5. Skin Irritation/Rash
Most common complication
More with ileostomies
High risk
Poorly sited stoma
Non-nippled ileostomies
Poorly fitting appliance
High output stoma
6. Skin irritation/rash
Peristomal rash with satellite lesions – Fungal
infection
Antifungal powder
Peristomal rash conforms precisely to outline
of appliance - Allergic reaction
Reactivation of inflammatory bowel disease
7. Stoma necrosis
1 to 5 % of patients undergoing ileostomy
Gooszen AW et al. Dis Colon Rectum. 2000;43:650-655
Higher incidence with colostomy
More commonly seen after emergency surgery and in
obese patient
Most often noticed within 24 hours postoperatively
Leenan LP et al. Dis Colon Rectum. 1989;32;500-504
8. Stoma necrosis
Causes
Excess tension over mesentery
Short mesentery
Obesity
Stripping of mesentery
Avoid dividing sigmoidal arteries
Progression of mesenteric ischemia
9. Stoma necrosis - examination
Use transparent stoma bag
Test tube test - to diagnose the level of necrosis
Lubricated small test tube inserted into the stoma
↓
Flashlight shone along the sides of the test tube
10. Stoma necrosis - Management
Necrosis above the level of fascia
conservative management - often left alone
Complications of limited necrosis
Flushed / retracted / stenotic stoma
Mucocutaneous separation
Necrosis below the fascia
immediate laparotomy and stomal reconstruction
14. Bowel obstruction
Observed for a period of 24 to 48 hours
Patient comfortable with the nasogastric tube
decompression
Abdomen- soft and free of signs
Early operation
Pain persists despite nasogastric tube decompression and
lavage
Increasing pain / distension, leukocytosis ,fever
15. Bowel obstruction
small bowel obstruction in patients with stoma requiring
re-operation
inflammatory bowel disease
colorectal neoplasms
2/3 of obstructions related to adhesions
1/3 related to the stoma
Hughes ESR et al. Dis Colon Rectum 1979; 22:469–471
16. Mucocutaneous separation
Causes
Tension- skin opening too
large for exteriorized bowel
Malnutrition
High dose steroids
Good ET nursing important
Packing of subcutaneous tissue with paste material / absorptive
powder until a new junction forms secondarily
Late consequence- stenosis at the skin level
17. Ileostomy Diarrhea
Etiology
Adaptation phase following resection
Short bowel syndrome
Malabsorption
Antibiotics related
Infectious
Radiation enteritis
19. Stoma Retraction
Stoma may appear flush or below skin
level
May result in leakage
Sore skin/skin excoriation
Causes:
Obesity/weight gain
Early removal of stoma rod
Stoma placement in skin fold
Short mesentery for constructing the
stoma
20. Stoma retraction
Intermittent: Positional
Upright position
Stoma length and protrusion satisfactory
Supine position , abdominal muscles relaxed
stoma becomes flush with the skin or may recede
below the skin level
↓
soiling and leakage
↓
difficulty maintaining satisfactory appliance seal
21. Stoma Retraction - Management
Skilled ET nursing
Convex faceplate placed firmly against the skin
sometimes maintain a satisfactory seal
Weight reduction
Persistent leakage and soiling
Revision ileostomy
22. Stoma retraction
Ileostomy revision. (A) Circumferential incision around stoma. (B and C) Stoma is
mobilized to fascia and peritoneum, and tip is resected. (D) Ileum is fixed to fascia. (E)
New Brooke maturation is done.
24. Stomal stenosis
Narrowing at skin or fascial level
‘Ribbon stools’ – end colostomy
Causes
Ischemia
Small opening in the skin or fascia
Radiotherapy
Crohn’s disease
Reaction to suture material
26. Stomal stenosis
Skin-level stenosis
detaching the skin from the mucosa
excising a small amount of skin to increase the trephine
size
Malt et al- technique for relieving stricture at fascial level
Malt RA et al. Surg Gynecol Obstet 1984; 159:175–76
28. Prolapse
Incidence : 11% at 13 years
Stoma increased in size & length
Higher incidence with loop
stomas esp. transverse loop
colostomies
Bleeds & easily traumatized
29. Prolapse
Risk factors
Obesity
Poor muscle tone
Larger trephine
Raised intra-abdominal pressure
Presentation
Enlarged stoma
Dislodgement of appliance
Bowel obstruction
Pain due to engorgement & constriction of prolapsed segment
30. Prolapse
< 10% complicated by incarceration, strangulation
Reduction of acute prolapse
Supine position
Apply sugar to reduce edema
Reduce with gentle rocking motion
Repair
Resection
muco-cutaneous disconnection, eversion of
prolapsed segment, resection of exteriorized bowel,
recreation of stoma
31. Parastomal Hernia
Incisional hernia related to abdominal wall stoma
‘There is already a hole there!’
Incidence
2-28 % - end ileostomy
4-48% - end colostomy
32. Parastomal Hernia
“It doesn’t matter if God Himself made your ostomy.
If you have it long enough you have a 100% risk of a
parastomal hernia.”
J Byron Gathright
33.
34. Parastomal hernia- types
True parastomal hernia
Subcutaneuous prolapse (pseudohernia) with intact
fascial ring
Intrastomal hernia
Pseudohernia due to weakness of abdominal wall
without fascial defect
36. SYMPTOMS
Asymptomatic +++
Parastomal discomfort with intermittent obstructive
episodes
Stoma appliance issues with leak and skin irritation
Obstruction/strangulation
37. Parastomal hernia
Physical examination with a finger in stoma- often all that
is necessary to diagnose and characterize
Abdominal CT scan helpful in c/o difficulty
~ 30% require repair – pain, obstruction, difficulty in
maintaining appliance
Steele SR et al. Am J surg.2003;185:436-440
38. SURGICAL MANAGEMENT
Local aponeurotic repair
Open repair with mesh
Laparoscopic repair
Relocation of the stoma
39. SURGICAL MANAGEMENT
LOCAL REPAIR
Aponeurotic repair-primary closure of the defect-
recurrence 50-76% (up to 100%)
41. Surgical management
Open mesh repair
SUBLAY proposed as the most advantageous technique
for mesh repair of PSH
Low weight polypropelene meshes are used
Have better resistance to infection than PTFE
Placed away from bowel
Recurrence rates from pooled studies 7-40%
42. Surgical management
Laparoscopic surgery
IPOM - Intraperitoneal Onlay Mesh
ePTFE - most commonly used mesh
2 layers
Inner non reactive layer for bowel contact
Prone to infection
43. Surgical management
Laparoscopic approach
Technical tips
Fashion the mesh before insertion in the abdomen with a
circular defect and a slit
A good way to reduce recurrence may be to place 2 pieces
of mesh one on top of the other
49. Laparoscopic IPOM vs
Sugarbaker
Muysoms, et. al.
IPOM – recurrence 72.7%
Sugarbaker – recurrence 14.2%
Mancini, et al
Retrospective review of 25 pts with Sugarbaker
technique
1 recurrence at 30 months. (4%)
50. Surgical management
Bioprosthetics
Studies are scant, low powered and have a short F/U
Most advantages are extrapolated from the use of bioprosthetics in
incisional hernias
Most studies seem to show a low incidence of complications and an
equivalent incidence of recurrence as synthetics
Recurrence rates vary between 9-27% depending on the studies
and the type of mesh used (human dermis vs porcine small bowel
submucosa)
51. SURGICAL MANAGEMENT
RELOCATION
Risk of recurrence at least as high as the primary site
Recurrence rates as high as 24-86%
Higher if relocated on the same side
The primary site should be treated as an incisional hernia
and repaired with mesh placement-recurrence rate 26-
48%
57. Fistula
Serious problem
Superficial fistula
Stitch abscess, trauma, crohn’s disease (indicate
recurrent disease)
Heal spontaneously
Major fistulas
Below the skin level
Reconstruction or resiting
Todd IP et al. Clin Gastroenterol. 1982; 11:268–273
Fistula tract debrided with a pipe cleaner soaked in
6% aqueous phenol
Greatorex RA. Br J Surg 1988; 75:543
58. Peristomal Varices
Causes
Primary Sclerosing
cholangitis
Alcoholic cirrhosis
Incidence
Upto 27% in those with
hepatic dysfunction
Strong SA. Semin Colorectal Surg.1994;
5:50–58.
59. Peristomal Varices
Control of bleeding
Direct pressure
Suture ligation
Mucocutaneous disconnection
Cauterization of stoma
Transposition of the stoma
Portosystemic shunts/TIPS
Liver transplantation
Mortality high; depends on severity of the underlying liver
disease
Roberts PL et al. Dis Colon Rectum 1990; 33:547–549
67. Divide IMA/IMV if necessary
Must have
good pulse in
marginal
artery!
Stay proximal
to Left colic!
68. Windows
Create windows through the
peritoneum of the left
mesocolon
Useful for providing extra
length
Be careful not to devascularize
colostomy!
69. “Bigger Hole!”
Expand fascial aperture or skin edges
Remove subcutaneous tissues
“Smaller Colon!”
Remove excess fatty tissues – epiploic appendages
Trim mesentery – leave 1 cm of mesentery on distal
bowel to preserve marginal artery
Decompress distended bowel
70. PseudoLoop
Herbert, et al -
maturation of
antimesenteric border
of colon
No Brooking, often
ends up skin level, or
retracted
Emergencies only, only
when no other stoma
will reach
71. Go North
In obese patients Supraumbilical placement of
stomas is desirable
Thinner abdominal wall
above umbilicus
Patients can see it !
72.
73.
74.
75.
76. Remember
Preoperative planning, operative technique,
postoperative education are of vital importance
“An Ounce of prevention is worth a pound of cure”
‘Make every stoma as though it were going to be
permanent’
77. Summary
High incidence of complications
Early recognition & management is desirable
Patient education & involvement of ET is essential
78. Summary
PSH
Very common condition
Only a small proportion will require surgical therapy
The high recurrence rates underline the fact that there is
no perfect operation for this condition
Promising results with laparoscopy and bioprosthetics
Prophylactic mesh placement seems to be the way to go
