Introduction
The term ostomy originates from the Latin word stoma, meaning “opening” or “origin,” and from the Greek word stomat, meaning “mouth.” Historically it is unclear when and how the first ostomies were created, although evidence suggests that the earliest use of fecal diversion was probably related to traumatic fecal fistulas. The first mention of stomas in the surgical literature is by Littre in the early eighteenth century, yet stomas did not become part of surgical practice until decades later, with the creation of ventral and lumbar colostomies for the treatment of imperforate anus and obstructing cancers.
Ileostomies have their origins in the late nineteenth century, when they were used as a means of managing ulcerative colitis. Although the ileostomy was potentially life saving in the treatment of advanced disease, it was soon discovered that the same principles of maturation that were applied to colostomies could not be applied to ileostomies. Early ileostomies that were left to mature spontaneously caused significant morbidity and mortality as a result of serositis, with subsequent development of strictures of the stoma and fluid and electrolyte losses. This constellation of symptoms later became known as “ileostomy dysfunction.” The work of Turnbull and Brooke in the early 1950s was instrumental in resolving these complications. The key was recognition of the causal role of serositis; the cure was to cover the serosa, either with a skin graft (Turnbull) or primary eversion of the bowel (Brooke). The Brooke technique continues to be the standard technique for the creation of ileostomies.
In addition to the many clinicians who have greatly contributed to the development of ostomy surgery and care over the years, enterostomal therapists have contributed hugely to the field. The first school of enterostomal therapists was established in 1961 as a collaboration between Turnbull and one of his former patients, Mrs. Norma Gill. Seven wound, ostomy, and continence nursing accredited programs currently exist throughout the United States, and their contributions to the care of patients with stomas and the management of ostomy complications are invaluable.
The temptation exists for surgeons to regard stoma construction as part of wound closure, which may mean that it is performed by residents. In reality, stoma construction is an important determinant of outcome because an improperly constructed stoma can lead to unnecessary inconvenience, stress, and financial expenditures for the patient. Although ostomy complications are relatively common, in most cases, further surgery is not required for correction. This chapter describes important principles in minimizing the incidence of ostomy complications and covers the specific complications themselves.
Ostomy Creation
Prevention of ostomy complications starts before they are created. Complications are less frequent when stomas are performed electively (37%) than in an emergency (55%). This difference can be explained not only by the difficulties posed by an emergency operation, such as peritonitis/contamination and a dilated bowel, but also by the lack of appropriate preoperative planning. Despite the indication for the stoma or the type of stoma, certain basic steps in the process should always be followed.
Preoperative Discussion and Consent
Appropriate informed consent and preoperative education is very important. As with any procedure, a full discussion of risks and benefits should be undertaken preoperatively. This step is especially important for ostomy surgery because of the psychological hurdles involved. Many resources are available to patients through the American College of Surgeons and the United Ostomy Associations of America.
Siting the Stoma
Many complications of a dysfunctional ostomy originate in poor placement. A poorly located stoma is prone to hernia, prolapse, skin excoriation from leakage, bleeding from appliance trauma, and parastomal sepsis. Preoperative marking is usually performed by the enterostomal therapist, but any surgeon operating on the bowel should be able to do it himself or herself. The standard locations are within the confines of the rectus abdominis muscle on either side of the midline, at a height that is visible to and accessible by the patient, in a flat area of skin without scars or dimples. This site usually ends up being just lateral and most often inferior but in some cases superior to the umbilicus ( Fig. 90-1 ). Initially the location is chosen with the patient supine, but it is also essential to evaluate the site with the patient standing and sitting.
Although various unique situations can lead to difficulty in proper siting of a stoma ( Box 90-1 ), the most common situation encountered is obesity. Extreme care must be taken in assessing the site to avoid placement within a crease or an area where the patient is unable to see or properly care for the stoma. In an obese abdomen, the ostomy is generally placed slightly on the upside of a fold. A more superior location provides better accessibility. Ideally there should be 2 inches of flat skin around the stoma to allow the appliance to adhere properly.
Obese patients
Bilateral paramedian incisions
Pelvic exenteration requiring both fecal and urinary diversions
Radiation of skin-grafted abdominal wall
Disturbed or absent rectus muscles (e.g., transverse rectus abdominis myocutaneous/vertical rectus abdominis myocutaneous flaps and bladder exstrophy)
Creating and Maturing the Stoma
To set up for the stoma construction, Kocher clamps should be clipped onto the cut edge of the anterior rectus sheath as it is displayed in the incision, and on the dermis. The clamps should be vertically aligned one over the other and kept in line so that the aperture is straight. A folded gauze pack is placed immediately under the site of the intended stoma and held there by the surgeon’s nondominant hand.
The diameter of the stoma aperture is a key to constructing an effective stoma. An ileostomy should protrude about an inch from the abdominal skin as a bud, which means that at least 2 inches of bowel should protrude, tension free, before maturation. To assist in stabilizing the bud, the skin aperture must not be too loose. It should just grip the bowel without narrowing it. Therefore, the diameter depends on the diameter of the bowel itself. A colostomy need not protrude more than 5 mm, and because the bowel is larger than the ileum, the aperture can be more generous. A stoma aperture that is too tight can produce a postoperative bowel obstruction that may appear to be an ileus.
The following steps should be performed:
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Incise the subcutaneous fat vertically in the middle of the aperture, using small retractors to deepen the wound to the fascia. Do not remove fat, which is needed to support the stoma.
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Incise the anterior rectus sheath vertically. If the bowel is big, small cruciate incisions can be made on either side ( Fig. 90-2 ).
FIGURE 90-2
Exposure and incision of the anterior rectus sheath.
(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography copyright 2009-2016. All Rights Reserved.)
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Using a Kelly clamp, separate the rectus fibers in the middle of the wound. Make sure the posterior fascia/peritoneum is visible for the entire length of the incision ( Fig. 90-3 ).
