Ostomias PDF

CHAPTER

Ostomy Construction and Management:

Personalizing the Stoma for the Patient 178
David E. Beck
M PREOPERATIVE CONSIDERATIONS
ore than a million patients in North America live
with some type of intestinal stoma.1 These stomas
are typically constructed as one of the last com- Patients undergoing either elective or emergency surgery
ponents of a long and challenging surgical procedure. in which the creation of an abdominal stoma is a possibility
Stomal construction is important because their function should have adequate preparation preoperatively. Emer-
will have significant impact on the ostomate’s life. Stomal gent surgery dictates a more rapid preparation than
creation is a technical exercise that if done correctly will elective surgery, but stoma considerations must not be
result in good function and minimal complications for neglected.
the remainder of the ostomate’s life. Conversely, if created Many patients lack knowledge of intestinal stomas. A
poorly, stoma complications are common and can lead few minutes of preoperative education by the surgeon
to years of misery. Intestinal stomas are in fact enterocu- combined with printed material is very helpful. In addition,
taneous anastomoses, and all the principles that apply to if available, all patients should meet with a wound ostomy
creation of any anastomosis (i.e., using healthy intestine, care nurse (WOCN) or enterostomal therapist (ET). The
avoiding ischemia and undue tension) are important in WOCN can provide specific information regarding stoma
stoma creation. This chapter reviews construction and appliances, dietary and clothing alterations, and pouch
management of ileostomies and colostomies. management. Most importantly, the WOCN will help to
select the appropriate abdominal wall site for the future
INDICATIONS stoma. Appropriate stoma placement decreases postopera-
tive complications and may improve the ostomate’s
Stomas are created either as a temporary means of fecal well-being. Bass et al. showed that preoperative counseling
diversion when an anastomosis is unsafe or unwise, or as and marking by an ET prior to surgery improves postopera-
permanent orifices for the passage of stool or urine when tive quality of life.2
surgical resection prohibits the body’s normal orifices In addition to meeting with a WOCN, patients scheduled
from accomplishing these tasks. for stomal surgery often benefit from the opportunity to
Permanent colostomies are usually created from the meet with other ostomates. Patients who have adjusted to
sigmoid or descending colon, usually in association with life with a stoma provide an excellent, nonmedical source
distal bowel resection. Colostomies proximal to the splenic of information and are often glad to share their experience
flexure function poorly, are often placed in locations with new ostomates. In addition, local chapters of the
difficult for ostomates to manage, and are at high risk United Ostomy Association of America and the Crohn’s
for complications. If a permanent colostomy is contem- and Colitis Foundation may be of benefit in this area.
plated using the transverse or ascending colon, the surgeon Patients should have their stoma site marked prior to
should strongly consider resecting the remaining large surgery. An abdominal surgeon should be able to locate
bowel and creating an end ileostomy.1 Common indications and mark stoma sites. In most circumstances, marking is
for a colostomy are listed in Box 178.1. simple, straightforward, and requires only a few minutes.
With the development and general acceptance of the Three abdominal wall landmarks outline the ostomy triangle
ileal pouch–anal anastomosis (IPAA), permanent ileosto- (Fig. 178.1): the anterior superior iliac spine, pubic tubercle,
mies are currently less common. Nonetheless, permanent and umbilicus. The stoma should lie within this triangle
ileostomies are created for inflammatory bowel disease, overlying the rectus muscle, generally at the site of an
familial adenomatous polyposis, multiple synchronous infraumbilical bulge in the abdominal wall. A site should
colorectal cancers, and a variety of other miscellaneous be located on a flat segment of the abdominal wall 5 cm
disorders. Poor anal function, comorbid diseases, or quality away from bony prominences, the umbilicus, prior surgical
of life considerations may make an ileostomy preferable scars, or skin folds. After the site has been selected and
to more complex reconstructive options in selected marked, the patient should sit up to ensure any new skin
patients. folds do not interfere with the stoma site. The patient’s
Temporary diverting stomas are usually created in beltline should be identified and avoided if possible because
association with distal bowel resections when anastomosis this decreases postoperative clothing restrictions.
is unsafe or to protect a distal anastomosis when operative Special circumstances may require additional consider-
conditions or comorbidities make proximal diversion of ation. In obese individuals, a large pannus may preclude
the fecal stream prudent. Three types of diverting stomas stoma placement below the umbilicus. The pannus is often
predominate: end sigmoid colostomy, loop colostomy, thicker in this area and may also hide the stoma from the
and loop ileostomy. patient’s vision, making management difficult. Patients
2147
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Ostomy Construction and Management: Personalizing the Stoma for the Patient CHAPTER 178 2147.e1

ABSTRACT
More than a million patients in North America live with
some type of intestinal stoma. These stomas are typically
constructed as one of the last components of a long and
challenging surgical procedure. Stomal construction is
important because their function will have significant
impact on the ostomate’s life. Stomal creation is a technical
exercise that if done correctly will result in good function
and minimal complications for the remainder of the
ostomate’s life. Conversely, if created poorly, stoma com-
plications are common and can lead to years of misery.
Intestinal stomas are in fact enterocutaneous anastomoses,
and all the principles that apply to creation of any anas-
tomosis (i.e., using healthy intestine, avoiding ischemia
and undue tension) are important in stoma creation. This
chapter reviews construction and management of ileos-
tomies and colostomies.
KEYWORDS
End ileostomy, end colostomy, loop ileostomy, loop sigmoid
colostomy, end loop stomas, end loop ileostomy, divided
loop ileostomy, end loop colostomy, ostomy complications
2148 SECTION IV Colon, Rectum, and Anus
BOX 178.1 Common Indications for Permanent Colostomy
Rectal cancer
Radiation proctopathy
Incontinence
Refractory anorectal Infection
Ischemia
Crohn disease
Diverticular disease
Sacral decubitus
FIGURE 178.2 A disc of skin is excised at the stoma site.
FIGURE 178.1 The ostomy triangle is defined by the anterior

superior iliac spine, the umbilicus, and the pubic tubercle on the
right and left sides of the abdominal wall for ileostomy and
colostomy placement, respectively.
confined to a wheelchair should be marked while in their

chair to avoid unanticipated postoperative difficulties. As
mentioned, despite these restrictions, the stoma should
pass through the rectus abdominal muscle to decrease the FIGURE 178.3 The anterior rectus sheath is opened vertically.
complications of parastomal hernia and stomal prolapse.
In complex or potentially problematic cases, a stoma site is generally through a midline incision, and the stoma is
can be marked and the stoma appliance left in place created after performing the indicated bowel resection.
for 24 hours to determine the accuracy of preoperative The premarked stoma site (usually in the right lower
placement. Other challenges can be addressed with such quadrant) is excised (Fig. 178.2). A skin disc the size of
procedures as abdominal wall contouring (described later). a quarter is removed, sparing all subcutaneous fat because
this fat is helpful to support the stoma in the postoperative
period. The fat is then separated with cautery to expose
OPERATIVE TECHNIQUES the anterior rectus sheath. The sheath is incised vertically
with cautery for 3 to 4 cm (Fig. 178.3). The rectus abdomi-
END STOMAS nis muscle is split in the direction of its fibers to expose
End ileostomies are routinely performed in association the posterior sheath. With the nondominant hand protect-
with either partial or total colorectal resections. Exposure ing the underlying viscera, the posterior sheath is opened
Ostomy Construction and Management: Personalizing the Stoma for the Patient CHAPTER 178 2149
FIGURE 178.6 Tripartite bites between the dermis, the

seromuscular layer of the bowel wall at the fascial level, and full
thickness of the cut edge evert the stoma.
The lateral ileal gutter may be closed if desired to prevent

small bowel obstruction secondary to small bowel rotating
around the ileostomy. This is done by suturing the free
edge of the ileal mesentery (taking care to avoid blood
vessels feeding the stoma) to the abdominal wall lateral
to the midline incision up to the falciform ligament.
FIGURE 178.4 The stoma site admits two fingers. There is no need to suture the ileum to the posterior
fascia of the abdominal wall because this has not been
shown to decrease the risk of prolapse or hernia. The
abdominal incision is then closed in routine fashion
including the skin.
The incision is protected to prevent contamination
with intestinal contents and the staple line removed from
the ileum. Ileostomies must be everted and matured to
prevent serositis and skin irritation because of the caustic
nature of the ileal effluent. This is accomplished by tri-
partite sutures containing dermis, the seromuscular layer
of the bowel at the fascial level, and full-thickness bites
of the cut edge of the ileum (Fig. 178.6). Three or four
of these everting sutures are placed at the ordinals without
tying. General traction on these sutures facilitates eversion
of the ileum. After the stoma has been everted, the
enterocutaneous anastomosis is completed with sutures
between the cut edge of the ileum and dermis. These
additional sutures (4 to 8) approximate the bowel mucosa
to the dermis. The bowel should appear pink and protrude
2 to 3 cm beyond the abdominal skin.
FIGURE 178.5 The ileum is prepared for ileostomy creation. As previously discussed, left-sided end colostomies are
usually created in association with distal colorectal resec-
tion. The lateral attachments of the colon are transected
with cautery and the defect is enlarged to admit two along the white line of Toldt until sufficient colon is
fingers (Fig. 178.4). mobilized to create a colostomy that protrudes from the
After the abdominal wall defect has been created, the abdominal wall and can be matured without tension. After
ileum is prepared. Any residual retroperitoneal attachments the colon has been sufficiently mobilized, the stoma site
are divided to facilitate passage of the bowel through the is prepared and the abdominal wall defect created similar
abdominal wall without tension. The mesentery may be to that described for end ileostomy. The only differences
cleared from the terminal 5 to 6 cm of the ileum. However, are that the premarked stoma site is usually in the lower
care is taken to leave at least a 1-cm strip of mesentery left quadrant and the cutaneous and fascial openings may
with the ileum as this generally carries a vessel paralleling need to be slightly larger to facilitate unrestricted passage
the ileal wall and will prevent stomal ischemia (Fig. 178.5). of the colon through the abdominal wall.
The ileum is then oriented with the cut mesenteric edge After the ostomy site has been successfully created, the
cephalad and passed through the previously created defect colon is oriented without twisting and passed through
in the abdominal wall. The ileum should protrude 5 to the abdominal wall. Again, the colon should protrude
6 cm beyond skin level and appear pink and well perfused. beyond the abdominal skin and appear well perfused.
“downstream” intestine. Diverting stomas consist of three

types: loop ileostomy, loop colostomy, and end loop stomas.
In the past, the most common loop stoma created was
the transverse loop colostomy, popularized for the treat-
ment of complicated diverticular disease and for protection
of distal anastomoses. The transverse loop colostomy is
often a poorly tolerated stoma with high complication
rates and therefore has largely been replaced by the loop
ileostomy. In addition, anywhere a loop ileostomy or a
loop colostomy is planned, an end loop ileostomy or end
loop colostomy can be performed at the surgeon’s
discretion.
The loop ileostomy is generally created in association
with distal bowel resection. After the resection and/or
anastomosis have been completed, a segment of terminal
ileum is selected. The most distal segment of the terminal
FIGURE 178.7 Creation of a loop end stoma. ileum that will reach the abdominal wall without tension
is selected. This generally corresponds to a segment 15
to 30 cm proximal to the ileocecal valve or from an ileoanal
There is no need to close the lateral gutter or to suture reservoir. The ileum is encircled with a Penrose drain or
the colon to the posterior abdominal fascia as neither of umbilical tape after its mobility has been ensured.
these maneuvers has been shown to prevent parastomal An abdominal wall defect is created as previously
hernia or prolapse. Alternatively, a retroperitoneal colos- described for an end ileostomy. The defect may need to
tomy can be created by tunneling the colon under the be slightly larger to accommodate both loops of bowel,
posterolateral peritoneum and exiting through the previ- which, by necessity, pass through the abdominal wall in
ously created stoma site. This has been associated with a loop stoma. Before passing the ileum through the
decreased rates of parastomal herniation and prolapse, abdominal wall, proper orientation is ensured and the
but the increased technical demands with its creation distal end is marked with a suture to prevent maturation
have limited its utility. of the incorrect segment after the abdominal incision has
After the abdominal incision has been closed and been closed. The ileal loop is passed through the abdomi-
protected, the colostomy can be matured. Colostomies nal wall without twisting and should protrude 4 to 5 cm
may be sutured with minimal eversion because distal beyond the abdominal skin. The midline incision is closed
colonic contents are not irritating to the surrounding appropriately and protected with a cutaneous drape. The
skin. distal aspect of the ileum just above the abdominal wall
Meagher et al. have devised a technique helpful in is transected along approximately 80% of its circumference
creating an end sigmoid colostomy in patients with a thick (from mesentery to mesentery). The distal end is then
abdominal wall.3 The stoma site is created in standard matured with simple sutures between the full-thickness
fashion. A small wound protector (used in laparoscopic terminal bowel and dermis. These sutures are placed close
specimen extraction) is then inserted into the stoma to one another to reserve the majority of the stoma site
trephine and opened maximally. The bowel is then passed for the functional, proximal stoma.
through the wound protector. The inner ring of the After the distal end has been sewn to the abdominal
wound protector is transected and removed. The remaining skin, the proximal end is everted. Three tripartite bites
wound protector is brought out externally. The authors are taken between the dermis, the seromuscular layer of
suggest this technique decreases spillage and minimizes the ileum 5 cm proximal to the transected end, and a
bowel trauma during stoma exteriorization, particularly full-thickness bite of the open end of the ileum. After the
in the obese patient.3 three sutures have been placed, they are tied with gentle
A variation of end stomas is the loop end stoma. This traction applied within the lumen to facilitate eversion.
type of stoma is useful in obese patients or those with a Maturation is completed with two additional sutures
shortened or thickened mesentery. In these patients, it between the dermis and the full thickness of the terminal
is difficult to get the stoma to reach the skin or the bowel’s ileum (Fig. 178.8). The loop stoma should protrude
blood supply may be questionable.4 A distal loop of bowel adequately, with its functional end occupying approximately
is selected and using an umbilical tape for traction, the 80% of the trephine circumference. Unless undue tension
loop end (close to the bowel end) is brought through is present, a support rod is generally not necessary.
the abdominal wall without dividing the mesentery (Fig. A loop sigmoid colostomy may be created to prevent
178.7). A stomal rod is helpful in maintaining traction, the fecal stream from reaching the rectum and anus in
and the bowel is matured as in a traditional loop stoma cases of incontinence, severe anorectal infection, or for
(see next section). This type of stoma can be made from proximal protection after complex anal reconstruction.
ileum or colon. This stoma is essentially created in identical fashion to
that of a loop ileostomy, with the exception that the stoma
LOOP STOMAS is commonly placed in the left lower quadrant. Eversion
As previously mentioned, diverting or loop stomas are is not strictly necessary because of the noncaustic nature
created to divert the fecal stream away from the of the effluent from the left colon. However, in many
A B
FIGURE 178.8 Creation of a loop ileostomy with support

rod. (A) A 4- to 5-cm loop of distal ileum is brought
through abdominal aperture with no twist. (B) A stoma rod
is passed through the mesentery. The ileum is opened
toward the nonfunctioning limb and a tripartite suture is
placed. (C) The rod is sutured to the skin and the
C remainder of the ileostomy is matured with sutures.
circumstances, an end loop or divided loop stoma, as distal staple line is transected, and the small opening in
described in the following section, is easier to create and the distal bowel is matured to the abdominal wall without
functions better than the standard loop colostomy.5 eversion. The remainder of the staple line lies buried in
There are three types of end loop stomas: end loop the subcutaneous tissue. The proximal bowel is then
ileostomy, end loop colostomy, and end loop ileocolostomy. everted and matured in a similar fashion to any end ileos-
These stomas have three main benefits: (1) they often tomy (Fig. 178.9). A single suture between the proximal
make stoma management easier in the postoperative end ileostomy and the distally matured segment connects
period because they appear very similar to end stomas, the two and completes the maturation. These stomas
(2) they can be created with remote sections of the completely divert the fecal stream and appear almost
intestine, such as an end loop ileotransverse colostomy, identical to end ileostomies.
and (3) they do not require formal laparotomy for stoma The end loop colostomy is created with a preselected
takedown. The end loop ileostomy and end loop colostomy segment of the sigmoid colon. It is mobilized appropriately
can be created in any situation in which a standard loop and passed through the previously created abdominal
ileostomy or loop colostomy might be performed. End wall defect similar to that of an end loop ileostomy. The
loop ileocolostomies can be created in association with abdominal incision is closed appropriately. The end
intestinal resection. For example, a right colectomy may colostomy is matured in a similar fashion to that of the
be performed for right colon trauma or for right colon end loop ileostomy. As previously mentioned for loop
ischemia and an anastomosis is deemed unwise. In this colostomies, the proximal end may be everted but a flush
situation, the ileostomy and the transected edge of the colostomy may also be created.
proximal transverse colon can be brought through one An end loop ileocolostomy can be performed in associa-
single stoma site, avoiding the need for a second stoma tion with resection of the right colon when an anastomosis
and laparotomy at the time of stoma takedown. is unsafe. Following resection, the terminal ileum is
Following intestinal resection and creation of an prepared as for any routine end ileostomy. Often a stoma
appropriate abdominal wall defect, the end loop or divided site will have to be created in the right upper quadrant
loop ileostomy is created as follows: A small defect is to facilitate passage of the ileostomy and the distal trans-
created in the mesentery at the preselected ileal stomal verse colon through the same abdominal aperture. After
site. The bowel is then transected with a linear stapling the stoma site has been created, the terminal ileum is
device. The proximal or functional end of the ileostomy brought through the abdominal wall, similar to an end
is brought through the abdominal wall as for a standard ileostomy. The stapled-off end of the proximal transverse
end ileostomy. The nonfunctional segment can be managed colon is brought through the abdominal wall defect. The
in several ways. It can be brought through the fascia and mesenteric defect can be closed as with any standard
sutured to the functional bowel or scarpa fascia. This colon resection.
method completely diverts the bowel. Another option is Following this, the abdominal incision is closed in
to bring the antimesenteric corner of the distal nonfunc- routine fashion. The antimesenteric corner of the trans-
tional bowel through the same stoma site. The incision verse colon staple line is then transected and matured
is closed appropriately. The antimesenteric corner of the without eversion to the abdominal wall stoma site.
A B C
D E
FIGURE 178.9 Creation of an end loop ileostomy. (A) The abdomen is explored through a midline incision and the ostomy opening is
created as previously described (see Figs. 178.2 to 178.4). (B) A segment of ileum that will reach the abdominal wall is selected and
divided with a liner cutting stapler. (C) Divided ends of the ileum are brought through the ostomy aperture (functional end is marked with
a suture). (D) The staples of the functional end are excised and the bowel is matured producing a 2 cm spout. Staples at the
antimesenteric end of the nonfunctioning end are excised, and the small end is sutured to the deep dermis and medial edge of
functioning stoma. (Sagittal view.) (E) Completed ileostomy.
Cutaneous sutures should be placed in proximity to save

the majority of the stoma site for the ileostomy. After this LAPAROSCOPIC STOMAS
has been completed, the staple line is resected from the If an ileostomy is needed in conjunction with a laparoscopic
terminal ileum and the ileum matured as for a standard bowel resection (protection of a low anastomosis) or an
end ileostomy (Fig. 178.10). The final suture between ileostomy alone is needed (diversion proximal to complex
transverse colon and the ileum is placed to complete the anovaginal fistula repair or anal canal reconstruction), it
maturation. can be created laparoscopically. Principles that apply to
This stoma has the previously mentioned advantages open ileostomy creation also apply when the operation
of avoiding a second stoma site for a mucous fistula. In is performed laparoscopically. The site should be selected
addition, because the terminal ileum and transverse colon according to the patient’s body habitus and functional
are in close approximation through the same stoma needs. If a colectomy in conjunction with the ileostomy
site, stoma takedown can be later performed directly is essential, then ileostomy siting should be considered
through a parastomal incision without the need for a at the time of trochar placement. A trochar can certainly
formal laparotomy. This may significantly decrease sub- be placed through the future stoma trephine, but sites
sequent morbidity and recovery time after the subsequent adjacent to the trephine within the footprint of the stoma
stoma takedown. appliance should be avoided. Trochars in place for the
Pneumoperitoneum is released, and the stoma trephine

is created in standard fashion around the grasper. The
loop is then eviscerated carefully without twisting. After
this is done, pneumoperitoneum is reestablished and
proper orientation is confirmed. (This is essential because
creating an ileostomy from the distal limb is highly
problematic for the patient [because it can lead to an
unanticipated mechanical small bowel obstruction] and
very embarrassing for the surgeon.) After proper orienta-
tion is confirmed, the stoma can be matured in standard
fashion. A loop, end loop, or end ileostomy can be created
as indicated based on the clinical setting. After completion
of stoma maturation, pneumoperitoneum is reestablished,
proper orientation confirmed, and the abdominal cavity
A B is checked for bleeding.
Similar to ileostomy, all types of colostomies can be
performed laparoscopically. Sigmoid colostomy is most
common. Techniques are very similar to the creation of
laparoscopic ileostomies. If trocars have been placed for
rectosigmoid resection, no additional ports will be needed.
If a colostomy is performed without other abdominal
surgery, then three or four ports may be necessary. A
camera port is placed through the umbilicus. Two ports
are placed in the right midabdomen and the right lower
quadrant, respectively. A fourth port may be placed through
the previously marked stoma site, if colonic mobilization
is required. If the colostomy is created in conjunction
with an abdominoperineal resection or sigmoid resection,
mobilization is often already completed at this point.
Occasionally, additional descending colon mobilization
is necessary to create a stoma without tension.
C If no colonic resection has been performed, then the
sigmoid and descending colon will require mobilization.
FIGURE 178.10 Creation of an end loop ileocolostomy. The sigmoid colon is retracted medially through the right
(A) Abdomen is explored via midline incision. (B) Terminal ileum midabdomen port, and the lateral peritoneal reflection
and right colon are resected. (C) Functional end of ileum and end is retracted laterally through the stoma port. The lateral
of nonfunctional colon are brought through the ostomy aperture. attachments are then taken down with scissors or cautery
Ostomy is matured as in Fig. 178.9D and E. through the right lower quadrant port. After mobilization
is complete, pneumoperitoneum is released and the colon
checked for length. Again, the distal end is marked with
colectomy or proctectomy can be used to perform the a marker tip attached to a grasper (if distal resection has
intracorporeal components of the ileostomy creation. not been performed) after orientation has been carefully
If the ileostomy is created without any additional confirmed.
abdominal surgery, then only two ports are commonly Pneumoperitoneum is then decompressed, and the
necessary: one at the umbilicus for the camera and a stoma trephine created in standard fashion. The colon
second through the stoma site to manipulate the terminal is brought through the abdominal wall defect without
ileum. Under either circumstance, the operative principles twisting and the stoma matured with standard technique.
are similar. As with ileostomy, end, end loop, or loop colostomy can
The terminal ileum is located just proximal to the all be created laparoscopically. After stoma completion,
ileocecal valve. The bowel is followed retrograde until a pneumoperitoneum is reestablished, orientation confirmed,
segment that easily reaches the abdominal wall at the and the abdominal wall cavity checked for bleeding.
stoma site is identified. Pneumoperitoneum should be
deflated when assessing ileal length, as the abdomen will MODIFIED ABDOMINOPLASTY (ABDOMINAL
not be distended when the ileostomy is created or in use. WALL CONTOURING)
Ileal mobilization is rarely required. Extreme care should Patients who may benefit from these techniques include
be taken to ensure proper orientation of the bowel. The those with stomal retraction (especially those who have
proper loop of bowel is grasped with a grasper through bowel limitations, e.g., continent ileostomies, dense
the stoma trephine and proximal and distal bowels carefully intraabdominal adhesions or short gut; prolapse; large
identified. If an additional port is available, the tip of a peristomal hernias; abdominal wall laxity, usually resulting
marking pen is grasped with a laparoscopic grasper and from major weight loss) and peristomal skin problems,
the distal end marked just beyond the grasper. (This is such as pyodermia. In many of these patients, stomal
not possible if the two-port technique is used.) relocation may not be the best option.
A B
C D
FIGURE 178.11 Modified abdominoplasty. Redundant abdominal wall folds of skin associated with ileostomy retraction. (A) Frontal view.
(B) Sagittal section demonstrating skin and subcutaneous fat incisions. (C) Excess skin and subcutaneous fat have been excised (frontal
view) and (D) sagittal section.
The technique is similar to that used by plastic surgeons.6 tissue. Care is taken to avoid injury to the bowel or its
A low curvilinear transverse incision is made at the inferior blood supply. The dissection should err on leaving addi-
abdominal fold or 2 to 3 cm above the pubis and anterior tional subcutaneous fat attached to the intestine. This
superior iliac spines (Fig. 178.11) and carried down to can be carefully resected later. A similar maneuver may
the fascia. A flap of skin and subcutaneous tissue is created be performed at the umbilicus if the surgeon and patient
by electrocautery dissection in a cranial direction, just prefer to preserve it in its normal location. Again, care
above the fascia. Perforating vessels are identified and is taken to preserve the tissue’s blood supply. If the
ligated or cauterized. As the dissection continues, the umbilicus is not to be maintained, it can be amputated
stoma will be encountered. With the flap on traction, the at the fascial level. The flap dissection is continued cranially
intestine is separated from the skin and subcutaneous just above the fascia until enough laxity or length is
E F
FIGURE 178.11, cont’d (E) Ileostomy relocated through upper flap and skin incisions closed. Closed-suction drains placed below flaps.
(F) Sagittal section.
obtained in the upper flap for the upper edge of the If the skin flap is not redundant enough to advance
previous stomal opening to reach the inferior portion of the original ostomy opening to the midline, the subcutane-
the incision without excessive tension or to the costal ous fat can be excised and the stoma returned to its
margins. Any associated peristomal hernia can be repaired original skin opening through the thinned flap. Either
at this time with suture repair of the fascia and/or mesh method is performed in such a manner to leave a smooth,
(synthetic or biologic) reinforcement. flat, thinned flap that provides a flat surface to site the
As the flap is retracted inferiorly, new sites for the appliance. The stoma is matured, and the midline incision
ostomy and, if desired, the umbilicus are selected and is closed. Subcutaneous closed-suction drains are placed
openings created in the flap. Excess subcutaneous fat can above and below the stoma. A similar technique can be
be carefully removed to thin the flap. Fortunately, there used through an inferior or inferolateral peristomal
is usually less subcutaneous fat above the umbilicus incision.
compared with below it. The excess, distal portion of the Rapid and significant weight gain in ostomy patients
flap is excised (see Fig. 178.11). The intestine and umbi- may produce stomal retraction. If attempts at weight loss
licus are brought through the respective flap openings have not been successful and stomal revision is not desir-
and matured with interrupted absorbable sutures. Excess able or feasible (e.g., continent ileostomy or short gut
bowel or umbilical tissue can be carefully excised. Closed- patients), liposuction is an excellent option. This method
suction drains are placed below the flap to avoid seromas is preferred if there is no associated stomal stenosis or
and the inferior incision is closed in layers. Because hernia. Experienced plastic surgeons can carefully use
intraabdominal dissections are avoided with this technique, liposuction techniques to remove subcutaneous fat around
patients usually recover quickly. Morbidity is usually associ- the stoma. Obviously, care must be taken to not injure
ated with infection, flap ischemia, or seromas. These are the stoma during the procedure and to leave a flat smooth
managed with wound care. peristomal skin surface for the ostomy faceplate. After
Several types of flaps can be used to modify the abdomi- the fatty tissue is removed, it will not be redeposited
nal wall around the stomas. Most involve peristomal despite additional weight gain.
dissections and removal of skin and subcutaneous fat.
The medial approach starts with an incision through the ANTIADHESION BARRIERS AND STOMAS
midline incision down to the fascia (Fig. 178.12A). Dis- Some authors have advocated the use of carboxymethyl
section is carried laterally just above the fascia until the cellulose (CMC) and sodium hyaluronate (Seprafilm;
stoma is reached. The ostomy is dissected free of the skin Genzyme, Cambridge, Massachusetts) when creating
and subcutaneous tissue as described previously. After the temporary loop stomas to facilitate ostomy reversal.7,8 Very
stoma is freed, lateral dissection to the flanks will provide little is known about this, and it has not been subject to
enough laxity to advance the previous stoma site to the the rigors of a clinical trial. Authors suggest that wrapping
midline (advancement flap). As above, a new ostomy the ileum at the time of stoma creation will minimize
opening, in fresh skin, is created. Excess fat may be excised adhesions between the stoma and the abdominal wall,
around the stoma, and redundant midline skin is resected. making stoma takedown easier. One study by Kawamura
A B
FIGURE 178.12 Medial approach. (A) Frontal view with skin incisions marked. (B) Cross section demonstrating midline incision and areas
of subcutaneous fat excision. (C) After removal of excess subcutaneous tissue, incision is closed, flaps attached to fascia, and stoma
matured with adequate eversion.
et al. suggests shorter operative times in the antiadhesion responsibility to ensure the patient is educated in appliance
group.7 Another study by Salum et al. found fewer stomal management.
adhesions when an antiadhesion product was used.8 The appliance must be emptied frequently enough to
The technique is described as follows. The loop selected avoid overfilling and dislodgement of the pouch. This is
is eviscerated and a sheet of CMC is cut in half. The determined by the location of the stoma and the patient’s
proximal and distal limbs of the bowel and their adjacent natural bowel pattern. Ileostomies are usually emptied
mesentery are wrapped in a sushi roll style. After the four to six times per day, with colostomies emptied once
barrier has adhered, the loop is brought through the or twice per day or even once every other day. The entire
abdominal wall at the preselected site and the stoma appliance only needs to be changed every 4 to 7 days.
matured in standard fashion. The utility of this technique The exact details vary from individual to individual, but
has been difficult to prove, but minimizing adhesions a common technique for changing a typical one-piece
between the ileum and the abdominal wall should, in system is explained in Box 178.2.
concept, make dissection at the time of ileostomy takedown Pouches should generally be changed when the stoma
easier. is least active, which is often after a period of fasting. The
time will vary from individual to individual, but changing
the appliance when the stoma is less active avoids the
ENTEROSTOMAL THERAPY need to control fresh output during the procedure.
A dedicated WOCN or ET’s contribution to the long-term The noise and odor of gas emitted from a stoma are
quality of life of an ostomate is simply immeasurable. a major concern to most ostomates. Anything that causes
Such therapists provide preoperative counseling, early gas before creation of the stoma is likely to create gas
postoperative education and guidance, and act as a long- following its construction. Gas comes from two sources:
term resource for individuals with stomas. They supply swallowed air and bacterial breakdown of ingested food-
information on appliance choices, local support groups stuffs, particularly carbohydrates. The amount of swallowed
such as the United Ostomy Associations of America and air can be minimized by avoiding the use of straws, exces-
the Crohn’s and Colitis Foundation, suggest dietary or sive talking while eating, chewing gum, and smoking.
clothing modifications that may alleviate stoma-related Each individual can best identify which foods lead to gas
problems, and aid in the management of skin problems, production, but beans, broccoli, onions, Brussels sprouts,
parastomal hernias, prolapse, and other complications. beer, and dairy products in lactose-deficient individuals
In most situations, an ET or surgical nurse will provide are common culprits. Avoiding these foods is a personal
detailed postoperative education for a new ostomate. choice but will decrease the quantity and odor of stomal
However, if this support is unavailable, it is the surgeon’s flatus. Yogurt, parsley, and orange juice have been
complications are peristomal skin irritation, leakage, high

BOX 178.2 Stoma Care output, and ischemia. The most commonly reported late
complications include parastomal hernia, prolapse, obstruc-
1. Gather all supplies. tion, and stenosis.
2. Gently remove soiled pouch by pushing down on skin
while lifting up on pouch. Discard soiled pouch in INCIDENCE
odor-proof plastic bag. Save tail closure. In the absence of a universally accepted definition of what
3. Clean stoma and peristomal skin with water; pat dry. If constitutes a stomal complication, adverse events may be
indicated, shave or clip peristomal hair. mild (e.g., transient skin irritation or leakage), or require
4. Use stoma-measuring guide or established pattern to major revisional surgery (parastomal hernia or necrosis).
determine size of stoma. Presized pouch: Check to be In a 20-year retrospective review of 1616 patients in the
sure pouch opening is correct size. Order new supplies if Cook County Hospital database, Park et al. reported a
indicated. Cut-to-fit-pouch: Trace correctly sized pattern 34% incidence of complications, 28% being early and
onto back of barrier or pouch surface and cut stomal 6% classified as late.9 The most common early complica-
opening to match pattern. After stomal shrinkage is tions were skin irritation (12%), pain associated with poor
complete, this step may be omitted and preparation of stoma location (7%), and partial necrosis (5%). The most
the clean pouch may be completed before the soiled common late complications were also skin irritation (6%),
pouch is removed. prolapse (2%), and stenosis (2%). Of note, complications
5. Apply skin barrier paste or skin sealant to skin. Allow to
varied greatly by service, with ostomies created by general
dry.
surgeons associated with a 47% complication rate, whereas
6. Remove paper backing from pouch or barrier to expose
the complication rate for colorectal surgeons was 32%.
adhesive surface; center pouch opening over stoma and
press into place. Attach closure.
Duchesne et al. retrospectively reviewed 164 ostomates
cared for at Charity Hospital in New Orleans.10 The overall
From Lavery IC, Erwin-Toth P. Stoma therapy. In: Cataldo P, MacKeigan complication rate was 25%; 38% of the complications
J, eds. Intestinal Stomas. New York: Marcel Dekker; 2004:65.
were early and 62% were late. As is typically the case, ileos-
tomies were associated with a higher complication rate
than colostomies. The most common complications were
associated with decreased odor. Odor-proof pouches, necrosis (22%), prolapse (22%), skin irritation (17%),
charcoal filters, and pouch deodorants (such as commercial and stenosis (17%). Risk factors for complications included
deodorants, mouthwash, and perineal deodorants) may inflammatory bowel disease, ischemic colitis, and increased
also help. Orally ingested deodorants are also available body mass index. As others have observed, obesity markedly
and include bismuth subgallate and chlorophyllin complex. increased the risk of skin irritation.11 Of particular note
However, the most important key to preventing odor is was the sixfold decrease in stoma complications when an
good peristomal hygiene and creating a leak-proof seal ET was involved in the patient’s care.
at the time of appliance change.
A period of adjustment occurs in all ostomates, but SKIN IRRITATION AND LEAKAGE
attention to detail at the time of appliance change, Skin irritation is very common among patients with a
combined with minor dietary and clothing modifications, stoma. In a review of 610 patients, it was by far the most
should make a stoma completely unnoticeable to all except common early local complication.11 The problem is far
the ostomate’s closest acquaintances. In addition, abdomi- more commonly seen in patients with an ileostomy owing
nal stomas should not preclude participation in almost to the liquid, caustic effluent14; this highlights the need
any physical activity. for proper technique when an ileostomy is created.
Although a minor degree of skin irritation on occasion
is probably inevitable, most significant cases of skin irrita-
COMPLICATIONS tion are potentially preventable. Preoperative marking by
Despite modest advances in surgical technique and an ET can help to ensure proper siting and a secure fit.
enterostomal therapy, complications after stoma creation Appropriate location and careful appliance fitting minimize
remain extremely common. The rate of stoma-specific the noxious, irritating effect that can be associated with
complications in the literature varies quite widely, ranging leakage or unprotected peristomal skin (Fig. 178.13).
from 10% to 70%, depending on the methodology of the Patients also need to be monitored for allergic reactions
study, the length of follow-up, and the definition of a to the components of the appliance.
complication.9–13 For example, virtually all ostomates will Particular attention must be paid to older patients who
have at least transient episodes of minor peristomal irrita- may have limitations in eyesight or dexterity. Patients with
tion, and skin irritation is often the most commonly a high-output stoma are at particular risk for skin irritation
reported stoma complication. Studies reporting only and ulceration if they do not have an appropriately fitted
problems that require revisional surgery will obviously appliance. Obesity has been frequently reported to be
indicate a much lower rate of complications. As such, the associated with an increased risk of skin irritation, likely
relative incidence and frequency of the specific complica- owing to technical problems with stoma construction.15
tions vary substantially from series to series. Consideration should be given to placing the stoma in
Stoma-related complications may be classified as those the upper abdomen, where there is typically much less
that occur early (within 1 month of surgery) or late (more subcutaneous fat and the patient can see it much more
than 1 month postoperatively). The most common early readily.
with mucosal hyperplasia and there is a steady decrease

in ostomy output. However, patients with an ileostomy,
particularly those who have had concomitant small bowel
resection, are at risk to become dehydrated. Most often,
this is easily managed by oral rehydration with one of the
commonly available sports drinks. However, patients who
have lost considerable absorptive surface owing to previous
bowel resection and/or those with recurrent/residual
Crohn disease are at particular risk. In addition to the
loss of absorptive surface area, ileal resection also removes
the fat or complex carbohydrate stimulation of the so-called
ileal brake, which slows gastric emptying and small bowel
transit.18 Fluid and electrolyte maintenance in these
patients may require a period of parenteral hydration
and nutrition.
Clostridium difficile enteritis is an increasingly reported
FIGURE 178.13 Skin irritation around the stoma site from a poorly cause of ileostomy diarrhea, especially in patients who
fitting appliance. have had a total colectomy for inflammatory bowel
disease.19 The typical presentation is ileostomy diarrhea
followed by ileus. This condition has been associated with
The patient should be instructed to avoid creams or a high mortality, although early recognition and treatment
ointments that may interfere with the adherence of their appears to be associated with better outcomes.20
appliance. In the postoperative period, a stoma will tend Ileostomy diarrhea may be treated in its milder forms
to become less edematous and the abdomen becomes with oral fiber supplements or cholestyramine, which can
less distended. As such, it is quite common to need to thicken secretions. Histamine receptor antagonists or
downsize the appliance at the first postoperative visit to proton pump inhibitors are often useful in reducing
minimize exposed skin. Changing a stoma too frequently gastric fluid secretion, especially in the first 6 months
may lead to excessive wear and tear on the parastomal after surgery when hypergastrinemia is most severe.21
skin; on the other hand, too long an interval between Often, antimotility agents (e.g., loperamide or diphenoxyl-
changing the appliance may be associated with erosion ate) or opiates (e.g., codeine or tincture of opium) may
of the protective barrier. be required to slow intestinal transit. In refractory cases,
Even with the help of an excellent ET, specific skin somatostatin analogue has been used with some success.
infections may occur. Fungal overgrowth is evident when Somatostatin reduces salt and water excretion and slows
there is a bright red rash around the stoma with associated gastrointestinal tract motility. However, its clinical use has
satellite lesions. This is typically easily treated by dusting met with variable results.22 Special mention is made of
the parastomal skin with an appropriate antifungal powder patients with an anastomotic small bowel leak. Good
or an oral agent in refractory cases. If the dermatitis results have been reported with exteriorizing the leak and
conforms precisely to the outline of the stoma appliance, reinfusing the ostomy effluent into the downstream limb
then an allergic reaction to the wafer or other component until gastrointestinal continuity can be restored. This has
of the appliance is likely the culprit. Peristomal skin irrita- led to weaning parenteral nutrition in a substantial number
tion may also be associated with reactivation of inflam- of patients.23
matory bowel disease. A related problem in patients with an ileostomy is the
Fortunately, most cases of skin irritation and leakage development of urinary stones. The obligatory loss of
are readily managed by conservative means. However, a fecal water, sodium, and bicarbonate reduces urinary pH
redundant pannus, surgical scars, or creases with poor and volume.24 Whereas approximately 4% of the general
stoma siting may result in the need for revisional surgery. population develop urinary stones, the incidence in
Revising the site of the stoma or combined abdominal patients with an ileostomy is approximately twice that.
wall recontouring and stoma revision may be necessary.6,16 Whereas uric acid stones comprise less than 10% of the
calculi in the general population, they comprise 60% of
HIGH-OUTPUT STOMAS stones in ileostomy patients. There is also an increase in
For obvious reasons, a high-output state is typically the incidence of calcium oxalate stones.25
described in association with an ileostomy rather than a
colostomy. Marked diarrhea and dehydration occur in BOWEL OBSTRUCTION
5% to 20% of ileostomy patients, with the greatest risk Life table analyses suggest that bowel obstruction is a
occurring in the early postoperative period. An ileostomy rather common complication of ostomy creation. Twenty-
usually functions by the third or fourth postoperative three percent of patients with an ileostomy ultimately
day.17 The output typically peaks on the fourth postopera- develop bowel obstruction.26 Adhesions are probably the
tive day, with an output of up to 3.2 L reported. Because most common cause, but small bowel volvulus or internal
the ostomy effluent is rich in sodium, hyponatremia can hernia may be the culprit. Although it is frequently
be a problem. The particular window of vulnerability for mentioned that suture of the mesentery to the lateral
dehydration appears to be between the third and eighth abdominal wall may prevent volvulus or obstruction,
postoperative day. In time, the small bowel typically adapts retrospective analyses have not shown any benefit to this
maneuver.26 Treatment is not dissimilar to other patients end colostomy.30 The occurrence of these hernias increases
presenting with a mechanical small bowel obstruction. with time31; as such, the reported incidence depends
However, special note must be made of food bolus greatly on the length of follow-up. Most patients with a
obstruction. Many patients with an ileostomy may develop parastomal hernia can be managed expectantly or with
signs and symptoms of bowel obstruction owing to the a belted appliance; however, patients with unrelenting
accumulation of poorly digested foodstuffs (e.g., popcorn, pain, obstruction, or difficulty maintaining an appliance
peanuts, and fresh fruits and vegetables). A careful history generally require surgical repair.
may reveal dietary indiscretions. Furthermore, the possibil- Patient-specific factors such as obesity, advanced age,
ity of a food bolus obstruction should be considered in and chronic obstructive pulmonary disease appear to
any patient with an ileostomy who has radiologic evidence increase the risk of parastomal herniation.13 From the
of a distal obstruction. A red rubber catheter may be technical standpoint, making the smallest possible opening
inserted gently into the ostomy and saline irrigation initi- in the abdominal wall without making the stoma ischemic
ated. If suspicious concretions begin to pass into the seems prudent. However, many of the other preventive
stoma, the irrigations may be carefully repeated until the measures, such as lateral space closure, fascial fixation,
obstruction is relieved. or stoma placement through the rectus muscle, appear
to have no effect on the incidence of these hernias. The
ISCHEMIA use of prosthetic mesh prophylactically, especially in
Edema and venous congestion are very common after the sublay position, may reduce the risk of parastomal
stoma creation, owing to mechanical trauma and compres- herniation.32–34
sion of the small mesenteric venules as they traverse the Unfortunately, the results of surgical correction have
abdominal wall. This is typically self-limiting and requires historically been poor, highlighting the importance of
no treatment.27 However, ischemia may be related to careful patient selection and prudent attempts at conserva-
tension on the mesentery or excessive mesenteric division, tive management in patients without clear indications for
particularly in obese patients or those undergoing emer- surgery. In one of the largest reported series, 63% of
gency surgery.28 A common error is dividing the sigmoidal patients developed a recurrent hernia and 63% had at
vessels to obtain the length to allow a colostomy to reach least one complication.35 The most commonly described
the skin. In these cases, the inferior mesenteric vessels techniques are direct repair, stoma relocation, and mesh
should instead be divided proximally and/or the splenic repair. The recurrence rate with mesh repairs (0% to
flexure mobilized, preserving the sigmoid arcades. 33%) clearly appears to be lower than that of direct repair
If ischemia becomes apparent, a glass test tube or (46% to 100%) or stoma relocation (76%).30,36,37
flexible endoscope may be inserted into the stoma. If the A wide variety of mesh repairs have been described,
stoma is viable at fascial level, then the patient may be but it remains uncertain what type of mesh should be
carefully observed. However, if there is question about used and what the optimal position is for placement. The
the viability of the stoma at the fascial level, immediate intraperitoneal or underlay mesh repair, championed by
laparotomy and stoma revision is required. Early ischemia Sugarbaker, has probably been associated with the most
is seen in 1% to 10% of colostomies and 1% to 5% of encouraging results.38 Intraabdominal pressure tends to
ileostomies.29 keep the mesh in place. One benefit of the intraperitoneal
technique is that a concomitant incisional hernia may be
PARASTOMAL HERNIA repaired at the same time. Various laparoscopic techniques
Parastomal hernia is probably the most common stoma have been successfully used for intraperitoneal mesh
complication requiring operative intervention (Fig. placement.39–41 Concerns have been expressed about the
178.14). A parastomal hernia develops in 2% to 28% of long-term risk of mesh erosion, prompting interest in the
patients with an end ileostomy and 4% to 48% with an use of biologic mesh materials.37,42
Mesh may also be placed using an extraperitoneal
fascial onlay technique.43,44
A curvilinear lateral incision is made outside the outline
of the stoma wafer. The hernia sac is entered, and omentum
and bowel are reduced. An onlay mesh is secured to the
fascial defect. The advantage of this technique is that it
avoids a major intraperitoneal procedure, making it
attractive in patients who are poor candidates for
laparoscopy/laparotomy. However, the recurrence rate
with this procedure is undoubtedly much higher than
with underlay placement of the mesh.
STENOSIS
Stoma stenosis may result from ischemia, excessive tension,
retraction, or recurrent inflammatory bowel disease. The
reported incidence is typically less than 10%.27 Mild
asymptomatic stenosis does not require any treatment.
Skin-level stenosis is readily treated with local procedures
FIGURE 178.14 Large parastomal hernia. such as a Z- or W-plasty, whereas those associated with
FIGURE 178.17 The characteristic blue hue of peristomal varices is

visible only after removing the stoma appliance.
space closure do not appear to reduce the incidence of

stoma prolapse.
Although the prolapse is often unsettling to the patient
or health care providers, asymptomatic prolapse requires
FIGURE 178.15 Prolapsed ileostomy. no treatment, especially if the stoma is temporary. When
the prolapse causes ischemia, obstruction, or pouching
problems, surgical intervention is warranted and usually
straightforward. The stoma is freed up from the abdominal
wall and the bowel delivered until taut. The redundant
bowel is amputated and the mucocutaneous border
reestablished. In cases of incarcerated prolapse without
advanced ischemia, sugar can be applied as a desiccant
to facilitate reduction and obviate the need for urgent
surgery.49
PERISTOMAL VARICES
Stomal varices may cause life-threatening hemorrhage.
The varices occur at the level of the mucocutaneous
border of the ostomy secondary to the anastomoses
between the high-pressure portal venous system and the
low-pressure subcutaneous veins of the abdominal wall.50
FIGURE 178.16 Large prolapse of a transverse loop colostomy. The diagnosis is suspected in ostomates with serious liver
disease and confirmed by the typical purplish hue or
“caput medusae” of the peristomal skin. Common scenarios
Crohn disease usually require formal bowel resection.45 include extensive liver metastases after abdominoperineal
Timing of surgery is an important consideration in patients resection for rectal cancer or sclerosing cholangitis in a
with a retracted and/or stenotic stoma. Fourteen percent patient who has undergone total proctocolectomy with
of colostomies and 12% of ileostomies develop retraction ileostomy for ulcerative colitis. A high index of suspicion
within 3 weeks of surgery; many of these will develop a is critical, and the stoma wafer must be removed to allow
stenosis, ultimately requiring revision.46 With good enter- for skin inspection (Fig. 178.17).51
ostomal therapy (e.g., use of a convex pouch) and tem- Patients with an acute bleed are managed with local
porizing measures, such as gentle digital dilation, the pressure with epinephrine-soaked gauze or suture ligation
acute inflammatory response is permitted to subside. and minimizing local trauma to the ostomy site. Additional
This facilitates the ability to perform a local revision at a therapy is directed at lowering the portal pressure by such
later date when the bowel and mesentery are less friable procedures as transjugular intrahepatic portosystemic
and rigid. shunting (TIPS). Unfortunately, TIPS has a limited dura-
tion of action, usually 6 to 12 months. Percutaneous coil
PROLAPSE embolization may be another option.52 Because many
The risk of stoma prolapse has been reported to be 11.8% patients have a short life expectancy (e.g., extensive liver
at 13 years (Fig. 178.15).47 Transverse loop colostomies metastases), a mucocutaneous disconnection (the stoma
are especially notorious for prolapse (Fig. 178.16); the is freed up to the level of fascia, thereby dividing the
efferent limb is virtually always the offending cause. This portosystemic connections) or stomal relocation may be
is one of the reasons why loop ileostomy is commonly considered. Unfortunately, these are difficult and bloody
preferred to loop colostomy for temporary fecal diversion.48 procedures, and the portosystemic anastomoses typically
Although often advocated, mesenteric fixation or lateral reform within 1 year. Long-term success may require a
liver transplantation, based on the patient’s life expectancy inflammatory bowel disease patients after colectomy. J Gastrointest
and the status of the associated liver disease. Surg. 2007;11:138.
21. Buchman AL, Scolapio J, Fryer J. AGA technical review on short
bowel syndrome and intestinal transplantation. Gastroenterology.
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22. Szilagyi A, Shrier I. Systematic review: the use of somatostatin or
Portions of this chapter were adapted from the previous edition octreotide in refractory diarrhea. Aliment Pharmacol Ther. 2003;15:
1889.
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of small bowel origin with continuous enteral nutrition and succus
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Israelsson LA. Parastomal hernias. Surg Clin North Am. 2008;88:113. versus J-pouch. Br J Surg. 1990;77:149.
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CHAPTER

Ostomy Construction and Management:

BOX 178.1 Common Indications for Permanent Colostomy

FIGURE 178.2 A disc of skin is excised at the stoma site.

FIGURE 178.1 The ostomy triangle is defined by the anterior

confined to a wheelchair should be marked while in their

FIGURE 178.6 Tripartite bites between the dermis, the

The lateral ileal gutter may be closed if desired to prevent

“downstream” intestine. Diverting stomas consist of three

FIGURE 178.8 Creation of a loop ileostomy with support

Cutaneous sutures should be placed in proximity to save

Pneumoperitoneum is released, and the stoma trephine

complications are peristomal skin irritation, leakage, high

with mucosal hyperplasia and there is a steady decrease

FIGURE 178.17 The characteristic blue hue of peristomal varices is

space closure do not appear to reduce the incidence of

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