2. Stoma (Greek) = Mouth
stoma is a surgical bypass of a natural conduit
An opening of the intestinal or urinary tract onto the
abdominal wall, connected surgically or appearing
inadvertently
Maingots

3. Colostomy
End – left iliac fossa
Loop
Ileostomy
End – right iliac fossa
Loop
Loop-End
Split
Continent (Kock’s pouch)

4. Temporary
Permanant

5. Voluntary group of 40,000 people with various stomas
In USA, Canada
15,000 ostomies review
Ileostomy – UC - Peak incidene – 20yr – 40 yr
Crohns – lower peak – same age group
Colosomy – Colo-rectal cancers – pear – 60 yr – 80 yr

6. After ostomy
Resumed home – 90%
Vocational activities – 73%
Social activities – 92%
Sexual activities – 70%
73% of registered UOA
conventional Ileostomy, Sigmoid colostomy
After procto-colectomy sexual dysfunction is due to
autonomic denervation, not because of stoma

7. Development & availability of stoma equipment
Good surgical technique
Specialized nursing techniques, Counseling
Pre-operative
Post-operative

8. Overall incidence of stomas decreasing
New surgical techniques
Stapling devises
Local treatment for selected rectal tumours
Sphincter saving procedures for UC, Familial polyposis

9. Colostomy
Colo-rectal cancer
Diverticular disease
fistula
Anal incontinence
Ileostomy
Crohn’s disease
Ulcerative disease

15. A flat area of skin - for adequate adhesion of appliance.
The patient should be able to see the stoma.
Skin creases, folds, previous scars, Umbilicus, and
bony prominences should be avoided.
The stoma site should not be located at the beltline.
The site should be identified with the patient lying,
sitting, and standing.
Preexisting disabilities should be taken into account.

16. Ileostomies – right iliac fossa
Sigmoid colostomy – left iliac fossa
Transverse colostomy – right/left upper quadrant

17. Randomized controlled trails
Ileostomy superior – low incidence of
complications in stoma formation/ closure
(high incidence of intestinal obstruction)

18. Midline vertical incision
Adequate blood supply on either side (skin & bowel)
Without tension
Avoid pre-existing infection
Avoid too small hole at fascial level
No twist
Stoma hole at the end of the surgery.

19. Circular skin – excise adequate ( 2.5 cm diameter)
Subcutaneous fat should not excised – supports stoma
Cruciate incision in rectus sheath
Muscle split in fiber direction

20. End colostomy
Loop colostomy
Types
By Function
Decompressing colostomy
Diversion colostomy
By Anatomy
End-sigmoid colostomy
End-descending colostomy
Transverse colostomy
Caecostomy

21. Decompressing colostomy
distal obsructive lesions causing massive proximal colon dilatation
Severe sigmoid diverticulitis with phlegmon
Toxic megacolon
Types
Blow-hole
stoma constructed in the caecum/ transeverse colon
Tube type cecostomy
Loop - transverse

24. Rarely performed
Reserved for severely acutely ill – with massive
distension and impending perforation of colon
Elderly
Immunocompromised patients
Disadvantage
can not evaluate other parts of the colon for
potential ischemic necrosis due to massive
dilatation

27. Malecot/ Mushroom catheter placed in the caecum
Advantage
Less chance of prolapse
Disadvantage
Tubes usually blocked with feces
Drain poorly
leak stool adjacent to the drain

28. Diversion of intestinal content
Distal segment of bowel completely resected – APR
Known/suspected perforation of distal bowel
obstructing carcinoma
diverticulitis
leaking anastomosis
trauma
Crohn’s disease
Failed/ reconstruction of anal sphincter

29. Right iliac fossa
Simoid/ descenting colon
Should not protrude > 1.5 cm to 2cm
To avoid herniation & prolapse
fixation of colon to the abdominal wall
extra-peritoneal tunneling of colon – difficult for
reversal & revision.

30. Interrupted
Absorbable
Sutures
Full thickness
bite at the end
Sero-muscular
bite at skin level

31. Quick & temporary method.
Acute colonic obstruction/ for diversion
RUQ – proximal transverse colon
LIF – left colon
Disadvantages
Large hole – where colon is greatly dilated
Para-stomal heria, prolapse
Appliance leakage
Risk of damage to marginal artery

34. Stoma stricture
Colostomy necrosis
Para-colostomy hernia
Colostomy prolapse
Colostomy perforation

35. This vogue has passed
Still has place In colo-rectal trauma
After resection of damaged colon
Proximal & distal ends colon tracked together along
anti-mesenteric surfaces with interrupted
absorbable sutures
Easier to close

36. After total procto-colectomy
Distal end of the ileum is prefered
(save length, future ileal pouch)
Right iliac fossa
Aim – 2.5 cm spout
Mesenteric surface oriented superiorly
Ease until 5cm of ileum protrude above the skin
Superior 2 sutures – 5cm serosal bite from end
Inferior 1 suture – 4cm serosal bite from end
Series of interrupted absorbable sutures
Everted spout directed downwards

39. To rest the distal bowel/ to protect an anastomosis
Distal ileal loop preferred
Similar to loop colostomy
Proximal limb – lower position
Marking suture to identify proximal limb
Supporting rod may be used
Ante-mesenteric 80% circumferential incision – distal limb
Proximal limb everted
Muco-cutaneous sutures

41. ileum and its supporting mesentery are grossly
thickened and the surgeon is encountering difficulty
in preparing a sufficient length of well-vascularized
ileum for a conventional end ileostomy.
ileum is prepared as in a conventional end ileostomy,
but the vascular arcades are left undisturbed.
stapled closed end of the ileum lies just within the
abdominal cavity.
Ileostomy constructed same as conventional loop
ileostomy.

42. Bringing out two cut ends at different sites
Proximal end – ileum
Distal end – ileum/ colon – mucous fistula
can be included in the abdominal wound
Advantage
Completely defunctions the bowel without the risk of
intra-abdominal leakage from a closed distal stump.
Disadvantage
difficult to close - necessitates reopening of the main
incision.

43. Ileal pouch reservoir
Non-return nipple valve
Emptied regularly via a catheter

44. Intestinal reservoir for feces was first described by
Nil Kock – 1967
Originally described – U shaped pouch will interrupt
co-ordinated perisstalisis and would enhance the
capacity
Since then J, S shaped pouches have been used with
similar results.

45. Has been used as an alternative to conventional ileostomy
Selected patients ( ileo-anal anastomosis – alternative)
Ulcerative colitis
Familial polyposis
Malfunctioning ileostomy
Poorly located ileostomy
Severe injury to the peri-stomal skin – allergic reaction to
ostomy appliance
Contraindication
Crohn’s disease (recurrence)

49. Kock-pouch continent ileostomy showing a Marlex
mesh collar reinforcing the nipple valve

50. Obstruction
Fistula
Incontinence (nipple valve slip)
Pouchitis

51. Obstruction
Fistula
Incontinence (nipple valve slip)
Pouchitis

53. Constructed intestinal segment with well-maintained
vascularity, connected to urinary tract to allow
egress of urine through stoma
Indications
After removal of urinary bladder - invasive cancer
Severe obstructive uropathy
Severe neurogenic bladder (spinal cord injury)
Congenital abnormalities
spina bifida
bladder exstrophy

55. Leaking appliance – common
improper construction – flush stoma
spigot configuration is best
Radiation skin breakdown – relocation
Stone formation in the conduit
Crystal formation around the stoma
good hygiene
acidification – with venigar
Recent advances
Kock’s continent urinary diversion

56. End ostomy Loop ostomy
Vascular compromize
More chances of stomal necrosis
Easy to fix stoma appliance
Leak rate less
Reversal is difficult
Good vascularity
Less chances of stomal necrosis
Difficult to fix
Leak rate more than end
Easy to reverse

57. Loop Ileostomy
At least 12 weeks
to settle edema inflammatory adhesions
Peri-stomal skin incision 2 mm from the muco-
cutaneous junction
Sharp dissection – divide adhesions
Excise rim of skin
end-to –end anastomosis
Loop colostomy
Same as loop ileostomy closure

59. Complication rate in life time
Colostomy – 25%
End-ileostomy – 57%
Loop-ileostomy – 75%
Cumulative complication at 20 yrs for ileostomy
Ulcerative colitis – 76%
Crohn’s disease – 56%
Many complications can be successfully managed with
proper entero-stomal care
Surgical correction is often unsatisfactory

60. Skin – Excoriation, Ulceration
Ischemia
Obstruction
Retraction
Para-stomal Hernia
Prolapse
Fistula
Stenosis
Other - Bleeding, perforation, Cancer

61. Mild ischemia – common – resolve in few days
Satisfactory healing depends on blood supply
Loop ostomies has better healing rate than end ostomies
Recommended
Prepare relevant bowel segment for the stoma before end of
the operation – asses blood supply at the end
Patchy necrosis confined to the mucosa – heal by secondary
intension
Complete necrosis of ileostomy – urgent revision
Short segment colostomy with necrosis – no necessity to
revise, heal with stenosis, fistula will form.

62. consequence of postoperative ischemia
Mild stenosis - simple dilatation – if effluent is liquid
Substantial stenosis – sub-acute obstruction – revision

63. Common – loop colostomy
Loop colostomies usually assiated with a degree of
para-stomal hernia
Usual complaint
difficulty in fitting the appliance/ leakage
Best option – close the stoma
Another option – devide loop – convert to end stoma
distal segment return in to abdome
Proximal – amputate prolapse
High recurrence rate

64. Repair co-existing para-stomal hernia
Emerging stoma through rectus abdominis/ fix the
mesentary to the abdominal wal

65. Commom in ileostomy
Causes
1.Leak – poor adhesion between serosal surfaces of
everted stoma
2.Para-stomal hernia
If retracted stoma is mobile
Series of non-cutting linear staplling
Avoid mesentary
If retracted stoma is immobile - laparotomy

67. Formation of an abdominal stoma necessarily involves
creating a defect in the abdominal wall to
accommodate the emerging bowel. Such defects
may become enlarged as a result of tangential force
applied to the edge of the opening, and this
enlargement may lead to hernia formation
Intra abdominal pressure
Obesity
Emergency procedure – large opening
Optimal – incision which admit 2 fingers

68. Clinically
Unsightly bulge at stoma site
Leakage around the stoma appliance
Skin rahes
Difficulty in irrigation
Obstruction/strangulation

69. Surgical correction
Local repair
Prosthetic mesh repair
Stoma relocation

71. Stenosis
Para-stomal hernia
Post-operative adhesions
Recurrent disease
Crohn’s disease in proximal ileum
Recurrent cancer
Retrograde contrast study - help in identifying the
cause

72. Full thickness bite through the bowel while froming
stoma
Pressure necrosis – tightly fitting appliance
Recurrent disease – Crohn’s disease
Treatment
laparotomy - reformation of stoma at new site

73. BLEEDING
Trauma, inflammatory polyps
PERFORATION
Trauma (irrigation) Recurrent disease
SKIN ULCERATION
Contact dermatitis
CANCER FORMATION
Recurrence at stoma site/ de-novo cancer

75. devastating news to a patient
sites should be marked preoperatively.
They should be on flat skin, away from scars and
avoiding bony prominences and the umbilicus. The
positioning of the patients clothing should also be
taken into account.

77. Appendix is used to create a conduit between the
skin surface and the urinary bladder
Indication
Urethral cancer
Neurogenic bladder
Spinal cord injuries
Spina bifida

79. Continent ileostomy (Kock pouch) is an alternative
to end ileostomy for patients who have undergone
total proctocolectomy. The procedure reached its
height of popularity in the late 1960s and early
1970s, but has been supplanted by restorative
proctocolectomy, an operation that preserves the
natural route of defecation. Continent ileostomy is
still appropriate for selected patients with
ulcerative colitis and familial polyposis who are not
candidates for restorative proctocolectomy, for
whom restorative proctocolectomy or end
ileostomy have failed, and in a few other selected
cases. Complication rates have decreased during
the past three decades following technical

81. connecting the appendix to the abdominal wall and fashioning a valve mechanism
that allows catheterization of the appendix.
Indication
Fecal incontinence