• 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.
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.
An opening in the bladder created to connect the bladder to an
opening on the lower abdomen.
The ureter (or ureters) is attached to the skin’s surface through
a small opening in the abdomen.
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
• 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
Depending on the purpose for which the
diversion has been necessary, a colostomy
may be :
1) temporary or 2) permanent
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
• Double barrel colostomy: The bowel is severed and both
ends are brought out onto the abdomen. Only the proximal stoma is
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
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.
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
• A sigmoid colostomy is usually
brought out at the Lt. iliac fossa.
• A Transverse colostomy is usually
brought out in the Rt.
• # 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
• # 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
• # 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.
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).
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.
Complications of colostomies
• The following complications can occur to any colostomy but are
• more common after poor technique or siting of the stoma:
3) necrosis of the distal end;
4) fistula formation;
5) stenosis of the orifice;
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.
• Candidiasis= Yeast Related Infection
• Folliculitis= hair trauma
• Irritant Dermatitis= Inflammation of
the skin around the stoma
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.
The Brooke Ileostomy
Bryan Brooke – My Surgical Idol
(1) End Ileostomy.
In cases where total proctocolectomy is
1- Ulcerative colitis.
2- Crohn’s disease.
3- Familial polyposis Coli.
2) Loop Ileostomy.
as an alternative of a loop colostomy for Defunctioning
1- Low rectal anastomosis following a
anterior rectal resection procedure.
2- Ileoanal pouch procedure following
Technique of Ileostomy:
• The ileostomy opening should be 5 cm
lateral to the umbilicus and brought out
through the lateral edges of the rectus
• It is usually made in the Rt. Iliac fossa.
It should be spouted.
Complications of Ileostomy:
3- ParaIleostomy Hernia.
5- Necrosis and gangrene of the distal end.
6- Stenosis of the Ileotomy orifice.
7- Skin reaction around the stoma. (Excoriation,
• 8- Fluid and electrolyte imbalance. (Ileostomy
1- Trauma to the caecum.
2- Closed loop syndrome.
(In desperately ill patients with advanced
Site: Rt. Iliac fossa.
• Almost entirely due
to poor stoma siting
• Occurs in 3-60%
• Result of Chemical
• Fungal irritation by
• May be due to
abscess or fistula
– Fistula common in
– Fistula from taking too
much bowel wall on
seromuscular bites of
– Abscess often due to
• Convex appliances
are key to avoid
• Can be revised
• May require
laparotomy and resiting if severe
Criteria taken into consideration
when positioning a stoma:
• 1- Away from any bony
(Anterior superior iliac spine , Symphysis
• 2- Away from the umbilicus.
• 3- Away from any previous
• 4- Visible when the patient stands.
• 5- Comfortable for the patient.
• name and role
• explain to the patient what you will be
• explain to the patient why you want to
• gain full consent from the patient
• confirm the patients name and age
• 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
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
Stomas should be a healthy,,,how
it should be like ??????
• 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
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.
the surrounding skin for erythema, rash,
ulceration and mucocutaneous junction
• PALPATE the surrounding area for
tenderness and masses such as parastomal
abdomenAUSCULTATION to ensure bowel
sounds are present and therefore an
indication of a working bowel
• 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
“Better to create an
ugly stoma in a good
location than a pretty
stoma in an ugly
• Should have an ostomy bag in place
• Depending on location of ostomy may
produce liquid or solid fecal matter
• Digestive enzymes may corrode skin
• Ostomy site should be pink or red
• Most pouches can be emptied without
“It doesn‟t matter if a
good doctor made your
ostomy. If you have it
long enough, you have
a 100% risk of a
J Byron Gathright,
• Wash your Hands
• Assemble your
• Wear Gloves
• Clean around the
• Observe the Stoma
• Measure the stoma
• Measure the Stoma
• Transfer the
Measurement to the
• Cut the Wafer to Fit
• Remember to keep the
area dry and be ready
• 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
• 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
• Prepare for
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
■ 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
■ Complications include skin irritation, prolapse,
retraction,necrosis, stenosis, parastomal hernia,
bleeding and fistulation
What makes a Stoma Difficult?
Does this Person really need this stoma?
Quality of life issues
Elective vs. Emergent
Will this be reversed?
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
8. Mark site with X
Choose an area
visible to patient,
but below level of
9. Examine mark with
10. Mark and cover
in skin fold
Appropriate lengths for stoma
– Total bowel length
above skin = 6-8 cm
– Loop = 3 cm at
– Height of spout after
creation > 20 mm
– Total bowel length
above skin 2-4 cm
– Height of stoma after
be > 5mm
Persson E, Colorect Dis 2009
A Difficult Situation
65 year old man
Diabetic with CHF
Septic with peritonitis
Get the idea???
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
• Obese patients cannot see their lower
• Thicker abdominal wall adipose tissue
requires increased amount of length of
Preoperative planning, operative
education are of vital importance
Make every stoma as though it
were going to be permanent
Go North Young Man
• In obese patients Supraumbilical
placement of stomas is desirable
• Improved Pouching
• Decreased skin irritation
• Thinner abdominal wall
• Patients can see it
How to differentiate a colostomy from
Resources for Ostomates
• Baily & love
• United Ostomy Associations of America
• ASCRS website
• Wound, Ostomy, and Continence Nursing