVE TECHNIQUE
The

colon is opened
transversely along the
teniae and the contents
suctioned.
Using 3-0 absorbable
sutures, the colostomy
is secured by taking

37

OPERATIVE TECHNIQUE
If

complete diversion is
required, the transverse colon is
divided with a GIA-60 stapler.
The peritoneal covering of the
mesentery is incised on both
sides.
The vessels in the mesentery
are divided and ligated with 2-0
silk sutures.
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OPERATIVE TECHNIQUE
The

proximal colon is then

matured in the usual
fashion.
The distal mucous fistula is
usually left closed unless
there is fear of closed loop
formation, in which case it
is also matured

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40

41

42

CLOSURE
After

constructing the
colostomy, any remaining
open abdominal incision
is approximated in the
usual fashion.
Next, the colostomy bag
is closed over the stoma.
43

3.ILEOSTOMY
is

performed when it is necessary to

remove or bypass the entire colon and
rectum.
or to protect a distal colorectal, coloanal,
or ileoanal anastomosis .
If the anorectal sphincter mechanism is
removed, a permanent end ileostomy is
required .
If the anorectal sphincter mechanism is
retained, there is the potential for
reversal.

44

ILEOSTOMY
An

ileostomy may be constructed either as

an end or a loop stoma.
An end ileostomy is still considered the
standard of care for patients with Crohn's
disease who require panproctocolectomy.
Loop ileostomyis frequently used to
provide temporary fecal diversion following
sphincter-saving rectal resections.
A temporary loop ileostomy is also
constructed to provide protection of a
distal coloanal or colorectal anastomosis.
45

end ileostomy
The

ileum having been brought through

the abdominal wall, the ileostomy is
created by everting the end of the ileum.
Three sutures are placed: one on the
antimesenteric side and one to each side
of the mesentery.
Each suture takes a full-thickness bite of
the cut edge of the ileum, a seromuscular
bite of the emerging ileum at skin level,
and a subepidermal bite of the skin edge.
46

end ileostomy
The

spout is created when these

sutures are tied
A nontoothed forceps or a Babcock
tissue forceps is sometimes helpful for
everting the ileum.
Gaps between the three sutures are
filled in with further absorbable
sutures, which include only the end of
the ileum and the skin edge.
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end ileostomy

48

Loop ileostomy
A

soft catheter or a length of nylon tape is

passed through a small window made in the
mesentery of the ileum, and the ileal loop to
be used for the stoma is eased through the
hole in the abdominal wall and left protruding
a few centimeters above skin level.
A suture is placed to mark the distal limb.
A semilunar incision is made in the
mesenteric border of the distal limb at skin
level, extending around most of the
circumference of the ileum.
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Loop ileostomy
A

Babcock tissue forceps is inserted into the

loop and used to grasp the wall of the proximal
limb.
The cut edge of the ileum is peeled back to
evert the bowel wall and create a spout from
the proximal limb of the loop.
The stoma is completed by placing interrupted
absorbable sutures between the cut edge of the
ileum and the subepidermal layer of the skin.
A few of these sutures also take a
seromuscular bite of the emerging ileum at skin
level.
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51

Colostomy

closure

Done

4-6 weeks later as soon as Pt

recovered from his original operation.
Wash distal & proximal colon daily for 23 days.
Give MgSO4 PO or neomycin 500mg PO
QID for 2 days, then CAF PO & rectal
metronidazole.
Infiltrate skin with Lidocaine with
adrenaline around colostomy opening.
Insert

traction sutures around the colostomy.

52

Colostomy: closing
contd.
Make

an elliptical incision
around the colostomy, insert
your index finger through the
opening while freeing it from the
surrounding skin.
Use a fine knife & sharp scissors
to dissect it free from the
surrounding skin, fascia &
abdominal muscles.

53

Colostomy: closing
contd.
Using

sharp dissection clear the sheath

of rectus muscle until you reach the
edge of the opening through which the
gut is passing.
Close the 2 openings of loops
extraperitoneally or intraperitonealy &
close abdominal wall.
Do a Lords procedure (maximal anal
dilation with 2 fingers) before the Pt
goes back to the ward.
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Colostomy:
complications
Colostomy

necrosis

Retraction
Prolapse
Obstruction/defunctioning
Parastomal

hernia
Dehydration
Skin irritation
Distention of distal end with mucus
Feces entering to distal limb
55

Colostomy: complications
contd.
Dehiscence
Infection
Peritonitis
Stricture

of stoma
Adhesions
Ileus
Intestinal obstruction, etc.
56

mgt of common
complications

1.Stoma Stricture

causes-not suturing full

thickness of the edge of stoma to
skin during stoma maturation.
-serositis/serosal
gangren.
-ischemia, usually as
a result of resection of too much
57

Mgt

of stricture

Repair

may require a
simple local procedure if
the stricture is focal at the
skin level.
Revision of the stoma via a
transabdominal approach if
the stricture involves a
58

Mgt of Colostomy
Necrosis
Causes:excessive resection of
colonic mesentery.
excessive tension on
the mesentery.
creation of a fascial
opening too small to
accommodate the
bowel and its
mesentery.
poor perfusion due to
low-flow states

mgt:-

If the necrosis is limited to

the area of the stoma
anterior to the fascia, it
may be observed
carefully, and stoma
revision performed
electively at a later date if
necessary.
If the necrosis extends
into the peritoneal cavity,
the abdomen should be
explored and the stoma
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re-created

Mgt of Paracolostomy
Hernia

CAUSES

relocated or repair if
Symptomatic.
Local suture repair often
fails.
broad fascial mesh
repair appears to be a
more rigorous method
of repair, but still there
is a substantial risk of
60
recurrence.

daily

pressures
of Valsalva
maneuvers.
stomas
created out
side the rectus
sheath .

Asymptomatic hernias
should be observed
recurrence.

MGT

61

mgt Colostomy Prolapse

Prolapse

of the colostomy is seen most

often with the transverse-loop colostomy

Causes: lack

of fixation of the transverse

mesocolon to the retroperitoneum.
the size of the fascial opening necessary
to bring both limbs of the colon and the
mesocolon to the skin level
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mgt Colostomy Prolapse

The

surgical treatment of this complication is

difficult, and the best treatment is to rid the
patient of the primary disease and restore
intestinal continuity.
If this is not possible, the loop colostomy
should be converted to an end colostomy with
mucous fistula.
Prolapse of an end colostomy can be managed
by a local procedure in which the
mucocutaneous junction is disconnected, the
redundant colon resected, and the
mucocutaneous junction recreated.
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mgt of Colostomy Perforation

Perforation

of the colon just

proximal to the stoma most
often occurs during careless
irrigation with a catheter or
during contrast x-ray studies
when a catheter is placed in
the colostomy and a balloon is
inflated.
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mgt of Colostomy Perforation

It

is a surgical emergency and must be

dealt with by laparotomy and
reconstruction of the colostomy with
adequate drainage, if there is significant
fecal or barium contamination.
Cases of mild inflammation with
extravasation of air only can be
managed with antibiotics and localized
drainage, and surgery can be avoided.
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Referances
1.UpToDate 2011
2.ACS.Surgery.2007
3.Maingots Abdomenal Operation
4.Grays Anatomy for students

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Read more on colostomy.

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