Types of intestinal stomas. (a) End stoma , (b) loop stoma , (c) end-loop (Prasad, defunctioned loop, divided loop) stoma, (d) pseudo-loop (loop-end) stoma
Preoperative Planning, Patient Workup, and Optimization
Stoma Site Selection and Marking
All patients scheduled for colon or rectal surgery with planned or potential stoma creation should undergo a dedicated outpatient visit with an experienced wound, ostomy, and continence nurse (WOCN) and be marked preoperatively. The American Society of Colon and Rectal Surgeons (ASCRS) and the WOCN Society have published a joint position statement on proper site marking for fecal diversion . While site selection is a priority during the visit, the WOCN can assist in setting expectations, addressing misconceptions and anxieties about stomas, and directing patients toward adequate support and resources available after surgery .
In addition to the preoperative marking and education by the WOCN, the surgeon’s role is important to optimize stoma function at the time of creation. The ostomy should be meticulously constructed to allow for easy pouching and reduction in the risk of stoma complications and peristomal skin irritation . Anatomical considerations and the disease process requiring surgery guide proper site selection for stoma formation. Firstly, the bowel segment selected for stoma creation will influence its location (ileum, transverse, or sigmoid colon). Secondly, it is desirable to lead the bowel through the rectus muscle. Thirdly, the patient’s body habitus and pannus size, folds, divots, and their clothing preferences should be taken into consideration .
Nonobese patients are also at risk of stoma complications, including parastomal hernia. Traditional teaching recommends that the stoma should be sited within the borders of the rectus muscle to reduce the incidence of parastomal hernia formation. However, a recent Cochrane review of 9 retrospective cohort studies with a total of 761 patients failed to show a reduced hernia formation with the transrectus approach compared to lateral pararectus stoma placement .
Unplanned Stoma Creation
While preoperative stoma site marking is a must for all elective cases, the patient undergoing emergency surgery may not be in a condition to allow for marking, or the patient’s abdominal contour immediately prior to emergency surgery (e.g., LBO, fluid retention, or anasarca) may not reflect the true body habitus and may obscure even deep abdominal creases and folds.
In a patient with LBO, the distended and fragile colon may be difficult to handle and get to the abdominal wall. Venous compression at the fascial aperture adds to the challenge as it can lead to ischemia in this tenuous bowel. The surgeon should assess the cecum and right colon in a left-sided obstruction in case there is vascular compromise or wall compromise due to shear stress. Colonic decompression should be considered early as it greatly facilitates the manipulation of the colon and reduces the risk of rupture and stool spillage. A purse-string suture can be placed at the anticipated site of the colostomy to decompress the colon in a controlled manner. This should facilitate a smaller colostomy aperture and ease pulling the colon through the abdominal wall. Rarely, it may be the case that only the antimesenteric side of the colon can be matured , leading to a stoma that does not fully divert the fecal stream and may require revision later .
Operative Setup and Surgical Techniques
Intestinal diversion, if it is not the primary procedure, is typically performed as the concluding stage of an operative procedure. Both colostomy and ileostomy maturation can be accomplished with the patient in any supine or semi-supine position. Patients in high lithotomy will need to be repositioned into low lithotomy or modified low lithotomy. Patients in prone or left lateral decubitus position will require repositioning and redraping. For laparoscopic stoma creation, the patient is placed in lithotomy with arms tucked at the sides.
Routine mechanical or antibiotic bowel preparation prior to ileostomy formation is not required but should be performed prior to colostomy formation. Preoperative antibiotic prophylaxis covering gastrointestinal flora is administered prior to the procedure. Sequential compression stockings are utilized throughout the case. An oral gastric tube and Foley catheterization are not required. If stoma formation is part of a longer operative case, the above considerations should be dictated by the primary procedure being performed.
Aperture Creation When the Primary Operation Has Been Performed Through a Midline Incision
A Kocher clamp is placed on the fascial edge to keep the abdominal wall in alignment. A folded dry laparotomy pad is then placed intra-abdominally.
A circular disk of skin is excised at the site previously marked. The skin aperture for ileostomy should be 2 cm in diameter and slightly larger for colostomy. There are two techniques to excise the skin aperture; the first is to grasp the central portion of this skin with a second Kocher clamp and pull and excise the tented skin and dermis. The second technique is to use cutting cautery or scalpel to develop a cruciate incision into the subcutaneous tissue and then excise the “dog ears” to create a circular incision.
The subcutaneous tissue is divided down to and through Scarpa’s fascia until the anterior rectus sheath is exposed. Army-navy, curved S, or appendiceal retractors will assist in exposing the fascia.
A vertical incision is then made in the anterior rectus sheath. This aperture should be slightly larger than the skin aperture, or about 3 cm. A small 1 cm cruciate incision is made laterally. The operating surgeon will now place their supinated nondominant hand under the laparotomy pad and apply some upward pressure for improved exposure.
The rectus muscle is split in the direction of its muscle fibers, and the retractors are advanced into the incision to now expose the posterior rectus sheath. The posterior sheath is now incised with cutting cautery to expose the intra-abdominal laparotomy pad, thus avoiding bowel injury. The defect should be approximately 2 fingerbreadths in diameter for ileostomies and 3 fingerbreadths for colostomies.
The previously divided bowel is then delivered through the aperture that has been created in the abdominal wall. A Babcock clamp can facilitate delivery of the ileum or colon but is important to push the bowel out, rather than pull it, as the bowel and mesentery are easily injured.
The bowel is then carefully oriented to ensure the mesentery is straight. The mesentery should be oriented in the cephalad direction.
The midline incision is then closed using the preferred technique and then either dressed or covered with an operative towel before the stoma is Brooked .
Primary Aperture Creation Without a Secondary Incision
The technique begins with excision of the circular disk of skin at the previously marked site.
Once the retractors are advanced into the incision to expose the posterior rectus sheath, the posterior sheath is grasped with two tonsil clamps and elevated, and Metzenbaum scissors are utilized to open the posterior sheath and peritoneum .
Stoma Maturation for End Ileostomy or Colostomy
Care must be taken to ensure that the planned stoma does not change its orientation while attention may be turned to closing other incisions or port sites first. If the end of the bowel has been stapled to control enteric spillage, this staple line is removed. Care is taken not to allow the stoma to drop back into the abdominal cavity or for enteric contents to seep into the aperture.
Four to five absorbable sutures (3-0 or 4-0, either chromic catgut or braided suture, on a small tapered needle such as an SH or CV-23) are then used to evert or “Brooke” the stoma. The first suture is passed from mucosa-to-serosa on the antimesenteric side of the bowel, and then a seromuscular bite is taken 3–4 cm proximal to the cut edge of the bowel, then through a subcuticular layer of skin. Passage of the suture through the epidermis can result in peristomal skin complications, such as persistent mucosal islands or scarring. Of note, The ASCRS practice guidelines recommend that whenever possible, both ileostomies and colostomies should be fashioned to protrude above the skin surface .
This process is repeated as Brooke sutures are placed at each cardinal location on the bowel. The small end of an army-navy retractor or the back of an Adson tissue forceps is then used to evert the bowel wall as these sutures are sequentially tied down.
Additional intervening sutures are then placed to approximate the mucocutaneous junction. These need not be numerous, and should not include the seromuscular bite.
If desired, the stoma can be digitized to confirm an adequately patent fascial aperture and a finger placed alongside the stoma to ensure the aperture is not too tight. A pouching system is placed.
Stoma Maturation for Loop Ileostomy or Colostomy
The appropriate length of colon or ileum is identified. If the stoma is meant to be a terminal loop ileostomy, the site of stoma maturation is approximately 20 cm proximal to the ileocecal valve.
It is recommended to mark this length of bowel and to indicate which direction is distal. This can be achieved through dyed and undyed suture or long- and short-tailed marking sutures, with cautery or with a tip of a sterile marking pen used intra-corporeally.
To deliver the bowel through the abdominal wall, a Penrose, umbilical tape or 14F red rubber catheter can be passed just under the mesenteric side of the bowel.
The bowel is now carefully oriented to ensure the afferent and efferent limbs are identified by the previously placed suture or mark, and with direct visualization.
If desired, the red rubber catheter can be secured to the deep dermis using 3-0 nylon suture.
Approximately 80% circumference of the antimesenteric portion of the bowel is opened with a horizontal incision using cutting cautery. This should not be at the apex of the exposed loop but on the distal end.
The proximal end of the stoma (efferent into the stoma appliance) is matured similarly as above using cardinal everting Brooke sutures.
The distal edges are secured to dermal edge with simple sutures, again excluding the epidermis , to complete the maturation, and a pouching system is applied.
Operative Technique for Laparoscopic Stoma Creation
Enter the abdomen using the Optiview port under direct visualization at Palmer’s point in the left upper quadrant. Alternatively the abdomen can be entered at the planned site of stoma creation using an open cutdown technique.
Once intra-peritoneal and the abdomen is insufflated, perform diagnostic exploration of the abdomen to assess for adhesions or carcinomatosis. Plans for either ileostomy or colostomy will dictate port placement. For ileostomy creation, a 5 mm port will be placed infra-umbilically, and a second 5 mm port will be placed in the left lower quadrant for triangulation. Often, however, a two-port technique is feasible when simply pulling up a loop ileostomy.
The cecum and terminal ileum are identified, and the small intestine is lifted and run proximally for about 10–20 cm from the ileocecal valve. Look for excess mobility of the ileal mesentery to reach the abdominal wall where the patient was previously marked. If the mesentery is stuck, some lysis of adhesions or mobilization of the cecum can be performed. This can be done sharply, so advanced energy devices are not necessary. The surgeon should avoid creating the ileostomy too close to the ileocecal valve, to allow for easy mobilization and a tension-free, well-vascularized small bowel anastomosis at the time of ileostomy reversal. However, creating the stoma too proximal may increase the risk of high ileostomy output.
Once the site is chosen, use an intracorporeal suture to mark the proximal and distal direction of the small bowel. Clamp the small bowel with a padded grasper.
The stoma aperture is created at the previously marked site. See “Primary aperture creation without a secondary incision.”
Pneumoperitoneum is maintained with a finger placed through the stoma site intraperitoneally until it is widened enough to fit two fingers. As pneumoperitoneum is maintained with two fingers in place, a Babcock is inserted between the fingers, and, under laparoscopic visualization, the small intestine is lifted to the Babcock and then grasped. It is carefully pulled through the abdominal wall without twisting the mesentery. De-sufflate and confirm that there is no excessive tension on the bowel and its mesentery.
Once pulled through, a hemostat is pushed through the mesentery just underneath the bowel wall and then replaced with a 14-18F red rubber or stoma bar. If there is minimal to no tension on the stoma, consideration can be given to avoiding the use of a supporting bar or rod.
The abdomen is re-insufflated and explored again to make sure the mesentery is straight and under no tension. One last check is that a finger will fit along the side of the stoma within the aperture and the ports are removed under direct visualization and pneumoperitoneum is released.
The skin incisions are irrigated and closed with subcuticular sutures, and the abdomen is covered except for the stoma.
The stoma is matured identically to the open approach for loop ileostomy.
Note: For laparoscopic colostomy creation, the steps are very similar. The part of the colon used for the stoma is the most variable aspect of the operation. This decision depends on the reason for stoma creation, abdominal adhesions, mobility, presence of carcinomatosis, diameter of the colon, fatty mesentery or epiploica, and preoperative marking. Generally, we try to bring up the sigmoid colon or the most distal aspect of the colon that is mobile. Without a redundant sigmoid, the left colon may need to be mobilized by taking down the white line of Toldt. If a more proximal colostomy is created, such as at the distal transverse, the omentum should be taken down and mobilization performed both proximal and distal to the site of the planned colostomy. More mobilization performed laparoscopically will allow for more length, easier reach, and less tissue to be pulled through the abdominal wall. We routinely Brooke our colostomies, so the same steps listed above for ileostomy are carried out during colostomy creation.
The minimally invasive approach to colon and rectal surgery in general and stoma creation is widely supported. Particularly in conjunction with an enhanced recovery program, there has been decreased morbidity, decreased length of stay, and increased patient satisfaction . Laparoscopic approach to ileostomy or colostomy creation is safe and can be a fast and minimally morbid operation .
During laparoscopic stoma creation, it is particularly important to maintain proper bowel orientation. A retrospective review of 161 patients undergoing laparoscopic loop ileostomy formation demonstrated a 5% rate of obstructive complications, owing to improper orientation, adhesive kinking of the ileostomy, or tight fascia . Re-insufflation and peritoneal exploration after exteriorization of the bowel should be employed to reduce twisting, and the stoma should be digitized to judge appropriate size of the fascial aperture. If proper orientation during loop colostomy creation is in question, endoscopy should be performed.
Single-incision “scarless” technique in the setting of stoma creation for temporary fecal diversion has also been described [21–24]. The technique begins by developing the cylindrical trephine stoma incision at the site previously chosen and marked by an enterostomal therapist. For this reason, the single-incision approach is not appropriate when multiple sites of stoma maturation have been marked and are being considered. A commercially available single-incision port device is then introduced, or a “glove port” can be fashioned by securing a sterile glove around a small wound protector. Laparoscopy is then used to grasp the appropriate length of terminal ileum or colon, and great care is taken to keep this oriented while delivering it through the stoma aperture .