Colostomy Large intestine Surgery

1. Colostomy
Large Intestine
Dr Subhasish Paul

2. A colostomy is a connection of the colon to the skin of
the abdominal wall, mainly for the drainage of the
faecal matter.
Why colostomy is constructed on the abdominal wall
rather than in the perineum?
 no sphincteric control
 appliance can be maintained.
Colostomy are constructed as treatment for-
Obstructing lesions of distal large intestines
actual or potential perforations.
.

3. Temporary colostomy Permanent colostomy
•Congenital Megacolon
•Anorectal Malformations
•Sigmoid volvulus
•Perforation of left sided
colon
•Left sided colonic growth
•High anal fistula
•Trauma affecting left colon
•Abdominoperineal
Resection
•Carcinoma anal canal
•After Hartmann’s
operation
Indications

4. Types by Anatomical location
End Sigmoid colostomy (most common)
End Descending colostomy ( preferred one)
Transverse Colostomy
Cecostomy
Proximal Colostomy (Rt colon) Distal Colostomy (Lt colon)
Right colon absorbs water and
has irregular peristaltic
contractions
↓↓
Expels Liquid ,high volume and
foul smelling
Few mass peristalsis
Content is more solid
Stoma output can be
regulated by irrigation

5. Determination of Colostomy Location
Site for colostomy evaluated in
Standing
Sitting &
Supine position
Avoid
•Deep folds of fat
•Scar
•Bony prominences, so that the colostomy bags can be
fitted properly

6. Types based on Function
To provide decompression
of the large intestine
To provide diversion of faecal
matter
Mainly Temporary Colostomy
Few Indications
•Distal Obstructing lesions
causing dilation of proximal colon
•Severe sigmoid Diverticulus with
phlegmon
•Toxic megacolon in selected
paitiens
Permanent Colostomy
Indications
•Distal bowel segment completely
resected (AP Resection)
•Suspected perforation or
obstruction of distal bowel
(obstructing carcinoma ,diverticulitis
, leaking anastomosis or trauma)
•Destruction/infection of distal
colon( Crohn,s disease or failed anal
sphincter reconstruction)

7. Types of
Decompressing
Stomas
“Blow hole”
colostomy
Tube
cecostomy
Loop colostomy

8. “Blow hole” cecostomy / Transverse colostomy
Rarely done
Severely ill patients with massive distension &
Impending colon perforation
Choice of site of incision is mostly Distended cecum or
sometimes transverse colon
Disadvantages
Significant inflammation around the stoma
After few weeks intestinal prolapse may occur
Thus this type of colostomy is done for very short period of
time

9. Construction of blow-hole cecostomy or colostomy
About 4-6cm transverse incision is
given over the abdominal wall in
the most dilated part
Absorbable sutures between the
peritoneum and the seromuscular
layer of the bowel to be
decompressed which seals the
intestine from remainder of the
abdominal cavity
needle decompression of the gas-
distended viscus is performed to
reduce the tension on the intestinal
wall.

10. a second layer of absorbable sutures is
placed between the seromuscular layer of
the intestine and the fascia of the
abdominal wall.
Subsequently, the colon is incised, usually
with release of a large amount of
liquid and gas.

11. The stoma is completed by placement of sutures between
skin and colonic wall

12. Construction of a tube cecostomy
The cecostomy is constructed over the
most dilated aspect of the cecum
(similar to that used for a “blow hole”
colostomy)
A very large Malecot or mushroom-
tipped catheter is used and is placed in
the cecum

13. The catheter is secured within the cecum by two purse-string
sutures
↓↓
The tube is brought through a right lower quadrant incision.

14. The cecum then is sutured to the peritoneum of the abdominal
wall at the entry site of the catheter
******
Advantage – Less chances of prolapse
Disadvantage- the tube often gets blocked with faeces

15. Loop-Transverse Colostomy
This type of colostomy is done in Mobile colon
It can’t be done if colon is massively dilated
possibility that the colostomy may become permanent
The stoma can be placed through the
rectus muscle either on the right or left
side, depending on later intentions of
closing or resecting the colostomy,
or it can be brought through the
midline

16. Tracheostomy tape is used to pull the loop of
colon through the incision

17. The fascia is then closed on either side of
the loop of colon tightly enough to allow
snug passage of one fingertip
The skin is then closed, on either side of
the loop of colon.
The tracheostomy tape is replaced by a
plastic rod/glass rod that frequently has a
suture/rubber tube through each end so
that it can be easily repositioned

18. The protruding loop of colon, which is
incised either longitudinally or
transversely to allow the best separation
of the edges of the colon
Full thickness of intestine is then sutured
to full thickness of skin with absorbable
suture material

19. Closure of temporary colostomy
Temporary colostomy is usually closed after 3 months
Criteria for Temporary Closure
•Integrity the distal colon should be normal and adequate
•Anorectal sphincters should be normal
•Cause of construction of colostomy is cured completely without any
recurrence.
Two types of closures are present- extraperitoneal and intraperitoneal
type.
Intraperitoneal closure is the commonly advocated technique now
1. It is done by placing a circumferential incision over the margin with
skin edge to pull out the colostomy stoma.
2. Part adjacent to the skin is resected and anastomosed using Silk or
vicryl.
3. Sutured bowel is placed into the peritoneal cavity a drain is placed
4. The peritoneal cavity abdomen is closed in layers

21. An end, completely diverting, colostomy usually is located in the left
lower quadrant
The site usually is marked with ink in the patient’s room and then is
scratched into the skin with a needle in the operating room
An end colostomy most often is
constructed after removal of the rectum
for low-lying malignancy
The entire left colon is mobilized on its
mesentery
Construction of an End Colostomy(Diverting Colostomy)

22. an opening in the abdominal wall is made at
the previously marked site by excising a 3
cm disk of skin
The fat, fascia, muscle, and posterior
peritoneum are incised longitudinally
The opening is then dilated, and the
closed end of the colon is pulled through
the abdominal wall

23. excising the staple or suture line
chromic catgut sutures between the full thickness of colon and skin.
Once the stoma construction is complete, an appliance is applied in the operating
room