A stoma should ideally be planned preoperatively if at all possible. This is best done for several reasons. First, there is no doubt that patients may experience a great deal of anxiety related to their surgery and the possibility of needing a stoma. Second, patient education is perhaps the best way in order to allay a patient’s fears and concerns regarding the surgery and the possibility of needing a stoma. The patient should be provided with ample opportunity to ask questions related to the stoma and the overall surgery. Videos may be a useful tool in order to demonstrate to the patient the role and function of a stoma in order to assist with preoperative consultation. In addition, online websites may be provided to the patient as an additional resource. Often times it is beneficial for the patient to speak to other willing patients in a similar situation who have a stoma so that many of their questions may be appropriately addressed. Third, the patient should be appropriately marked for a stoma by a qualified enterostomal therapist in order to arrange for the best placement for the ostomy since each patient’s body habitus is different. This will help ensure that the patient will have the best possible fit of the stoma device in order to make the stoma experience as pleasant and beneficial to the patient as possible. Stoma sites should be modified to avoid scars, skin creases, and other skin disorders. Stoma markings should be done with the patient in both the sitting and standing positions, and attention must be given to the beltline and pant height. Stomas should be placed through the rectus sheath and not lateral to it in order to have the rectus muscle provide support and reduce the incidence of parastomal hernias. In obese patients, a supraumbilical stoma placement may be necessary. Once the proper spot is determined for the stoma, the site is marked with indelible ink. In some situations of difficult placement, a stoma device may be placed on the skin at the proposed site and worn for 24 h in order to test the placement.

Siting through the umbilicus may be a reasonable alternative when there is no other good location. Raza and his colleagues felt that this was a good option based on their series of 101 patients; only four needed revision, and there were no parastomal hernias or prolapse [8]. Fitzgerald noted that after closure in infants and children, the scar resembles a normal umbilicus and is cosmetically superior to that of an ostomy placed elsewhere [9].

Stoma counseling is clearly an important part of stoma acceptance. This has been confirmed in a study that used multiple regression analysis to show that stoma adjustment was related to learning how to care for the stoma by the patient, interpersonal relationships that the patient has developed, and better stoma placement. The authors concluded that addressing the psychosocial concerns of the patient should become a part of the care routinely given to stoma patients, and preoperative counseling plays a major role in the care [10]. Such counseling will improve patient outcomes and patient satisfaction scores and may even reduce overall length of hospital stay.

Morbidly obese patients present a significant challenge in stoma creation. Some have advocated a loop end stoma in this patient group in order to prevent bowel ischemia [11]. Another technique that has been described to assist in the stoma creation in the morbidly obese patient utilizes an Alexis wound protector placed in the abdominal wall at the stoma site. This will facilitate the bowel to pass through the abdominal wall with less friction and resistance because of the extensive subcutaneous tissues in these patients [12].

The advantages of laparoscopic stoma creation include smaller incisions, thereby reducing the chance of large wound infections that may occur with formal laparotomy, less postoperative pain, and reduced use of pain medication thereby reducing the time to first stool and reduction of postoperative ileus. In addition, the laparoscopic technique is ideally suited to stoma creation since it often does not require specimen extraction making this one of the easiest laparoscopic procedures to perform. In addition there are no incisions except for the port sites thereby facilitating the placement of the stomal appliance over the stoma site without the need of placing the appliance over an abdominal incision.

Another advantage of the laparoscopic technique may be seen in the patient undergoing a concomitant bowel resection along with a planned stoma. In these cases, the surgeon should use a port at the site of the presumed stoma and then exteriorize the bowel through this area at the completion of the surgery. In these cases, the surgeon may spare the patient an abdominal incision. However, some care must be taken upon using the laparoscopic technique with regard to bowel orientation. Since many surgeons prefer placing the proximal portion of a loop stoma at the upper aspect of the skin and abdominal wall defect, one must ensure that the bowel is properly oriented upon delivery through the abdominal wall and that the bowel is not twisted or kinked. Even upon creating end stomas, twisting of the bowel at the fascial level may result in a mechanical obstruction of the bowel. The surgeon should always reinsufflate the abdomen after the bowel has been exteriorized in order to best visualize the orientation of the mesentery and ensure that the bowel has not been twisted.

Most importantly, one must assure that the proper proximal portion of the bowel is exteriorized in those patients undergoing an end stoma. Division of the bowel and maturation of the incorrect limb will result in a complete bowel obstruction and will ultimately result in a return trip to the operating room to correct this problem. While this problem would rarely if ever occur in open stoma creation, it is a possibility in the laparoscopic technique if one fails to identify the proper orientation of the bowel especially in cases of colonic redundancy. This problem may be avoided by ensuring complete visualization of the bowel and by identifying the upper aspect of the rectum noted by the convergence of the teniae coli and following the bowel proximal from that point. Another technique that may be used is to insufflate the rectum with air at the time of stoma creation in order to identify which end is most distal. If one is still having trouble identifying the proximal and distal portions of the bowel, then a loop stoma should be performed in order to prevent maturation of the incorrect side. Alternatively, one can always convert to an open procedure if there is still uncertainty about the correct anatomy.

Laparoscopic stoma creation has been compared to open stoma creation in several studies. A study from Germany showed fewer operative complications from open stoma creation compared to laparoscopic stoma creation. However, the mortality associated with the laparoscopic group was considerably lower. They concluded that for palliative stoma creation, there were significantly advantages using the laparoscopic technique for stoma creation [13].

The Cleveland Clinic Florida reported their experience with laparoscopic stoma creation early on. In their study of 32 patients who mostly underwent loop ileostomy, they converted to open surgery in five patients (two because of a noted enterotomy at the time of surgery), while two patients required reoperation for stoma outlet obstruction. One of these patients experienced a twisting of the bowel at the level of the fascia. The mean operative time was 76 min, and the mean length of stay was 6.2 days [14]. This long length of stay is most often related to stoma teaching.

A recent study reviewing a 10-year period confirmed the benefits of laparoscopic stoma creation. In this review of 80 patients who mostly suffered from advanced unresectable colorectal cancer, all but one patient underwent successful laparoscopic stoma creation. While the majority of patients underwent loop stoma formation of either the ileum or colon, only five patients suffered complications requiring reoperation including parastomal abscess, stomal retraction, small bowel obstruction, postoperative bleeding, and port site hernia. The average length of stay was 10.3 days. While this length of stay may seem long, it is most often related to proper patient teaching in stoma use and care [15].

The patient is placed supine on the OR table with the both arms tucked. The table is placed in Trendelenburg position and rotated to the side opposite the site of the stoma placement. This will help move the bowel more cranial and lateral for better visualization. The surgeon is positioned on the side of the patient opposite to the site of the stoma (i.e., the surgeon will stand on the patient’s right side for colostomy creation and on the left side for ileostomy placement). Typically the monitors are positioned by the feet of the bed for better visualization. However, if a more proximal transverse colostomy is planned, it would be preferable to position monitor toward the shoulders of the patient. The bladder should be decompressed with a Foley catheter for assistance with visualization and avoidance of bladder injuries. A rectal tube may be placed with a large syringe attached and positioned under the drapes for those patients undergoing an end colostomy or Hartmann’s type procedure. Insufflation by the operating room staff prior to stoma maturation will help ensure proper orientation of the bowel and allow for maturation of the correct limb of bowel as well. The tube will be removed at the conclusion of the operation.

There have been a variety of techniques described for laparoscopic stoma creation using zero, one, or more ports. Hellinger and his colleagues at the University of Miami have described a laparoscopic technique through a trephine incision and without a port and without gas insufflation for stoma creation in those patients who may not be able to tolerate a pneumoperitoneum [16]. This technique simply uses abdominal wall retraction and placement of the laparoscope within the trephine opening in order to identify and orient the bowel. The downside to this technique is that it does not allow a great deal of mobilization of the white line of Toldt due to limited visibility in cases where the bowel is not very redundant.