Ostomy

David Ray Velez, MD

Definitions

Ostomy: A Surgically Created Anastomosis of the GI Tract and Skin to Allow Fecal Diversion

Stoma: The Physical End of Bowel Protruding Through the Abdominal Wall

Bowel Segment

Ileostomy: Segment of Ileum Used for Ostomy
- Generally Higher Output with More Liquid Contents
Colostomy: Segment of Colon Used for Ostomy
- Generally Lower Output with More Foul-Smelling Feculent Contents

Bowel End

Loop-Ostomy: A Loop of Bowel is Brought to the Skin with Two Openings (One Proximal and One Distal)
- Defunctionalized Distal Limb: The Proximal Functional Limb is Everted to Occupy the Majority of the Aperture and the Distal Limb is Not Everted
- Double Barrel: Both Limbs are Everted to Occupy Similar Spaces
End-Ostomy: A Single End of Bowel is Brought to the Skin for Drainage

Permanence

Permanent Ostomy: No Plans for Later Takedown
- *A Permanent Colostomy is Preferred Over a Permanent Ileostomy if Able (Lower Risk of Dehydration and Electrolyte Abnormalities)
Temporary/Diverting Ostomy: Used to Allow Healing of a Distal Site Due to a High-Risk Anastomosis, Injury, or Wound with Plans for Later Takedown
- *A Temporary Loop-Ileostomy is Generally Preferred Over a Temporary End-Ostomy if Able Because it is Easier to Takedown in the Future

Colostomy

General Preferred Site

4-5 cm Circular Site
Just Inferolateral to the Umbilicus on Either Side
Within the Rectus Abdominis Muscle
- Provides Support and Stability
*May Consider Other Sites Dependent on Body Habitus – Obese May Be Better Suited in the Upper Abdomen

“Ostomy Triangle”

Patient Must Be Able to Visualize and Access the Stoma Easily

Ostomy Site Must Be Flat to Avoid Interference of Appliance Adherence

Avoid Creases, Folds, Beltline, Previous Incisions, Umbilicus, and Bony Prominences

Ensure ≥ 2 Inch Perimeter of Clear Intact Skin for Stoma Appliance Application

Ostomy Triangle

General Procedure

The Difficult Ostomy – Options to Gain Bowel Length if Difficult to Reach

Always Mark Site Beforehand (Obese Require a More Cephalad Site)
Fully Mobilize the Bowel (Splenic Flexure, Lateral Attachments, Omental Attachments, Retroperitoneal Attachments, and Any Adhesions)
“Pie Crust”/“Score” the Mesentery – Creating Sequential “Windows” within the Mesentery
Divide Mesentery/Blood Supply Proximally
- *First Ensure that There are Adequate Distal Arcades to Supply Blood for the Ostomy
- Divide IMA Close to its Base
- Divide IMV Just Lateral to the Ligament of Treitz
Ensure the Trephine/Opening is Large Enough
Consider a “Loop-End” Ostomy if the End Will Still Not Reach – Closed Blind End is Just Under the Skin if a Point a Few cm More Proximal Has Better Reach
- Also Known as an “End-Loop” or “Pseudo-Loop”
Subcutaneous Lipectomy – Remove Subcutaneous Fat and Fix Skin to the Fascia

Ostomy Bridge (Stoma Rod)

A Bar Placed Under a Loop-Ostomy to Stabilize at the Skin Level While Ostomy Granulates
Removed After 3-5 Days
Goal: Prevent Stoma Retraction
Outcomes:
- No Evidence of Reduced Risk of Stoma Retraction
- Increased Risk of Local Complications (Edema, Skin Necrosis, Irritant Dermatitis, Peristomal Abscess, and Bleeding)

Brooke Suture: (1) Full-Thickness Including Mucosa and Serosa; (2) Seromuscular Bite 2-3 cm Proximal; (3) At the Skin Edge

Definition: Reconnecting the Intestines and Closure of the Stoma to Allow Stool to Exit Through the Rectum Again

Timing

Preoperative Evaluation

If Protecting a Distal Anastomosis: Obtain a Contrast Enema or Flexible Sigmoidoscopy Prior to Reversal to Ensure Anastomosis is Intact
If After Hartmann’s Procedure for Perforated Diverticulitis:
- Consider a Flexible Sigmoidoscopy with Colonoscopy of the Remaining Proximal Colon if Symptomatic, if Otherwise Meets Normal Screening Criteria, if at High Risk (Crohn’s), or if Needed to Evaluate Anatomy
- May Consider Forgoing Preoperative Endoscopy in Asymptomatic Patients with No Other Indications

Considerations

End-Ostomy Will Require a New Bowel Anastomosis to Reestablish Continuity
Loop-Ostomy is Done Through a Peristomal Circumferential Incision and Can Be Closed Transversely or by a New Anastomosis
Use Sharp Dissection and Avoid Serosal Tears from Blunt Dissection

Wound Closure Techniques

Purse-String Closure (PSC)
- Generally Considered to Have One of the Lowest Risks of Surgical Site Infection (SSI)
- Allows Drainage Through the Small Central Opening
- Delayed Wound Healing by Secondary Intention Over Weeks
- Consistently Demonstrated Improved Cosmetic Outcomes to Primary Closure
Primary Closure
- Fastest Healing
- Higher Rates of Surgical Site Infection (SSI)
- Some Prefer Primary Closure Over a Penrose Drain to Allow Continued Drainage – Evidence Shows No Benefit with Similar Rates of SSI
Secondary Intention (Left Open)
- Lowest Risk of Surgical Site Infection (SSI) – Nothing Closed
- Longest Healing Time with the Greatest Need for Wound Care
Negative Pressure Wound Therapy (NPWT)
- Consistently Demonstrated Improved Rates of SSI Over Primary Closure but No Proven Benefit Over Purse-String Closure
- Has Been Used in Conjunction with Purse String Closure (PSC-NPWT) but with No Proven Benefit