GenSurg.nz

Stoma

Section: Colorectal Sub-section: Other Curriculum: Curriculum, page 25

Stomal complications

  • Early
    • Retraction
      • If full mucocutaneous seperation then revision is required immediately
    • Necrosis
    • Bleeding
  • Late
    • Peristomal skin issues
      • Issues
        • Erythema
        • Wet
        • Breakdown and ulceration
        • Granulation tissue
          • Bleed → apply silver nitrate
      • Management
        • Check fit and no leak
        • Use barrier film to coat and protect the skin
        • Stoma powder
    • Prolapse
    • Hernia
    • Bleeding
    • Retraction
    • Stenosis
    • Peristomal pyoderma gangrenosum

Difficult ileostomy

  • Metabolic problems
    • Sodium depletion
      • Can then get drop in potassium in attempt to preserve sodium by producing aldosterone
      • Sodium depletion if Urinary Na:K <1 (usually about 2)
    • Volume
      • Usually settles within 2 weeks of operation
      • Related to body weight
        • 70kg 500mL
        • 100kg 900mL
      • Same applies to pouches
  • Ileostomy/pouch dysfunction
    • Definition

      • 8 emptying’s/evacuations/ day

      • Relative to weight
    • Etiology
      • Ileal resection
      • Partial obstruction – active sodium secretion
      • Intra-abdominal sepsis
      • Crohn’s
      • Foods – beans, leafy green vegetables, beer, coffee, chocolate, spicy food, too much fiber, alcohol
      • Investigation
        • Urinary Na:K
        • Rule out infection
        • Rule out major causes
        • Rule out dietary factors
    • Treatment
      • Loperamide
      • Sodium – IL ileostomy fluid = 1 teaspoon salt
      • Pouches - isogel

Parastomal hernia

  • Incisional hernia related to an abdominal wall ostomy site
  • Incidence
    • 5-10% of colostomies
    • 3-10% of ileostomies
    • ≈10-20% require repair

Classification

  • Devlin Classification
    • Subcutaneous - hernia sac lies in subcutaneous plane
    • Interstitial - hernia sac lies within the layers of the abdominal wall
    • Intrastomal - sac penetrates the spout of an ileostomy
    • Peristomal prolapse - where the sac is within a prolapsing stoma
  •  European Hernia Society (EHS) classification

Etiology

  • Only true risk factor is BMI > 30
    • Risk factor most supported by evidence
  • Patient specific
    • Age
    • Wound infection
    • Chronic increased abdo pressure, COPD
    • Obesity, weight gain (or malnutrition)
    • Steroids/immunosuppression
    • Malignancy
    • IBD
  • Technical Factors
    • Emergency stoma
    • Surgical technique
    • Abdominal wall strength

Clinical

  • Generally asymptomatic
  • May present with difficulty placing stoma appliance
  • Pain – usually mind
  • +/- obstructive Sx

Management

  • Indications for repair:
    • Difficulty with stoma appliance – unable to see or fit
    • Recurrent obstruction
    • Skin breakdown
    • Strangulation
    • +/- cosmetic
  • Options:
    • Rejoin
    • Resite
    • Repair

Overview

  • Primary vs. Mesh
    • Primary
      • Technically simple
      • Avoids manipulation of intra-abdo contents
      • Has low morbidity
      • BUT has high recurrence rate
      • Significantly higher than mesh repair (OR 8.9)
    • Mesh
      • Complications rare but difficult to manage, include
        • Contamination
        • Erosion
        • Fistula formation
      • Usually preferred technique, may be some instances where primary repair is better
  • Open vs Lap
    • Not enough data to go other way
    • May have presumed lower morbidity and possibly improved outcomes
    • Best considered in patients without extensive intra-abdominal adhesions
    • Also better for smaller (%3C 8-12cm) hernias
  • Onlay vs Sublay
    • Onlay
      • Technically more straightforward
      • Avoids intra-abdo dissection
      • Higher risk wound infection
    • Sublay
      • Increased intra-abdo dissection
      • Increases risk for adhesions and intestinal obstruction
      • Associated with fewer recurrences
      • Intra-abdo pressure cannot dissociate mesh from the repair

Techniques

Primary Repair

  • Reduce the size of the facial defect by re-approximating the fascial edges with permanent sutures
  • Approach generally avoided because of the physics of parastomal hernia and nature of the defect
  • Unavoidable to cause tension on the repair
  • Leads to high recurrence rates

Onlay Mesh Repair

  • Incision made well away from stoma (typically in the midline)
  • Subcutaneous dissection along rectus and oblique fascia
  • Circumferentially around stoma
  • Hernia reduced
  • Abdo wall closed using tension free mesh repair
  • Note risk ischaemic injury to the skin

Sublay Mesh Repair

  • Less infection risk
  • Entails large dissection

Intra-abdominal Mesh Repair

  • Reduce hernia contents and close facial defect with mesh under the defect, and wide overlap

Sugarbaker

Keyhole

Parastomal Hernia-Contemporary Management, page 1 Parastomal Hernia Repair, page 1 Pauli, page 1

Prognosis / Natural Hx:

  • Most hernias develop within first few years of stoma formation
  • Mesh repair may lead to strictures (1/36 pts)

Stoma Siting Procedure

  • Determination of optimal site; assessed in a lying, sitting and standing position
  • Key Points
    • Positioning issues: contractures, posture, mobility e.g. wheelchair confinement, use of walker etc.
    • Physical considerations: large/protruding/pendulous abdomen, abdominal folds, wrinkles, scars/suture lines, other stomas, rectus muscle, waist line, iliac crest, braces, pendulous breasts, vision, dexterity, presence of hernia.
    • Patient considerations: Diagnosis, history of radiation, age, occupation
    • other: Surgeon and patient preference, type of ostomy or diversion, anticipated stool consistency.
    • Multiple stoma sites: Mark fecal and urinary stomas on different horizontal planes/lines. Procedure:
  1. Marking pen, surgical marker, transparent film dressing, flat skin barrier
  2. Carefully examine abdominal surface. Begin with patient fully clothed in sitting position with feet on floor. Observe the presence of belts, braces and any other ostomy appliances.
  3. Examine patient’s exposed abdomen in various positions (standing, lying, sitting and bending forward) to observe for creases, valleys, scars, folds, skin turgor and contour.
  4. Draw an imaginary line where the surgical incision is going to be. Choose a point approximately 2 inches from the surgical incision where 2 – 3 inches of flat adhesive barrier can be placed.
  5. With patient lying on back identify the rectus muscle. (This can be done having the patient do a modified sit up (raise the head up off the bed). Placement within the rectus muscle can help to prevent peristomal hernia formation and/or prolapse.
  6. Choose an area that is visible to the patient, and if possible below the belt line to conceal the pouch.
  7. Large abdomen; choose the apex of the mound or in extremely obese, place in the upper abdominal quadrants.
  8. It may be desirable to mark sites on the right and left sides of the abdomen to prepare for a change in the surgical outcome.
  9. Clean the desired site with alcohol and allow to dry. Then proceed with marking the selected site with a surgical marker / pen. You may cover with transparent film dressing if desired to preserve the mark.
  10. Once marked have the patient assume sitting, bending and lying position to assess and confirm best choice. It is important to have the patient confirm they can see the site.

Graph View

Backlinks