Open Colostomy

Linda Ferrari

Alessandro Fichera

INDICATIONS

Despite advances in medical therapy and surgical techniques, temporary or permanent fecal diversion with a colostomy is still frequently indicated.

The majority of elective colostomies are laparoscopically performed. However, open surgery may be indicated in the following circumstances: when dense adhesions preclude proper exploration of the abdominal cavity; in the presence of a large mass causing lack of intra-abdominal domain; severe comorbid conditions as a contraindication to pneumoperitoneum; or large bowel obstruction.

The leading malignant indications for elective permanent colostomy include very distal advanced rectal cancer; anal cancer, persistent or recurrent; advanced rectal cancer invading adjacent structures, requiring abdominoperineal en bloc resection to achieve adequate oncologic margins; cancers with direct invasion of the elevator muscles and patients with severe fecal incontinence undergoing ablative rectal surgery.

The leading benign indications for elective permanent colostomy are Crohn’s disease, diverticular disease, and radiation proctitis. In severe fistulizing perianal Crohn’s disease, refractory to medical management, fecal diversion may maximize the chances of healing the perianal disease. Recent evidence suggests that this strategy may not be as effective as previously thought. In extreme cases, especially if associated with stricturing or incontinence, a proctectomy with creation of an end colostomy is the only definitive option.

A sigmoid resection with colostomy and Hartman’s pouch may be appropriate for patients with Hinchey III-IV diverticulitis, too unstable to tolerate a definitive operation with anastomosis. An anastomosis may subsequently be performed once the patient is medically optimized.

In the acute phase, radiation proctitis may present with bleeding, which can be severe, requiring local endoscopic treatment or temporary fecal diversion. In the chronic phase, complicated by stricture, a proctectomy with end colostomy is the only option for these patients.

Colostomies are often created for distal large bowel obstruction due to neoplasia or benign stricture, or to protect a distal rectal anastomosis. In the latter case, the authors prefer to use an ileostomy. When there is colonic obstruction, if the ileocecal valve is competent, ileostomy may not be appropriate.

Preoperative planning and patient education are critical steps when preparing a patient for elective colostomy creation. Preoperative siting by a Wound and Ostomy Certified Nurse (WOCN) before an elective procedure identifies the ideal placement of the stoma either temporary or permanent. Furthermore, it improves patient outcomes and satisfaction, reduces the risk of possible future complications, and should be considered mandatory.

PREOPERATIVE PLANNING

Patient Education

Preoperative education is a critical component of elective colostomy planning. Properly educated patients experience a shorter hospital stay and fewer postoperative complications. Knowledge of what
to expect can alleviate fears and anxiety associated with surgery and help the patient understand the adjustments needed to live a normal life with a permanent colostomy.

Ideally, the patient should meet with the surgical team, including a WOCN provider, several days before elective colostomy surgery. At that time physical and psychological implications, as well as the patient’s available support system, should be reviewed. The WOCN provider should meet with the patient at the preoperative visit, during the postoperative recovery and for long-term follow-up in case of a permanent diversion. In an emergency, if at all possible, stoma marking should still be preoperatively performed by a WOCN provider followed by postoperative education evaluation, and assistance.

Colostomy Siting

Proper siting of the colostomy is a critical aspect of the preoperative planning that has shown to decrease long-term complications and improve patient satisfaction. Stoma marking should be performed by a WOCN provider in all patients undergoing elective temporary and, even more so, permanent fecal diversion.

In 2014, recommendations from the World Council of Enterostomal Therapists stated that preoperative education should include explanation of the surgical procedure, stoma site marking, and planning of postoperative management. In terms of siting they stated: “The ideal stoma site is located below the umbilicus, within the rectus muscle, away from the scars, creases, bony prominence, umbilicus, and belt line, on the summit of the infraumbilical fold, and visible to the patient.” The patient should be evaluated both standing and seated. The site should be within the rectus abdominus, because lateral placement will predispose to parastomal hernia. In general, the stoma should be sited above the belt line; however, in some patients with a relatively high belt line, placing the stoma above it may not be feasible or practical.

Additional considerations include body habitus and abdominal scars. In thin patients who may have lost weight due to illness, the stoma should be positioned taking into consideration anticipated weight gain. Patients with loose, mobile skin due to weight loss over a firm abdomen, create additional difficulty because the skin mark may descend significantly when the patient is standing, creating tension on the colostomy. In obese patients, the rectus muscles are hard to identify, because of the thick abdominal wall. In these patients, the stoma is often placed in the upper quadrants (Fig. 44-1) where the abdominal wall is usually thinner, thus facilitating the creation of the tract in a location that is more accessible and visible to the patient. This also prevents tension on the colostomy due to descent of the pannus when the patient is standing (Fig. 44-2).

Lastly, abdominal scars may create additional folds and potential for weakness of the abdominal wall, predisposing the patient to parastomal herniation.

FIGURE 44-1 Obese man undergoing open permanent end colostomy for a distal sigmoid malignant obstruction due to a large mass, requiring an open approach. The stoma is placed in the upper quadrants.

FIGURE 44-2 Marking for a transverse colostomy in an obese patient. The stoma will be placed in the upper quadrant were the abdominal wall is thinner and the stoma will be visible to the patient.

Bowel Preparation

The evidence to support the use of mechanical bowel preparation (MBP) remains controversial and perhaps poorly understood. It is accepted that MBP alone should not be offered for right colon resection and perhaps not even for left colectomies. However, data on colon resection from the National Surgical Quality Improvement Program clearly shows that MBP with oral antibiotics reduces the rate of surgical site infection by 50% over MBP alone or MBP with intravenous (IV) antibiotics, without increasing the risk of anastomotic leak, postoperative ileus, or Clostridium difficile infections. On the basis of this evidence and our own institutional experience, it is the authors’ and editors’ practice to use MBP with oral and IV antibiotics for all colectomy patients.

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