An 87-year-old female presented with abdominal pain, distention and constipation. Imaging showed a perforated sigmoid colon requiring a sigmoidectomy and Hartmann's procedure. Pathology found sigmoid diverticulitis. She was discharged but readmitted 2.5 months later for elective colostomy closure. Guidelines were presented on ostomy creation and closure techniques to reduce complications like hernias. Evidence supports laparoscopic and loop ileostomy approaches when possible. Proper stoma construction and postoperative care can prevent issues like dehydration that lead to readmission.

1. Case Presentation
Ali Chami
PGY4
9/9/2015

2. 87 year old female patient presented for abdominal pain,
distention and constipation of 2 days duration. Patient
described the pain to be localized in the right side of her
abdomen. It was colicky, severe, continuous, and
accompanied by several episodes of post prandial vomiting.
Pain was preceded by loose stools of several days duration.
No fever, chills, urinary symptoms, cough or dyspnea. Family
reported the patient to be somnolent with a decreased
activity.
PMH: HTN,DL, AV block with a pacemaker, CAD
PSH: Cholecystectomy
NKFDA
Meds: Concor, lotense, crestor, aspicot

3. On exam:
T: 36.7, BP: 130/80, P: 68, RR: 22
Conscious, oriented, drowsy
Distended abdomen with diffuse
tenderness on the right side, hyperactive
bowel sounds
DRE: Minimal stools
No abdominal masses, organomegalies, or
hernias
ROS: Bilateral pitting edema

4. Hb Hct WBC Neu Plt INR PTT
11.6 35.4 16.7 90% 292 1.18 33.6
SGPT SGOT Alk.P GGT Amylase Lipase Bil T/D CRP PCT
24 18 82 35 29 59 1.9/1.35 31 32
BUN Crea Na K Cl CO2 Alb/Glb
25 0.8 136 3.35 95 21 2.77/2.09
Urinalysis: 1-2 WBC, 6-8 RBC
CXR: No air under diaphragm

5. Patient was admitted to ICU for respiratory and
cardiac support.
Surgery team consulted
Decision made for laparotomy due to surgical
abdomen

6. OR
• Large amount of pus
• Perforated sigmoid colon
• Sigmoidectomy and Hartman’s pouch
• Colostomy

7. Pathology
• Sigmoid diverticulitis

8. Post-op
• Monitored in ICU
• Treated for pneumonia and UTI
• Transferred to regular floor
• Discharged day 15

9. Readmission
• Admitted 2.5 months later for elective closure
of colostomy

10. OR
• Release of extensive adhesions
• Parastomal hernia repair
• Excision of colostomy loop
• Colorectal anastamosis using EEA

11. Post-op
• Smooth course
• Discharged day 6 post-op

13. Introduction
• 100, 000 undergo operations resulting in a
colostomy or ileostomy
• Cancer, diverticulitis and IBD
• High rates of complications compared with
common surgical procedures
• 37 % in elective, 55% in emergency
• Morbidity varies among hospitals

14. Morbidity
• Negative effects on quality of life
• Long term morbidity related to ostomy care
• Half of ostomies are problematic: Prolonged
medical care, increased health costs
• Prolonged length of stay
• Increased need for outpatient care
• Vary by hospital
• Exacerbated by poor construction, siting, surgical
complications, and poor perioperative care

15. Guideline
• Surgical care of patients requiring an ostomy
• Choice of ostomy type
• Technical aspects of creation and closure
• Prevention and management of ostomy
complications
• Perioperative care

16. Outline
• Ostomy creation
• Ostomy closure
• Complications: Prevention and management
• Evidence for the value of an ostomy nurse

17. GRADE System

18. Ostomy Creation
• Performed for benign or malignant diseases
• Created under elective or emergency
conditions
• Fashioned from small or large bowel
• Considered temporary or permanent
• Made during curative or palliative intent
operations

19. Universal Rules
• Well vascularized bowel
• Sufficient mobilization to minimize tension

20. Guideline 1
• When feasible, laparoscopic ostomy
formation is preferred to ostomy formation via
laparotomy. Grade of Recommendation:
Strong recommendation based on low-quality
evidence, 1C.

21. Advantages
• Reduced pain and narcotic requirements
• Shorter hospitalization
• Earlier return of bowel function
• Fewer overall complications relative to open
• Easier to reverse

22. Technical Considerations
• 2 to 3 trocars can be used including one
positioned through the premarked ostomy site
• Rate of conversion: 0-16%
• Avoid twisting the exteriorized bowel for s loop
ostomy
• Avoid kinking the mesentery for an end ostomy
• Mark proximal and distal ends and repeat
insufflation to confirm correct orientation

23. Trephine Ostomy
• Small incision at the planned ostomy site
• Performed under regional anesthesia
• Success rates: 89-94%
• Acceptable short term results compared to
laparoscopic technique for fecal diversion

25. Guideline 2
• Loop ileostomy is preferred over transverse
loop colostomy for temporary fecal diversion
in most cases. Grade of Recommendation:
Weak recommendation based on moderate-
quality evidence, 2B.

26. Comparison
• Both effectively divert the fecal stream and
minimize the consequences of anastomotic
dehiscence
• Similar overall complication rates but different
profiles
• Colostomy: Wound infection, sepsis, stomal
prolapse
• Ileostomy: Post ileostomy closure bowel
obstruction, ileus, high output, higher admission
rates

27. Guideline 3
• Whenever possible, both ileostomies and
colostomies should be fashioned to protrude
above the skin surface. Grade of
Recommendation: Strong recommendation
based on low-quality evidence, 1C.

28. Evidence
• Surgical technique highly influences incidence of stoma
complications
• Surgeon controlled: Height or protrusion above the skin
• Strong association between stoma protrusion and ability of
the patient to successfully care for the ostomy
• Ileostomy: At least 2 cm over skin surface
• Colostomy: At least 1 cm
• Avoid ostomies that flush with the skin
• Techniques:
-Mesenteric vessel ligation
-End loop ostomies
-Upper abdominal sites for obese patients

29. Guideline 4
• When using a support rod for a loop ostomy,
a flexible or rigid ostomy rod may be used.
Grade of Recommendation: Weak
recommendation based on low-quality
evidence, 2C.

30. Guideline 5
• Use of antiadhesion materials may be
considered to decrease adhesions at
temporary ostomy sites. Grade of
Recommendation: Weak recommendation
based on moderate-quality evidence, 2B.

31. Evidence
• 4% of patient with loop ileostomies require
laparotomy for closure
• Carboxymethylcellulose with hyaluronate:
-Significantly fewer adhesions around the limbs of
ileostomy
-No difference in closure operative times
• Sprayable hydrogel barrier:
-Reduction in adhesion score
-Reduction in total operative time by 6 minutes

32. Guideline 6
• Lightweight polypropylene mesh may be
placed at the time of permanent ostomy
creation to decrease parastomal hernia rates.
Grade of Recommendation: Strong
recommendation based on moderate-quality
evidence, 1B.

33. Evidence
• Significantly lower rates of parastomal hernia
occurrence when synthetic mesh was placed
at time of ostomy creation
• Mesh type: Partially absorbable, lightweight
polypropylene, with large pore size
• Durable results 5 years after ostomy creation
• Conventional vs prosthetic mesh: 81% vs 13%
• Bioprosthetic material: Limited data

34. Guideline 7
• Extraperitoneal tunneling of end colostomies
may decrease parastomal hernia rates. Grade
of Recommendation: Weak recommendation
based on low-quality evidence, 2C.

35. Evidence
• Lower risk of parastomal hernia occurrence
6.4% vs 13.3%
• Can be used by laparoscopic technique

36. Guideline 8
• For patients with a new ileostomy,
postoperative care pathways may prevent
hospital readmission for dehydration. Grade of
Recommendation: Strong recommendation
based on low-quality evidence, 1C.

37. Evidence
• Dehydration affects 30% of patient, is a major
cause of morbidity and the most common reason
of readmission
• Postoperative care pathways:
-Patient education
-Patient self-care empowerment
-Standardized discharge criteria
-Tracking input and output after discharge
-Visiting nurse education
-Early follow up

38. Ostomy Closure
• A second operation required in case of
temporary ileostomies and colostomies to
restore intestinal continuity
• 17% morbidity and 0.4% mortality rate
• 4% require laparotomy, 7% develop bowel
obstruction

39. Timing of Closure
• Insufficient evidence to a guideline
• Studies suggest safety of selective early
(within 3 weeks) and late strategies depending
on clinical circumstances
• Early closure associated with reduced hospital
stay, bowel obstruction and medical
complications but increased wound infection
rates

40. Guideline 1
• Stapled and hand-sutured techniques are
both acceptable for loop ileostomy closure.
Grade of Recommendation: Strong
recommendation based on moderate-quality
evidence, 1B.

41. Evidence
• Similar results
• Higher bowel obstruction and operative time
rates in hand sewn group
• Addition of laparoscopy showed a lower
complication rate and shorter length of stay
but longer operative time (15 min)

42. Guideline 2
• Ostomy-site skin reapproximation should be
performed when feasible, and pursestring skin
closure may have advantages compared with
other techniques. Grade of Recommendation:
Strong recommendation based on moderate-
quality evidence, 1B.

43. Evidence
• Ostomy closure wounds are traditionally left
open to heal by secondary intention
• Can be closed completely or partially
• Less requirement for prolonged wound packing
• Techniques:
-Pursestring closure
-Linear closure
-Delayed primary closure
-Wound packing
-Closure over a drain

44. Guideline 3
• Laparoscopic Hartmann reversal is a safe
alternative to open reversal in experienced
hands. Grade of Recommendation: Strong
recommendation based on low-quality
evidence, 1C.

45. Evidence
• Documented safety in observational studies
• Lower complication rates, lower blood loss,
shorter hospital stay
• No difference in leak rates or mortality

46. Ostomy Complications
• Parastomal hernia
• Prolapse
• Stenosis
• Retraction
• Parastomal varices
• Skin conditions
• Metabolic disorders

47. Guideline 1
• Parastomal hernia repair should typically be
performed by using mesh reinforcement or by
relocating the stoma. Grade of
Recommendation: Strong recommendation
based on low-quality evidence, 1C.

48. Evidence
• Observational retrospective studies: Primary
suture results in a 70% risk or recurrent hernia
• Mesh or relocation is necessary for patients fit
for laparotomy or laparoscopy
• Relocation may be necessary in very large
hernias due to residual soft tissue defect
• In reversible ostomies, closure is an indication
in case of parastomal hernia

49. Guideline 2
• Prosthetic mesh may be used during
parastomal hernia repair with low short-term
risk of intestinal erosion or mesh infection.
Grade of Recommendation: Strong
recommendation based on low-quality
evidence, 1C.

50. Evidence
• Use of prosthetic mesh on open bowel has
been discouraged historically due to fear of
contamination and infection
• Infection rates range from 2.2-2.6%
• Techniques:
-Onlay: Highest recurrence rates
-Retromuscular
-Intraperitoneal using keyhole technique

51. Guideline 3
• Bioprosthetic material may be used as an
alternative to synthetic mesh for repair of
parastomal hernias. Grade of
Recommendation: Weak recommendation
based on lowquality evidence, 2C.

52. Evidence
• Collagen based bioprosthetic grafts are
commonly used in the setting of gross
contamination
• Recurrence rate: 7-27%

53. Guideline 4
• Laparoscopic parastomal hernia repair with
mesh may be a safe alternative to open mesh
repair. Grade of Recommendation: Strong
recommendation based on low-quality
evidence, 1C.

54. Evidence
• Observational studies established feasibility
and similar recurrent rates to open mesh
repair
• Techniques:
-Sugarbaker: Underlay with stoma limb exiting
through the mesh lateral to defect
-Keyhole/slit: 1 or 2 pieces of mesh with an
aperture cut for stoma limb as it exits abdominal
wall. Higher recurrence rates

55. Evidence for the Value of an Ostomy
Nurse
• All ostomy patients require education, training and
psychological support to successfully adapt to ostomy-
related self care
• Ostomy-related problems such as skin irritation and
leak are common and patients require medical
assistance to manage these problems
• Absence of adequate care may result in patients not
developing self-care skills
• 84% of cancer patients reported technical difficulties
• Emotional, social and marital problems may develop in
addition to increased health care needs

56. Evidence
• Health care professionals in general are not
comfortable managing ostomy-related problems
• Questionnaires of general practitioners and
nurses confirm that they do not have adequate
training to provide complete care to patients with
ostomies
• They rely on ostomy nurse specialists
• Site selection varies among non-specialist
surgeons and specialist surgeons

57. Guideline 1
• Ostomy education should have a preoperative
and postoperative component, and should
involve a specialized provider, such as a WOCN
nurse when possible. Grade of
Recommendation: Strong recommendation
based on moderate-quality evidence, 1B.

58. Evidence
• Benefit of perioperative education by an ostomy
nurse
• Decreased hospital stay
• Decreased need for unplanned healthcare
interventions post discharge
• Decreased time to ostomy care proficiency
• Decreased costs
• Fewer ostomy-related complications
• Highly valued by patients

59. Topics
• GI anatomy and physiology
• Planned surgical procedure
• Demonstration of appliances
• Description of lifestyle adjustments
• Psychological support
• Procedural training
• Nutrition
• Clothing, recreational and social issues

60. Guideline 2
• Preoperative ostomy site marking should be
performed by a trained provider whenever
possible. Grade of Recommendation: Strong
recommendation based on low-quality
evidence, 1C.

61. Evidence
• Several outcomes may be affected by ostomy
site marking
• Association between preoperative marking
and fewer problems
• Fewer ostomies that the patient cannot care
for
• Standard by ostomy nurse
• Surgeons should be trained and familiarized

62. Principles
• Use of multiple positions to identify adequate
sites: especially the sitting position
• Avoidance of folds and scars
• Consideration of clothing/beltline
• Siting within the rectus abdominis muscle
• Intraoperative circumstances may not allow
optimal siting in all situations

63. Guideline 3
• Follow-up care for ostomy teaching, care, and
support should be available to all patients.
Grade of Recommendation: Strong
recommendation based on low-quality
evidence, 1C.

64. Evidence
• Shorter hospital stays due to enhanced recovery
pathways providing less opportunity for ostomy
education and training
• Can be provided at home, outpatient, or
telephone setting
• Increased ability of patients to care for
themselves
• Fewer ostomy related problems and better
adjustment even for long term ostomy patients