"Doctor, this is going to be difficult." Surgeon: "I know, but we have to get this stoma out. Let's take our time and be very careful."

1. By professor Youssri Gaweesh
Professor of colorectal surgery
Faculty of Medicine
Alexandria University

2. Complications
 Technical
 Surgeon factors
 Judgment
 Technique
 Stoma type
 Post operative care
 Physiological
 Electrolyte
abnormalities
 Fluid balance
 Nutritional deficiencies
 Cholelithiasis
 Psychosocial issues

3. Early complications
 Stoma not working
 Ileus
 Small bowel obstruction
 Obstruction at abdominal wall
 Maturation of the wrong
stoma (sigmoid and ileum)
 Retraction
 Stomal necrosis due to vascular
compromise
 Muco-cutaneous separation
 Retraction
 Later stomal stenosis and
stricture
 Acute parastomal hernia with
signs of strangulation
 Working too much
 High output
 Leaking with peristomal
skin irritation
 Poor siting
 Non nippled ileostomy
 Muco-cutaneous
separation
 Wound infection
 Peristomal abscess and
fistula
 Necrotizing fascitis

4. Intermediate or late complications
 Stenosis
 Prolapse
 Parastomal herniation
 Peristomal varices in patients with portal hypertension

5. Overall Morbidity
 Widely varies
 21-70% (most 30-50%)
 Observer dependent
 Stoma type plays a huge role
 Likely underestimated by most studies

6. Vascular compromise
 In obese individuals, exteriorizing an ileostomy with an
adequate blood supply can be quite challenging.
 The thickened, foreshortened mesentery often does not
have enough length to reach the surface of the
thickened abdominal wall easily, especially when
attempting to create a loop ileostomy.
 In these instances, an end-loop configuration may
allow the bowel to more easily reach the abdominal
surface

7. Vascular compromise
 When assessing the vascular integrity of a congested
stoma postoperatively, transillumination with a
flashlight will demonstrate viability. A flashlight
placed in direct contact with a viable stoma will still
transilluminate bright red, even in the face of venous
congestion.
 Failure to transilluminate the surface of the stoma or
nonviable appearing mucosa beneath the surface
generally indicates that the stoma requires revision.

8. Vascular compromise
 If there is a question regarding viability below the
stomal surface, a well-lubricated blood collection tube
can be carefully passed into the stoma, below the
fascia if possible. When a light is shone into the tube,
viable mucosa will have a healthy, bright-red
appearance.
 Darker hues or frank infarction require revision if the
compromise extends below the skin level.
Compromise below the fascia requires relaparotomy.
 Questionable stomas can also be evaluated with a
pediatric proctoscope or flexible endoscope

9. Retraction
 Retraction of a stoma in the immediate postsurgical
period is usually a result of tension on the bowel or its
mesentery due to inadequate mobilization.
 Also, in patients who are malnourished, obese, or on
corticosteroid therapy, the stoma may retract due to
poor wound healing and gravity.

10. Retraction
 Mild distal stomal ischemia or stomal necrosis that is
managed expectantly may eventually result in
retraction with or without stenosis.
 Complete acute retraction with mucocutaneous
separation can result in subcutaneous or subfascial
contamination, peritonitis, and sepsis. In this case,
immediate laparotomy and revision is advised.

11. Retraction
 More commonly, retraction is seen without complete
mucocutaneous separation.
 The most significant problem in this instance is
obtaining a secure seal between the stoma appliance
and the abdominal wall, leading to fecal leakage and
significant peristomal skin irritation.
 The majority of these stomas with significant
retraction eventually require revision.

12. Retraction
 The approach to a retracted stoma is similar to distal
ischemia.
 If the mucosa is viable and there is no undue tension,
local revision can often be performed by detaching the
mucocutaneous junction, advancing the bowel and
excising devitalized tissue, and resecuring viable
mucosa to the skin using Brooke-type sutures.
 If this is not technically feasible, laparotomy and
complete revision is required.

13. PERISTOMAL SKIN IRRITATION
 In most instances, peristomal skin irritation is a direct
result of
 (1) chemical dermatitis due to exposure to the stoma
effluent due to leakage, and
 (2) desquamation of peristomal skin resulting from
frequent appliance changes. Often, appliance leakage
and local skin irritation result in the need for more
frequent appliance changes, starting a vicious cycle.

14. PERISTOMAL SKIN IRRITATION
 Additionally, allergic reactions due to sensitivity to
skin barriers, adhesives, and tapes are fairly common.
 Fungal irritation from Candida albicans colonization
of the peristomal skin also is commonly seen.
Antifungal powders may help alleviate this.

15. PERISTOMAL INFECTION, ABSCESS, AND FISTULA
FORMATION
 In the early postoperative period, parastomal
infections and abscesses are relatively uncommon,
with a reported incidence of 2 to 14.8%.
 Peristomal abscesses in the immediate postoperative
period are most commonly seen in the setting of stoma
revision or reconstruction of a stoma at the same site,
mainly due to preoperative colonization of the
peristomal skin and perioperative seeding of the
surgical site.

16. PERISTOMAL INFECTION, ABSCESS,
AND FISTULA FORMATION
 They may also be seen due to an infected hematoma or
an infected suture granuloma.
 In a patient with Crohn's disease, a peristomal fistula
in conjunction with an ileostomy is almost invariably
the result of recurrent Crohn's disease

17. Parastomal hernia (PSH)
 Definition
 Incisional hernia related to an abdominal wall stoma
 Varies in different studies
 Palpable defect or bulge adjacent to a stoma
 Cough impulse at ostomy site
 Radiologic definition-any intra-abdominal content
protruding along an ostomy
 Sometimes confused with prolapse

18. PHS subtypes
 Subcutaneous-subcutaneous sac
 Interstitial-sac within the muscular or
aponeuroticlayers of the abdomen
 Perstomal-the sac is circumferential enclosing the
stoma
 Intrastomal-in ileostomies, sac between the
intestinal wall and evertedintestinal layer
NB there may be a diffuse type of hernia due to stretch
and paralysis of abdominal muscles with the stoma on
the summit of this bulge.

21. INCIDENCE
 Believed to be between 30-50%
 50% occur within 2 years
 Incidence with ileostomy (0.8-10%)Several studies
failed to show any difference between ileostomies and
colostomies

22. Parastomal hernia
 Incidence is unknown
due to underreporting
and difficult dx.
 Estimated to be between
20-80%
 More frequent with
colostomy than
ileostomy
 Cingi et al
 23 patients
 Patient examination
(PE) detected PSH in
52%
 CT detected total of
78%

23. Parastomal Hernia
 Early
 Presents with acute
pain, mass, obstruction
 < 30 days from stoma
 Technical failure
 Too large of an aperture
in fascia
 Late
 Inevitable?
 Presents with slow
growing mass,
abnormal contour of
tissues around stoma
 Consequence of
increasing
intraabdominal tension
 “There’s already a hole
there, Doctor.”
R. Schwartz 2008

24. PSH risk factors
 Patient
 Waist circumference over
100cm
 Smoking
 Age
 Malnutrition
 Technical aspects
 Rectus/oblique?
 Preop Siting
 Aperture size > 2-3 fingers
(cm?)
 Emergent?
 Disease processes
 Obesity
 Diabetes
 IBD
 COPD
 Intraabdominal
hypertension
 Postop Sepsis
 Perioperative steroid use
 Malignancy
 Ascites

25. TECHNICAL CONSIDERATIONS IN
STOMA FORMATION
 Extraperitoneal vs intrapertioneal(9% vs17%)
 Transrectal vs lateral to the rectus (3% vs22%)
 Size of the trephine: 2.5cm usually
 Todd and Celestine-2cm for ileostomies and 1.5cm
for colostomies with a later retraction of 0.5cm

26. SYMPTOMS
 Asymptomatic +++
 Parastomal discomfort with intermittent obstructive
episodes
 Stoma appliance issues with leak and skin irritation
 Obstruction/strangulation
 10-20% have symptoms severe enough to require
surgical repair

27. SURGICAL MANAGEMENT
 Local aponeurotic repair with or without mesh
 Relocation of the stoma
 Open repair with mesh
 Laparoscopic repair

28. Primary Repair
 Just sew the hole around
the stoma
 High recurrence rate
historically 50-100%
 Add mesh?
 Still doesn’t work 50-
88% recurrence

29. SURGICAL MANAGEMENT
 LOCAL REPAIR
 Aponeurotic repair-primary closure of the defect-
recurrence 50-76% (up to 100%)
 Onlay mesh repair-involves applying a non
resorbable mesh on top of the primary repair and
fixing it to the fascia-recurrence 9-10% (small
studies without long follow up)
 Sublay mesh repair-the mesh is placed in the
properitoneal space after plication of the sac

30. SURGICAL MANAGEMENT
Different possible
locations for mesh
placement in
parastomal hernia
repair

31. LOCAL REPAIR

32. 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%

33. Re-Siting of Stoma
 Traditional boards answer for symptomatic PSH
 Has expected high recurrence rate
 Baig et al. 4/27 recurrences at 56 months
 3/16 with laparotomy
 1/11 without laparotomy
 Historically has rates up to 50-68% (essentially the
same as hernia rate for each new stoma)

34. Don’t do this

35. SURGICAL MANAGEMENT
 OPEN MESH REPAIR
 IPOM (Intraperitoneal Onlay Mesh) vs Sublay
 Keyhole technique vs Sugarbaker technique
(bowel entering lateral to the mesh)

36. Surgical management
 OPEN MESH REPAIR-
 IPOM ePTFE-most commonly used
 2 layers
 Inner non reactive layer for bowel contact
 Prone to infection
 Keyhole technique-risk of Button hole hernia with
shrinkage and contamination
 Sugarbaker Technique-risk of erosion of the bowel
where it passes under the mesh
 Recurrence 0-15%

39. Sugarbaker technique

40. 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%

41. Surgical management
 LAPAROSCOPIC APPROACH
 Done in a way similar to open IPOM
 Keyhole technique or Sugarbaker
 technique
 Recurrence rates vary between4-44%
 Higher risk of bowel injury 22%
 Higher risk of mesh infection (4% in one study)

42. Surgical management
 LAPROSCOPIC APPROACH:
 TECHNICAL TIPS
 Fashion the mesh before insertion in the abdomen
with a circular defect and a slit
 If the mesh is cut in a linear fashion the slit
will enlarge with intraabdominal pressure
 A good way to reduce recurrence may be to
place 2 pieces of mesh one on top of the
other

43. Laparoscopic techniques
 Lap vs Open
 McLemore – 49 pt with PSH
 Laparoscopic vs Open suture repair
 No significant difference in morbidity or short term outcomes
 Pastor – 25 pts
 4/12 laparoscopic had recurrence
 7/13 open had recurrence

44. Laparoscopic Keyhole vs
Sugarbaker
Muysoms, et. al.
Keyhole – recurrence 72.7%
Sugarbaker – recurrence 14.2%
Mancini, et al
Retrospective review of 25 pts with Sugarbaker
technique
1 recurrence at 30 months. (4%)

45. 5 cm

47. Surgical management
 BIOPROSTHETICS
 Studies reporting the use of bioprosthetics for treatment of
parastomal hernias 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
 BIOPROSTHETICS Recurrence rates vary between 9-27%
depending on the studies and the type of mesh used
(human dermis vs porcine small bowel submucosa)

48. An ounce of
prevention is worth
450 pounds of cure

49. Stomal Reinforcement

50. Prevention of PSH
 Metaanalysis of 3
randomized trials of mesh
vs no mesh
 12.3% vs 54.7%
 No increased morbidity
 Serra-Aracil et al
 5 year data
 Mesh - 14.8% hernia rate
 No mesh – 40.7% hernia
rate
 5 prospective observational
studies
 All show reduction in
herniation rate, no change
in morbidity
 Long term data
forthcoming
 Planned end
colostomies/ileostomies

51. Sublay
Sublay

52. Intra peritoneal

53. Prevention

54. Prevention
 Janeset al. randomized 54 patients to stoma
creation with sublay mesh vs no mesh with a
mean F/U of 24 months
 1 hernia occurred in the mesh group vs13 in the
non mesh group
 There was no complications
 Retrospective studies were also in favor of prophylactic
mesh placement

55. Prevention
 CONCLUSION
 Placement of mesh at the primary operation is
safe
 Reduces the occurrence of parastomal hernia
 Prophylactic meshes were also placed in contaminated
cases without infection
 More randomized studies needed

56. Conclusions
 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

57. The Difficult Stoma in the Operating Room.

58. A Difficult Situation
 65 year old man
 350 lbs
 Diabetic with CHF
 Perforated diverticulitis
 5 laparotomies
 Septic with peritonitis
Get the idea?

59. The Difficult Stoma
 Inflamed, thickened, foreshortened mesentery
 Prior operations
 Inflammatory changes
 Obesity
 Thick abdominal wall
 Poor tissue quality
 Distended colon
 Epiploic appendages

60. 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 preoperatively
 Obese patients cannot see their lower abdomen
 Thicker abdominal wall adipose tissue requires
increased amount of length of mobilization

62. Skin
Fascia
9 cm
9cm + 2cm = 11cm of Sigmoid Colon
9cm + 6cm = 15cm of Terminal ileum
BMI
48.7

63. Tips for success
 Avoid a Stoma if at all
possible
 Excise all inflamed
Sigmoid colon
 Segment used for stoma
must be free of
inflammation

64. Difficult End Colostomy
 Take down Left lateral
peritoneal reflection
fully
 Transect medial
peritoneal attachments
to left mesocolon.

65. Mobilize Splenic Flexure

66. Divide IMA/IMV if necessary
Must have
good pulse
in marginal
artery!
Stay
proximal to
Left colic!

67. Windows
 Create windows through
the peritoneum of the
left mesocolon
 Useful for providing
extra length
 Careful not to
devascularize colostomy!

68. “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

69. 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

70. “Better to create an ugly stoma
in a good location than a pretty
stoma in an ugly location.”
--Peter Cataldo

71. Thinner wall?
 Abdominal wall modification
 Lipectomy
 Meguid (1997) described technique of excision of
subcutaneous fat to reduce abdominal wall thickness
 Leave convex contour to abdominal wall – can lead to
pouching issues
 Liposuction
 Margulies elucidated technique of peristomal suction
lipectomy for removal of excess fat during stomal revision

73. SubQ plane

74. #1 Nylons
SubQ drain

76. Thinner Wall?
 Flaps
 Good for Retraction and pyoderma/skin ulcerations in
Obese people.
 Functionally Better than Lipectomy because of
restoration of flat abdominal wall, but have risk of
potential flap necrosis
 Not described for initial placement of ostomy

77. Decrease the friction
 Stuff bowel into 1 inch Penrose drain and slide
through trephine
 Sleeve of Sterile Glove (size 5 ½)
 Alexis wound retractor

78. Penrose Pass
 Mavroidis (1996)
 Passage of bowel into
large penrose drain
(1 inch)
 Passage of drain through
stoma aperture eased by
bowel compression and
decreased “catchin’.”
 Difficult to pass bowel
into drain

79. “Glove Cuff” Technique
 Horwood, et al. 2009

80. Alexis Wound retractor method
 Described by Meagher, et al 2009
 Stomal aperture created in usual fashion
 Small (2.5-6cm) Alexis inserted and wound retracted
 Colon passed through wound retractor
 Inner (green) ring divided and plastic sheath cut off
 Plastic slides out, Colon left in perfect position

81. Alexis Wound Retractor

82. (Anecdotal) Benefits
 “Noticeably” Smaller size of aperture
 Less tissue damage/bruising
 F/U < 14 months, but no retractions nor parastomal
hernia
 Abdominal wall 7-8 cm

83. Go North
 In obese patients Supraumbilical placement of stomas
is desirable
 Improved Pouching
 Decreased skin irritation
 Thinner abdominal wall
above umbilicus
 Patients can see it

89. Stoma Formation
 Is life altering for
patients
 Is not a benign
procedure
 Is associated with a high
rate of early and late
technical complications
 May require Operative
imagination

90. Remember
Preoperative planning, operative technique,
postoperative education are of vital importance
Make every stoma as though it were going to be
permanent

92. Park, et al. Cook County
 Retrospective analysis of 1616 pts (20 years)
 Data compiled by EST
 553/1616 complications (448 early/105 late)
 Early complications (28%)
 Skin irritation 12%
 Pain/poor location 7%
 Partial necrosis 5%

94. Park, et al. Cook County
 Late complications (6%)
 Skin irritation 6%
 Prolapse 2%
 Stenosis 2%
 Parastomal hernia not mentioned
 Trauma/colorectal had lowest complication rate
 No difference in emergent vs elective

96. Park, et al. Cook County
 Highest complication rate loop ileostomy (74%)
 Lowest complication rate transverse end colostomy
(5.8%)

98. Duchesne, et al -- LSU
 Case control study
 204 patients in 3 years had ostomies created
 Records available for 164
 Complications in 41/164 (25%)

99. Duchesne, et al.

100. Duchesne, et al.
 Risk factors evaluation
 Not relevant:
 Gender
 Penetrating/blunt
trauma
 Cancer
 Diverticulitis
 Ostomy quadrant
 Emergent operation

101. Significant Risk factors
Enterostomal nurse affords protective effect

103. Saha, et al.
 One of the first series of Colostomy complications
 Reviewed experience in 200 Patients with
colostomy
 21/200 with complications (11%)