Stoma (Greek) = Mouth
stoma is a surgical bypass of a natural conduit
An opening of the intestinal or urinary tract onto t...
Colostomy
End – left iliac fossa
Loop
Ileostomy
End – right iliac fossa
Loop
Loop-End
Split
Continent (Kock’s pouch)
Temporary
Permanant
Voluntary group of 40,000 people with various stomas
In USA, Canada
15,000 ostomies review
Ileostomy – UC - Peak incidene ...
After ostomy
Resumed home – 90%
Vocational activities – 73%
Social activities – 92%
Sexual activities – 70%
73% of registe...
Development & availability of stoma equipment
Good surgical technique
Specialized nursing techniques, Counseling
Pre-opera...
Overall incidence of stomas decreasing
New surgical techniques
Stapling devises
Local treatment for selected rectal tumour...
Colostomy
Colo-rectal cancer
Diverticular disease
fistula
Anal incontinence
Ileostomy
Crohn’s disease
Ulcerative disease
A flat area of skin - for adequate adhesion of appliance.
The patient should be able to see the stoma.
Skin creases, folds...
Ileostomies – right iliac fossa
Sigmoid colostomy – left iliac fossa
Transverse colostomy – right/left upper quadrant
Randomized controlled trails
Ileostomy superior – low incidence of
complications in stoma formation/ closure
(high inciden...
Midline vertical incision
Adequate blood supply on either side (skin & bowel)
Without tension
Avoid pre-existing infection...
Circular skin – excise adequate ( 2.5 cm diameter)
Subcutaneous fat should not excised – supports stoma
Cruciate incision ...
End colostomy
Loop colostomy
Types
By Function
Decompressing colostomy
Diversion colostomy
By Anatomy
End-sigmoid colostom...
Decompressing colostomy
distal obsructive lesions causing massive proximal colon dilatation
Severe sigmoid diverticulitis ...
Rarely performed
Reserved for severely acutely ill – with massive
distension and impending perforation of colon
Elderly
Im...
Malecot/ Mushroom catheter placed in the caecum
Advantage
Less chance of prolapse
Disadvantage
Tubes usually blocked with ...
Diversion of intestinal content
Distal segment of bowel completely resected – APR
Known/suspected perforation of distal bo...
Right iliac fossa
Simoid/ descenting colon
Should not protrude > 1.5 cm to 2cm
To avoid herniation & prolapse
fixation of ...
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
Disadv...
Stoma stricture
Colostomy necrosis
Para-colostomy hernia
Colostomy prolapse
Colostomy perforation
This vogue has passed
Still has place In colo-rectal trauma
After resection of damaged colon
Proximal & distal ends colon ...
After total procto-colectomy
Distal end of the ileum is prefered
(save length, future ileal pouch)
Right iliac fossa
Aim –...
To rest the distal bowel/ to protect an anastomosis
Distal ileal loop preferred
Similar to loop colostomy
Proximal limb – ...
ileum and its supporting mesentery are grossly
thickened and the surgeon is encountering difficulty
in preparing a suffici...
Bringing out two cut ends at different sites
Proximal end – ileum
Distal end – ileum/ colon – mucous fistula
can be includ...
Ileal pouch reservoir
Non-return nipple valve
Emptied regularly via a catheter
Intestinal reservoir for feces was first described by
Nil Kock – 1967
Originally described – U shaped pouch will interrupt...
Has been used as an alternative to conventional ileostomy
Selected patients ( ileo-anal anastomosis – alternative)
Ulcerat...
Kock-pouch continent ileostomy showing a Marlex
mesh collar reinforcing the nipple valve
Obstruction
Fistula
Incontinence (nipple valve slip)
Pouchitis
Obstruction
Fistula
Incontinence (nipple valve slip)
Pouchitis
Constructed intestinal segment with well-maintained
vascularity, connected to urinary tract to allow
egress of urine throu...
Leaking appliance – common
improper construction – flush stoma
spigot configuration is best
Radiation skin breakdown – rel...
End ostomy Loop ostomy
Vascular compromize
More chances of stomal necrosis
Easy to fix stoma appliance
Leak rate less
Reve...
Loop Ileostomy
At least 12 weeks
to settle edema inflammatory adhesions
Peri-stomal skin incision 2 mm from the muco-
cuta...
Complication rate in life time
Colostomy – 25%
End-ileostomy – 57%
Loop-ileostomy – 75%
Cumulative complication at 20 yrs ...
Skin – Excoriation, Ulceration
Ischemia
Obstruction
Retraction
Para-stomal Hernia
Prolapse
Fistula
Stenosis
Other - Bleedi...
Mild ischemia – common – resolve in few days
Satisfactory healing depends on blood supply
Loop ostomies has better healing...
consequence of postoperative ischemia
Mild stenosis - simple dilatation – if effluent is liquid
Substantial stenosis – sub...
Common – loop colostomy
Loop colostomies usually assiated with a degree of
para-stomal hernia
Usual complaint
difficulty i...
Repair co-existing para-stomal hernia
Emerging stoma through rectus abdominis/ fix the
mesentary to the abdominal wal
Commom in ileostomy
Causes
1.Leak – poor adhesion between serosal surfaces of
everted stoma
2.Para-stomal hernia
If retrac...
Formation of an abdominal stoma necessarily involves
creating a defect in the abdominal wall to
accommodate the emerging b...
Clinically
Unsightly bulge at stoma site
Leakage around the stoma appliance
Skin rahes
Difficulty in irrigation
Obstructio...
Surgical correction
Local repair
Prosthetic mesh repair
Stoma relocation
Stenosis
Para-stomal hernia
Post-operative adhesions
Recurrent disease
Crohn’s disease in proximal ileum
Recurrent cancer
...
Full thickness bite through the bowel while froming
stoma
Pressure necrosis – tightly fitting appliance
Recurrent disease ...
BLEEDING
Trauma, inflammatory polyps
PERFORATION
Trauma (irrigation) Recurrent disease
SKIN ULCERATION
Contact dermatitis
...
devastating news to a patient
sites should be marked preoperatively.
They should be on flat skin, away from scars and
avoi...
Appendix is used to create a conduit between the
skin surface and the urinary bladder
Indication
Urethral cancer
Neurogeni...
Continent ileostomy (Kock pouch) is an alternative
to end ileostomy for patients who have undergone
total proctocolectomy....
connecting the appendix to the abdominal wall and fashioning a valve mechanism
that allows catheterization of the appendix...
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
Stomas- Dr.Enja Amarnath Reddy
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Stomas- Dr.Enja Amarnath Reddy

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Stomas- Dr.Enja Amarnath Reddy

  1. 1. Stoma (Greek) = Mouth stoma is a surgical bypass of a natural conduit An opening of the intestinal or urinary tract onto the abdominal wall, connected surgically or appearing inadvertently Maingots
  2. 2. Colostomy End – left iliac fossa Loop Ileostomy End – right iliac fossa Loop Loop-End Split Continent (Kock’s pouch)
  3. 3. Temporary Permanant
  4. 4. Voluntary group of 40,000 people with various stomas In USA, Canada 15,000 ostomies review Ileostomy – UC - Peak incidene – 20yr – 40 yr Crohns – lower peak – same age group Colosomy – Colo-rectal cancers – pear – 60 yr – 80 yr
  5. 5. After ostomy Resumed home – 90% Vocational activities – 73% Social activities – 92% Sexual activities – 70% 73% of registered UOA conventional Ileostomy, Sigmoid colostomy After procto-colectomy sexual dysfunction is due to autonomic denervation, not because of stoma
  6. 6. Development & availability of stoma equipment Good surgical technique Specialized nursing techniques, Counseling Pre-operative Post-operative
  7. 7. Overall incidence of stomas decreasing New surgical techniques Stapling devises Local treatment for selected rectal tumours Sphincter saving procedures for UC, Familial polyposis
  8. 8. Colostomy Colo-rectal cancer Diverticular disease fistula Anal incontinence Ileostomy Crohn’s disease Ulcerative disease
  9. 9. 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.
  10. 10. Ileostomies – right iliac fossa Sigmoid colostomy – left iliac fossa Transverse colostomy – right/left upper quadrant
  11. 11. Randomized controlled trails Ileostomy superior – low incidence of complications in stoma formation/ closure (high incidence of intestinal obstruction)
  12. 12. 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 at the end of the surgery.
  13. 13. Circular skin – excise adequate ( 2.5 cm diameter) Subcutaneous fat should not excised – supports stoma Cruciate incision in rectus sheath Muscle split in fiber direction
  14. 14. End colostomy Loop colostomy Types By Function Decompressing colostomy Diversion colostomy By Anatomy End-sigmoid colostomy End-descending colostomy Transverse colostomy Caecostomy
  15. 15. Decompressing colostomy distal obsructive lesions causing massive proximal colon dilatation Severe sigmoid diverticulitis with phlegmon Toxic megacolon Types Blow-hole stoma constructed in the caecum/ transeverse colon Tube type cecostomy Loop - transverse
  16. 16. Rarely performed Reserved for severely acutely ill – with massive distension and impending perforation of colon Elderly Immunocompromised patients Disadvantage can not evaluate other parts of the colon for potential ischemic necrosis due to massive dilatation
  17. 17. 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
  18. 18. Diversion of intestinal content Distal segment of bowel completely resected – APR Known/suspected perforation of distal bowel obstructing carcinoma diverticulitis leaking anastomosis trauma Crohn’s disease Failed/ reconstruction of anal sphincter
  19. 19. Right iliac fossa Simoid/ descenting colon Should not protrude > 1.5 cm to 2cm To avoid herniation & prolapse fixation of colon to the abdominal wall extra-peritoneal tunneling of colon – difficult for reversal & revision.
  20. 20. Interrupted Absorbable Sutures Full thickness bite at the end Sero-muscular bite at skin level
  21. 21. Quick & temporary method. Acute colonic obstruction/ for diversion RUQ – proximal transverse colon LIF – left colon Disadvantages Large hole – where colon is greatly dilated Para-stomal heria, prolapse Appliance leakage Risk of damage to marginal artery
  22. 22. Stoma stricture Colostomy necrosis Para-colostomy hernia Colostomy prolapse Colostomy perforation
  23. 23. This vogue has passed Still has place In colo-rectal trauma After resection of damaged colon Proximal & distal ends colon tracked together along anti-mesenteric surfaces with interrupted absorbable sutures Easier to close
  24. 24. After total procto-colectomy Distal end of the ileum is prefered (save length, future ileal pouch) Right iliac fossa Aim – 2.5 cm spout Mesenteric surface oriented superiorly Ease until 5cm of ileum protrude above the skin Superior 2 sutures – 5cm serosal bite from end Inferior 1 suture – 4cm serosal bite from end Series of interrupted absorbable sutures Everted spout directed downwards
  25. 25. To rest the distal bowel/ to protect an anastomosis Distal ileal loop preferred Similar to loop colostomy Proximal limb – lower position Marking suture to identify proximal limb Supporting rod may be used Ante-mesenteric 80% circumferential incision – distal limb Proximal limb everted Muco-cutaneous sutures
  26. 26. ileum and its supporting mesentery are grossly thickened and the surgeon is encountering difficulty in preparing a sufficient length of well-vascularized ileum for a conventional end ileostomy. ileum is prepared as in a conventional end ileostomy, but the vascular arcades are left undisturbed. stapled closed end of the ileum lies just within the abdominal cavity. Ileostomy constructed same as conventional loop ileostomy.
  27. 27. Bringing out two cut ends at different sites Proximal end – ileum Distal end – ileum/ colon – mucous fistula can be included in the abdominal wound Advantage Completely defunctions the bowel without the risk of intra-abdominal leakage from a closed distal stump. Disadvantage difficult to close - necessitates reopening of the main incision.
  28. 28. Ileal pouch reservoir Non-return nipple valve Emptied regularly via a catheter
  29. 29. Intestinal reservoir for feces was first described by Nil Kock – 1967 Originally described – U shaped pouch will interrupt co-ordinated perisstalisis and would enhance the capacity Since then J, S shaped pouches have been used with similar results.
  30. 30. Has been used as an alternative to conventional ileostomy Selected patients ( ileo-anal anastomosis – alternative) Ulcerative colitis Familial polyposis Malfunctioning ileostomy Poorly located ileostomy Severe injury to the peri-stomal skin – allergic reaction to ostomy appliance Contraindication Crohn’s disease (recurrence)
  31. 31. Kock-pouch continent ileostomy showing a Marlex mesh collar reinforcing the nipple valve
  32. 32. Obstruction Fistula Incontinence (nipple valve slip) Pouchitis
  33. 33. Obstruction Fistula Incontinence (nipple valve slip) Pouchitis
  34. 34. Constructed intestinal segment with well-maintained vascularity, connected to urinary tract to allow egress of urine through stoma Indications After removal of urinary bladder - invasive cancer Severe obstructive uropathy Severe neurogenic bladder (spinal cord injury) Congenital abnormalities spina bifida bladder exstrophy
  35. 35. Leaking appliance – common improper construction – flush stoma spigot configuration is best Radiation skin breakdown – relocation Stone formation in the conduit Crystal formation around the stoma good hygiene acidification – with venigar Recent advances Kock’s continent urinary diversion
  36. 36. End ostomy Loop ostomy Vascular compromize More chances of stomal necrosis Easy to fix stoma appliance Leak rate less Reversal is difficult Good vascularity Less chances of stomal necrosis Difficult to fix Leak rate more than end Easy to reverse
  37. 37. Loop Ileostomy At least 12 weeks to settle edema inflammatory adhesions Peri-stomal skin incision 2 mm from the muco- cutaneous junction Sharp dissection – divide adhesions Excise rim of skin end-to –end anastomosis Loop colostomy Same as loop ileostomy closure
  38. 38. Complication rate in life time Colostomy – 25% End-ileostomy – 57% Loop-ileostomy – 75% Cumulative complication at 20 yrs for ileostomy Ulcerative colitis – 76% Crohn’s disease – 56% Many complications can be successfully managed with proper entero-stomal care Surgical correction is often unsatisfactory
  39. 39. Skin – Excoriation, Ulceration Ischemia Obstruction Retraction Para-stomal Hernia Prolapse Fistula Stenosis Other - Bleeding, perforation, Cancer
  40. 40. Mild ischemia – common – resolve in few days Satisfactory healing depends on blood supply Loop ostomies has better healing rate than end ostomies Recommended Prepare relevant bowel segment for the stoma before end of the operation – asses blood supply at the end Patchy necrosis confined to the mucosa – heal by secondary intension Complete necrosis of ileostomy – urgent revision Short segment colostomy with necrosis – no necessity to revise, heal with stenosis, fistula will form.
  41. 41. consequence of postoperative ischemia Mild stenosis - simple dilatation – if effluent is liquid Substantial stenosis – sub-acute obstruction – revision
  42. 42. Common – loop colostomy Loop colostomies usually assiated with a degree of para-stomal hernia Usual complaint difficulty in fitting the appliance/ leakage Best option – close the stoma Another option – devide loop – convert to end stoma distal segment return in to abdome Proximal – amputate prolapse High recurrence rate
  43. 43. Repair co-existing para-stomal hernia Emerging stoma through rectus abdominis/ fix the mesentary to the abdominal wal
  44. 44. Commom in ileostomy Causes 1.Leak – poor adhesion between serosal surfaces of everted stoma 2.Para-stomal hernia If retracted stoma is mobile Series of non-cutting linear staplling Avoid mesentary If retracted stoma is immobile - laparotomy
  45. 45. Formation of an abdominal stoma necessarily involves creating a defect in the abdominal wall to accommodate the emerging bowel. Such defects may become enlarged as a result of tangential force applied to the edge of the opening, and this enlargement may lead to hernia formation Intra abdominal pressure Obesity Emergency procedure – large opening Optimal – incision which admit 2 fingers
  46. 46. Clinically Unsightly bulge at stoma site Leakage around the stoma appliance Skin rahes Difficulty in irrigation Obstruction/strangulation
  47. 47. Surgical correction Local repair Prosthetic mesh repair Stoma relocation
  48. 48. Stenosis Para-stomal hernia Post-operative adhesions Recurrent disease Crohn’s disease in proximal ileum Recurrent cancer Retrograde contrast study - help in identifying the cause
  49. 49. Full thickness bite through the bowel while froming stoma Pressure necrosis – tightly fitting appliance Recurrent disease – Crohn’s disease Treatment laparotomy - reformation of stoma at new site
  50. 50. BLEEDING Trauma, inflammatory polyps PERFORATION Trauma (irrigation) Recurrent disease SKIN ULCERATION Contact dermatitis CANCER FORMATION Recurrence at stoma site/ de-novo cancer
  51. 51. devastating news to a patient sites should be marked preoperatively. They should be on flat skin, away from scars and avoiding bony prominences and the umbilicus. The positioning of the patients clothing should also be taken into account.
  52. 52. Appendix is used to create a conduit between the skin surface and the urinary bladder Indication Urethral cancer Neurogenic bladder Spinal cord injuries Spina bifida
  53. 53. Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached its height of popularity in the late 1960s and early 1970s, but has been supplanted by restorative proctocolectomy, an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for restorative proctocolectomy, for whom restorative proctocolectomy or end ileostomy have failed, and in a few other selected cases. Complication rates have decreased during the past three decades following technical
  54. 54. connecting the appendix to the abdominal wall and fashioning a valve mechanism that allows catheterization of the appendix. Indication Fecal incontinence

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