The document discusses various aspects of stomas, including their definitions, types, surgical indications, and management principles, particularly in relation to bowel trauma. It outlines different stoma types such as end stomas, loop stomas, and colostomies, as well as their advantages and disadvantages in clinical settings. Additionally, it emphasizes postoperative care, education for patients, and complications associated with ostomy procedures.

1. Introduction
• Stoma means :
Stoma is an artificial opening or 'mouth like' to the exterior of the abdominal wall so
as to drain the content from the tubula structures inside, like bowel or ureter
word “Stoma” comes from the Greek word meaning mouth or opening.1 An
intestinal stoma is an opening of the intestine on anterior abdominal wall made
surgically.2
Stomas are used for the treatment of certain surgical diseases of the
gastrointestinal (GI) tract in situations where diversion of,
decompression of, or access to the bowel lumen is needed and no
medical alternatives are available. No specific contraindications for the
use of intestinal stomas are recognized, other than those for surgery in
general.

2. Types of Stoma and indications in Abdiminal
trauma
• End stomas have a single aperture at the skin sur face, and those created from loops generally have two apertures in the same stomal
wound.5,15 Loop-type stomas have a proximal afferent (functioning) aperture and a distal efferent (non functioning) aperture, and may be
created from the bowel in continuity (without dividing the bowel), or separately (using both the proximal and distal portions of a
transected bowel)
• Divided loop : tow ends, one nondivided messenter
• Divided end loop or split loop: tow ends and tow mesentry as iliocolostomy or colocolstomy after resection of segment
• End Loop : loop with closed end
• Double barrel stoma used for transverse colon injury
• Hartman pouch: for colon splenic flexure or distal sigmoid ‫اتاكد‬
• Mucosla fistula? ??
• Cutaneous ureterostomy-cut ends of one or both ureters are apposed to the skin of abdominal wall.
• Ilea/ urinary conduit-segment of isolated ileum can be used to drain urine from the ureter as urinary ileal conduit. Ureters are anastomosed
to a closed ileal conduit. lleal stoma is brought out as stoma. Different types of continent ileostomies are in use to prevent leak, soakage and
discomfort.
• Temporary endcolostomy In severe preneal or Preanal trauma to facillitate healing.

3. For an end stoma (see the images below), the bowel is divided, and the proximal end is brought
through the abdominal wall. The distal nonfunctioning limb can be brought out through the same
abdominal wall opening as the end stoma (ie, double-barrel stoma), it can be brought out through a
separate incision (ie, mucous fistula), or it can be closed and left in the peritoneal cavity (ie,
Hartmann procedure).
• A loop stoma is created by maturing a segment of bowel over a rod or tube without completely
dividing the bowel. Loop stomas provide excellent decompression and have the advantage of
simple closure without the need for a separate laparotomy in most cases. However, loop stomas are
not completely diverting, because proximal contents can spill over into the distal limb. Therefore,
they should be used with caution in patients in whom stool in the distal bowel may be problematic.
• A decompressing stoma, or blowhole, is created in patients in unstable condition by opening the
antimesenteric border of bowel without mobilizing the entire loop of bowel.
• Stomas can also be formed in association with an anastomosis for proximal or distal venting or
irrigation (ie, Bishop-Koop [12]
and Santulli stomas; see the image below). These stomas were initially
designed for the treatment of infants with meconium ileus but have been adapted for many other
purposes.

4. Diagrams illustrate pediatric stomas. (A) End stoma (inset shows everting
maturation); (B) double-barrel stoma, with end stoma and mucous fistula divided
and brought through same incision (inset shows closed mucous fistula sutured to
abdominal wall); (C) loop stoma; (D) decompressing blowhole stoma; (E) Bishop-
Koop stoma; and (F) Santulli stoma

5. Loop iliostomy VS colostomy
• Loop iliostomy
Advantage
• Lower risk for postcreation and postclosure skine and Intra abdominal infiction.
• Improve patient quality of life in relation to bad smell and Stool.
• Lower risk of parastomal hernia and prloaps.
Disadvantage
• Skin iretation ‫اتاكد‬
• High output and risk of dehydration and renal filure, so it is not prefered in
pediatric surgery and in patient with renal filure.
• Higher risk of adhesion and intestinal obstraction.

6. Loop iliostomy VS colostomy
• Loop Colostomy
Advantage
• Low risk of adhesion, renal and skin irretation
Disadvantage
• higher risk for postcreation and postclosure skine and Intra abdominal
infiction.
• patient quality of life in relation to bad smell and Stool.
• Higher risk of parastomal hernia and prloaps.

7. but the most recent literature indicates that loop ileostomy is favored. A large meta-analysis by
Geng et al found that there was a lower incidence of sepsis, prolapse, and parastomal hernia in
those who had a diverting ileostomy rather than those with diverting colostomy. Ileostomy
reversal demonstrated less wound infection and incisional hernias. 1
Another meta-analysis by
Rondelli et al also concluded that prolapse and sepsis were more common with loop colostomy.
Despite higher incidence of dehydration in these patients, loop ileostomy is still favored since
dehydration is not as morbid as sepsis or prolapse. 2
The reversal of loop colostomies has also
been fraught with more complications compared with loop ileostomy closure. A study by Klink et
al supports the increased incidence of dehydration in loop ileostomy (15% in ileostomy group vs.
0% in colostomy group); however, the rate of wound infection was much greater in the colostomy
group (27% in colostomy and 8% in ileostomy) after closure. They also found that return of bowel
function was quicker and hospital stay was shorter after ileostomy reversal compared with
colostomy closure. 3
There are situations where surgeons prefer a loop colostomy such as in
patients with preexisting renal insufficiency and in those in which stoma reversal is unlikely

8. Main technical principles for optimal stoma
• proper stoma siting on the abdominal wall,
• Adequate mobilization of the bowel,
• Preservation of blood supply,
• eversion of the bowel wall during stoma maturation.

9. Main nontechnical principles for optimal
stoma
• providing education and support for patients with stomas,
• Learing patients how to manage stoma-related complications

10. Principals of proper stoma site
• The surgeon selects the site of the stoma. ,. Stoma is usually sited
midway between anterior superior iliac spine and umbilicus. ,. It should
be away from the belt line. ,. It should be away from the scar, creases,
and bony points. ,. Patient should be assessed for proper size, adequacy
for stoma in lying down, sitting, and standing positions. ,.. Proper stoma
appliances should be decided after thorough check-up and discussion
with patient and patient's relative. ,. Stoma site should be marked
properly before surgery. ,.. lleostomy is usually sited in the right iliac
Iossa, colostomy in left iliac Iossa. ,.. Allergy for the particular appliances
should be checked for. ;.. The patient should consult stoma therapist.
• ‫شوف‬ Atlas book page 128

11. • The stoma is distant from the incision, through the midportion of
the rectus muscle away from skin folds (eg, groin, flank), bony
prominences (eg, rib cage, iliac spine), and umbilicus (see the image
below).
• Stoma location in infants and neonates (see the image below)
follows these same principles whenever possible; however, the small
size of the abdominal wall in infants and the short mesentery of the
bowel chosen for the stoma often limit the options. For temporary
stomas in infants, the bowel can be brought out directly through or
adjacent to the umbilicus (see the images below). [13]
This site is
easier for appliance placement and results in a cosmetically superior
scar when the stoma is ultimately closed.

12. Summery of Bowel Trauma types and
managment

13. Grade of bowel injury

15. Indication of Stoma in bowel injury depend
on
Most small bowel destructive injuries should be resected and reconstituted unless damage control conditions prevail. In contrast to the
small bowel, the management of colon injuries has received great scrutiny.Ushering in the dawn of modern-day trauma surgery, the World War II
military experience dictated that all colon wounds, destructive or not, be
managed by colostomy. This philosophy remained surgical dogma until the
1980s.
In a comprehensive review of the literature since 1979, primary
repair of the colon for nondestructive wounds was shown to have a leak rate
of 1.6%.
32 Compared to patients receiving colostomy for similar types of
wounds, the incidence of intra-abdominal abscess was 4.9% for primary
repair and 12% for colostomy, and overall complication rate was 14% for
primary repair and 30% for colostomy. Mortality rates were similar at 0.11%
for primary repair and 0.14% for colostomy. These findings clearly show the
superiority of primary repair for nondestructive wounds of the colon.
Several risk factors for anastomotic failure pertaining to destructive colon
injury have been addressed in the literature: hypotension, shock, interval
from injury to operation, amount of fecal contamination, associated organ
injury, transfusion requirement, and comorbid disease.
35 No data have
conclusively shown that any of these risk factors increase the likelihood of
anastomotic failure. Patients with massive blood loss or shock may be better
served by undergoing a damage control procedure, with delay of definitive
repair.
Interval from injury to repair greater than 12 hours can be a relative
contraindication to definitive repair if there is widespread (greater than one
quadrant) fecal contamination. Greater than one or two organ system injury
has been a concern, but this may just be a marker for degree of shock and
overall physiologic derangement. Comorbidities, such as AIDS and cirrhosis

19. deserve special consideration and these patients may be better off with the
establishment of an ostomy diversion.
37,38 Patients with any of these risk
factors have a higher incidence of intra-abdominal abscess and overall
complication rates32
Multivariate analysis showed no significant difference in mortality or
abdominal complications between diversion and primary anastomosis groups.
The authors concluded that “patients can be managed by primary repair
regardless of risk factors.” This study certainly demonstrates a liberal use of
resection and primary anastomosis in relatively sick and injured cohort of
patients. However, the ultimate decision for the choice of operation was up to
the discretion of the surgeon at the time of operation on a case-by-case basis
—for which there is no substitute.

20. Sabiston
Colon injuries that are encountered in the unstable patient should be
resected. Depending on the need to abbreviate the operation, colostomy can
be created then or the gastrointestinal tract left in discontinuity until after
the patient has been adequately resuscitated. Delayed primary anastomosis
or creation of a colostomy can be performed on return to the operating
room.
Leak rates after delayed primary anastomosis have been found to be
equivalent to those with immediate anastomosis performed in the setting of
hemodynamic stability.49 Significant associated injuries, underlying medical
disease, or delayed injury recognition with the development of severe
peritoneal inflammation may also suggest the need for colostomy.

21. • Mechanism of injury : Low velocity gunshot (civillian gunshot) / stp
woond or high velocity gunshot/blast injury/ High energy blunt
trauma

23. Stoma in Small intestinal injury

24. Stoma in large intestinal injury
• Injuries proximal to the middle colic artery are best man
with a right hemicolectomy and ileocolostomy anastomos
• ‫اتاكد‬ Injery tow transverse colon Managed by segmental rese
double barral colostomy or premery repire
• Distal injuries require segmental resection with colocolos
anastomosis. In the setting of shock, immediate anastom
should be avoided because of an unacceptably high leak

25. Management of Cecum

26. Management of Right hemicolon

27. Management of left hemicolon

28. Management of Rectum
Drainage of the presacral space has traditionally been a component of
managing rectal perforations as a result of experience gained in the
military theater. More recent work has suggested that presacral drainage
is unnecessary, especially in the setting of low-energy, nonmilitary types
of penetrating rectal trauma.50 Until more definitive studies emerge, one
approach is to drain lower rectal injuries that occur posteriorly or
laterally because these have likely entered the presacral space and are
at greater risk of abscess formation. Other injuries sustained by the
extraperitoneal rectum can be managed with fecal diversion alone. Rectal
injuries that involve more than 50% of the luminal circumference may
require resection of the rectum above the injury with the creation of an
end colostom

29. Postop managment
• In general, postoperative patients are managed by an Enhanced
Recovery after Surgery (ERAS) protocol that emphasizes early
ambulation and initiation of oral diet, avoidance of nasogastric tubes
and drains, narcotic-sparing pain regimens, use of selective peripheral
mu-opioid receptor antagonists (alvimopan) and selective pro-motility
agents.

30. Postop Education
• Recommended education topics include anatomy and function of the ostomy, pouching procedural
training, nutrition, clothing,medications, body image, psychological issues,sexual and intimacy issues
• Education regarding common complications including leakage and dermatitis, Creation of an
ileostomy results in loss of the ileocecal valve as well as the water reabsorption provided by the
colon, with the resulting risk of dehydration and electrolyte derangement. Early postoperative output
can often be >1,000 mL/day; however, adaptation occurs with increased ileal water reabsorption over
several weeks’ time. Daily output should ideally between 500 and 750 mL. Patients are educated on
the importance of maintaining adequate hydration and are given discharge prescriptions for Lomotil
(diphenoxylate and atropine) tablets with instructions on how to titrate to stoma output. Other
medications that may be helpful in managing high ileostomy output include psyllium (Metamucil),
cholestyramine (Questran), loperamide (Imodium), and tincture of opium. If necessary, arrangements
may be made for the patient to receive outpatient vitamin B12 supplementation.
• Outpatient follow-up is also a vitally important aspect of overall perioperative care. A number of
studies have shown that postdischarge ostomy support is associated with fewer ostomy-related
problems, more independence, improved ostomy adjustment, and improved quality of life.

31. • Once wound has healed patient can take bath by removing the appliances. After
bath skin is dried up and stoma appliances can be fit again. Patient should be taught
about the stoma care and its appliances. Care and prevention of skin excoriation due
to leak is also looked into. Psychotherapy is given for the patient. Skin should be
absolutely dry prior to placing the stoma appliances. Patient can have normal diet.
Diet, which regulates the bowel action, is better. Plenty of water is advisable. Patient
can go for normal work, exercise like sports, swimming, tennis. Stoma appliances
suitable for these works are available. Antidepressants, anticholinergics might cause
constipation. So these drugs should be taken carefully. Using irritant solutions near
stoma should be avoided. It may lead to dangerous complications. Patient can have
normal sexual activity. Patient should have additional stoma bags in hand so as to
use if required urgently. Patient should be aware of different appliances available
and should be well-versed with its use. He can take the help of the stoma societies.

32. Complication
maingout page 645, fisher and farow
• COMPLICATIONS AND MANAGEMEN of Ileostomy Creation PatientsSkin Irritation and Pouching Issues
Because of the liquid nature of the ileal effluent and is much higher in patients with suboptimal stoma
siting.skin irritation (up to 60), appliance fixation difficulties (up to 50%)peristomal leakage of the ileal effluent
(up to 40%).
• High output
Many postoperative patients with new ileostomies experience a large volume
of liquid output in the first few weeks after the operation. The daily volume
of ileostomy output may be over a liter shortly after ileostomy creation, but
should slow down to 500 to 800 mL after the small bowel has had a chance to
adapt and increase its absorptive capacity. However, some patients may
persistently have high output for various reasons including partial
obstruction, short gut syndrome, or intrinsic bowel abnormalities.
The two main problems with high-output ileostomies are dehydration
often accompanied by electrolyte abnormalities and pouching difficulties due

33. to the liquidity and volume of the effluent. The first step in the diagnostic
workup is to rule out an underlying obstruction, which can cause the bowel
proximal to the obstruction to secrete large volumes of fluid. Assess for an
obstruction at the level of the fascia by inserting a finger into the stoma. A
contrast study or ileoscopy through the ileostomy will demonstrate a more
proximal obstruction.
Other possible etiologies include enteritis, short bowel syndrome, or
inflammatory bowel disease. Most commonly, high ileostomy output is
attributable to dietary indiscretion, and can be managed with a combination
of diet changes, fiber supplementation, and medications. General principles
for managing high ileostomy output are avoidance of concentrated sugars,
hydrating with a combination of water and electrolyte beverages, and eating
foods with a balance of protein, healthy fats, and soluble fiber (Table 15-4).
Patients should be cautioned against drinking large amounts of water in an
effort to keep up with the high volumes of watery ileostomy output they are
experiencing, as this is may exacerbate electrolyte deficiencies and will not
help to slow the output. Rather, they should be counseled to eat as well as
hydrate with a diluted electrolyte drink.

34. Fiber supplementation in the form of the soluble fiber pectin, powders
dissolved in drinks, and fiber wafers are more effective than fiber pills.
Medications such as loperamide, diphenoxylate-atropine, and tincture of
opium can also be helpful in reducing the stoma output. Introduce one drug at
a time and increase the dose as needed. Patients with fast transit may not
absorb capsules or tablets, so elixir or orally disintegrating formulations may
be more effective.
If all of these measures are unsuccessful at controlling the output and
dehydration with electrolyte and/or nutritional deficiencies continues to
occur, then the patient may require long-term parenteral replacement of fluids
and electrolytes. Malnutrition due to poor absorption may require total
parenteral nutrition

35. Closure
• Early vs late closureEarly closure, at around 2 weeks, is practised by
some surgeons but is technically more difficult at this stage. A delay
of 6–8 weeks allows the stoma to mature and the planes around the
stoma to become better defined. The additional wait will also allow
the patient to regain nutritional and immunological status after a
major operation, and will also reduce the risk of thromboembolic
complications. However, the patient has to learn to manage the
stoma in order to

36. Pt live with stoma