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John Migaly

Indications/Contraindications

The importance of appropriate planning and technique in the formation of a colostomy is often underestimated; however, it should be noted that a significant number of elective colostomies and urgent colostomies tend to be permanent. Despite the impromptu circumstances of many colostomies, a thoughtful and consistent approach toward colostomy creation can avoid a problematic ostomy, which can be equivalent of a “life sentence” for the patient if the ostomy is poorly fashioned.

Colostomies may be created for one of a variety of elective, semielective, or urgent indications. Colostomies are created in cases where diversion of the fecal stream may be necessary in distal colitis, and for diversion in cases of intra-abdominal catastrophes such as diverticular perforation, ischemic necrosis of the colon, or iatrogenic perforation. Proximal diversion may be necessary for debilitating fecal incontinence, in cases of necrotizing soft tissue infection or sacral decubitus where patients may have large, nonhealing perineal or sacral wounds. Stomas may be useful adjuncts for complex repair of rectovaginal or rectourethral fistulas.

Ostomies are very often performed in cases of large bowel obstruction secondary to neoplasia or to protect a distal rectal or coloanal anastomosis. In cases of colonic obstruction where proximal diversion may be necessary, quite often an ileostomy is not appropriate as a form of diversion, because although it will divert the fecal stream, it may or may not decompress the colon depending on whether the patient has a competent ileocecal valve. In cases where the ileocecal valve is competent, the cecum can still become distended, ischemic, and subsequently perforate; therefore a colostomy may be more appropriate.

The indications for open rather than laparoscopic colostomies are primarily situational. In many instances the patients may have had multiple prior abdominal surgeries and thus a laparoscopic approach may not be advisable or feasible. Very often, obesity and body habitus may dictate the choice of the procedure. In situations where there is acute large and/or small bowel dilatation, laparoscopy may not be practical because of the lack of intra-abdominal domain; therefore an open technique is utilized.

Preoperative Planning

Choosing a Site for a Colostomy

One of the most important aspects involved in the creation of a colostomy is choosing an appropriate position on the abdominal wall for the colostomy. The siting of an ostomy is quite important for the obese patient and for the thin patient alike. The patient should be marked for the stoma in both the standing and the seated position. Often times a stoma site will be ideal in the standing position and not in the seated position. Folds of skin may be far more prominent in the seated position than in the standing position. These folds should be avoided as it is very difficult to maintain a seal with the colostomy appliance when the stoma is seated in a fold. Care should be taken to choose a site for the stoma that is within the body of the rectus and not lateral to the rectus sheath. This positioning can often be quite deceiving in obese patients as the landmarks can be obscured by the patient’s pannus. A stoma that is lateral to the rectus sheath can predispose the patient to a parastomal hernia. Another important factor in marking someone for a stoma is the belt line. Ideally, stomas should be sited above the belt line, but there are some patients who have relatively high belt lines where a high or above the belt line stoma is not practical.

In patients that have had multiple abdominal procedures, the site of the stoma does not necessarily have to be away from prior incisions unless there is significant skin dimpling, retraction, or excavation of that segment of the abdominal wall. In fact it might be cosmetically preferable for that particular patient to avoid an additional incision.

Bowel Preparation

In urgent or emergent cases where a stoma is needed, bowel preparation is usually not safe, feasible or necessary. In fact, most elective colostomies do not merit a mechanical bowel preparation.

Surgery

Positioning

Traditionally, we position the overwhelming majority of patients scheduled to undergo colorectal surgery, including colostomies, in the low lithotomy position. This position allows access to the anus for proctoscopy, colonoscopy or any other adjunctive anorectal procedures. It also allows better visualization and manipulation of the upper abdomen from a low incision; this is particularly useful in cases where splenic flexure mobilization is necessary. In these cases, standing between the patient’s legs can be advantageous.

Technique

End Colostomy

An end colostomy is most commonly placed in the left lower quadrant and is usually created after an abdominoperineal resection or a Hartmann’s procedure. After the resection is completed, the colostomy is created by mobilizing the left colon such that there is adequate reach for the colostomy to come out of a left lower quadrant aperture. Quite often, it is necessary to mobilize the splenic flexure in order to have adequate reach to the left lower quadrant and to be delivered through a thick abdominal wall. If reach is still a problem, then the root or base of the left colon mesentery can be mobilized as long as the vascular arcades are not disrupted.

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