The Difficult Stoma



The Difficult Stoma


Hermann Kessler

Mariane G. M. Camargo



Risk Factors for the Difficult Stoma


Preoperative Variables

Preexisting conditions at surgery that cannot be influenced and associated with difficult ostomy placement are as follows:



  • High body mass index


  • Old age


  • Emergency surgery


  • Inflammatory bowel disease (IBD)


  • Previous abdominal scars or incisions


  • Abdominal wall hernias


  • Skin problems


Operative Variables Encountered during Surgery

Variables encountered during surgery that affect the available length of bowel and reach of mesentery to allow for a tension-free stoma creation and sufficient blood supply or perfusion:



  • Obesity


  • Large pannus


  • Foreshortened or thickened mesentery secondary to inflammation


  • Mesenteric fibrosis


  • Short bowel syndrome


  • IBD

Special factors aggravating exteriorization of the ostomy are as follows:



  • Peritoneal adhesions from previous extensive abdominal surgery


  • Carcinomatosis


  • Desmoid tumors


Ostomy Siting



  • Always mark the patient preoperatively, even in the holding area or emergency room (see Fig. 44-1).


  • Rely on the help of enterostomal therapist.


  • When talking to the patient, recognize the impact on their quality of life, answer questions, and provide education about stoma care and alleviate fears.


  • Ideal preoperative siting:



    • 5 cm of flat skin: keeps flat even with position change. This will prevent leakage and pouching problems.







      FIGURE 44-1 ▪ The “stoma triangle”: Umbilicus, anterosuperior iliac spine, and pubic symphysis.


    • Marking should begin with identification of the “ostomy triangle” bounded by the anterior superior iliac spine, the pubic tubercle, and the umbilicus (Fig. 44-1). The stoma is placed at the center of this triangle on either side, through the rectus muscle.


    • Traditionally, an ileostomy is placed on the right side and a colostomy on the left. However, if “conventional” placement leads to stoma tension, the surgeon may need to choose an alternate site.


  • Siting method:



    • Start supine.


    • Raise head or cough help to identify rectus muscle.


    • Identify creases: sit, bend over, or stand.


    • Identify belt line and where pants lay.


    • Confirm that the patient has the ability to see and touch the stoma.


  • Special circumstances:



    • Disabled: mark in position they spend majority of time.


    • Brace: mark with brace on.


    • Radiation: avoid prior or future radiation fields.


    • Two stomas: site at different levels (ileal conduit higher than colostomy).


    • Burns: may not be able to wear belt/protective garment


Perioperative Considerations


Patient Positioning



  • Patient is generally in modified lithotomy position.


  • Endoscopic access to bowel should be available.


  • Intraoperatively, a decision may be necessary to use a different bowel segment for ostomy creation.


  • Often, the open approach is indicated (previous abdominal surgeries, adhesions, friable tissue, comorbidity, insufficient overview expected).


Equipment and Supplies



  • Laparoscopy:



    • Video instrumentation: video camera unit, 5-mm 30-degree laparoscope, a light source, monitoring and recording devices


    • A gas insufflator


    • A suction and irrigation device



    • A laparoscopic 5-mm dissecting device


    • Adequate sterilizing and disinfecting devices


    • Electrocautery


    • Kocher clamp


    • Right-angle retractors


    • 12-mm Hasson balloon trocar


    • Three 5-mm trocars


    • Laparoscopic scissors


    • Laparoscopic 5-mm Babcock clamp


    • 5-mm Maryland dissector


    • 5-mm bowel grasper


    • Plastic rod for loop ostomies


    • 3-0 absorbable braided sutures


    • Potential instruments: 10-mm trocar, laparoscopic staples, laparoscopic biopsy forceps


    • Colonoscope should be present in operating room.


  • For open surgery, a consolidation set for colorectal surgery has all the needed instruments for the stoma construction.


Abdominal Wall Defects



  • There may be no surgical solution for the best-eligible spot of stoma creation.


  • A multidisciplinary team with a hernia specialist and/or plastic surgeon for abdominal wall reconstruction may be helpful.


Obesity

Special challenges:



  • Copious subcutaneous tissue of thick abdominal wall: This makes it difficult to pass stoma through.


  • Distance that bowel needs to traverse can increase if local area changes position with ambulation.


  • Obese mesentery and large omentum contribute to difficult stoma exteriorization.


  • Higher risk of postoperative complications


  • Higher risk of stoma-related complications (Fig. 44-2)






FIGURE 44-2 ▪ Obese patients with retracted stoma.


Tips for Obese Patients



  • If an elective ostomy creation can be deferred in an obese patient, weight-loss surgery to be considered.


  • Separate fat from fascia and then pass ostomy in two steps (open surgery).


  • Subcutaneous lipectomy


  • Ellipse of skin and subcutaneous tissue removal


  • Abdominal wall modification:



    • Modified abdominoplasty or abdominal wall contouring


    • Liposuction



  • Use an upper quadrant of the abdomen as a stoma site (Fig. 44-3A and B): subcutaneous tissue is thinner and anchored to the costal margins, reducing shifting and mobility of thick subcutaneous tissue with ambulation; distance between vascular origins and the proposed stoma site is usually shorter, providing better arterial supply.


  • Avoid placing the stoma in a large fold (Fig. 44-3C).






FIGURE 44-3 ▪ A. Upper quadrant siting of the stoma in an obese patient; (B and C) it is important to identify the line of sight, because patient cannot see below it, and identify creases and folds. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)



Shortened Mesentery

The shortened mesentery is often a result of fibrosis, adhesions, or inflammation and can be further complicated by fragility of soft tissue and bowel itself, often resulting in challenges with reach. Examples include:



  • Patients with central obesity


  • Patients with a history of desmoid tumors


  • IBD


  • Previous laparotomies


  • Previous peritonitis


  • Prior external beam radiotherapy


  • Previous history of bowel resection: intestinal ischemia, necrotizing enterocolitis, omphalocele, or gastroschisis


ILEOSTOMY


Technique



  • Maximizing the mesenteric length:



    • Division of the terminal ileum as close to the cecum as possible.


    • Ligation of the ileocolic artery at its origin, vascular supply via preserved collaterals of mesoileum (Fig. 44-4).






      FIGURE 44-4 ▪ Ligation of the ileocolic artery at its origin. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)


    • Dissection of the base of the small bowel mesentery to the third portion of the duodenum.


    • Creation of windows in the small bowel mesentery overlying the superior mesenteric artery (first, inject the mesentery with saline to lessen the chance of injuring the main feeding vessel) (Fig. 44-5).







      FIGURE 44-5 ▪ Creation of windows in the small bowel mesentery overlying the superior mesenteric artery. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)


    • Division of the immediate peristomal mesentery for 5 cm or less.


  • Rectus abdominis muscle-splitting incision (˜3 cm aperture).


  • Suture cut edge of the ileum to the dermis and not the epidermis, to prevent mucosal implants (2.5-cm spout for easy pouching) (Fig. 44-6).






    FIGURE 44-6 ▪ Intestinal mucosal implants along parastomal needle tracks—to be avoided.


  • Creation of an end-loop ileostomy (when the intestinal segment providing the best reach is located proximally to the proposed end ostomy site) (Fig. 44-7).







    FIGURE 44-7 ▪ Creation of an end-loop ileostomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)


  • Creation of a loop-end ileostomy in discontinuity (Fig. 44-8) (when an everted loop ostomy cannot be created when the proposed segment will not reach the anterior abdominal wall without undue tension despite freeing of the small intestine mesentery to the duodenum). The distal corner end may be matured out the inferior aspect (Fig. 44-8A) or divided and placed in or under the fascia (Fig. 44-8B).






    FIGURE 44-8 ▪ A and B. Creation of a loop-end ileostomy. The afferent limb is brought to the skin as an end ileostomy after dividing the mesentery at an appropriate distance. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)


  • Elongated division of the anterior rectus fascia, rectus muscle, and posterior sheath to minimize the risk of vascular compression (Fig. 44-9).







    FIGURE 44-9 ▪ An 8- to 10-cm incision is placed through the peritoneum and posterior fascia. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)


  • An extra-small wound protector can be used as a delivery device, facilitating passage.


  • A long, flexible mesenteric support rod, which can be attached to a ureteric filiform catheter, may be used for mechanical support (severe obesity, carcinomatosis, dense adhesions that prevent adequate mobilization, or in cases of extensive bowel resection) (Fig. 44-10).






FIGURE 44-10 ▪ A. A long mesenteric support rod is inserted through the skin away from the ostomy, (B) passing through the subcutaneous tissues as well as the mesentery and again back to the skin. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)


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Apr 13, 2020 | Posted by in GASTOINESTINAL SURGERY | Comments Off on The Difficult Stoma

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