DefinitionGreek: ‘mouth’Stoma =  an artificial opening in the abdominal wall, which connects a hollow viscus(bowel, urinary tract) to the outside environment/ to divert faeces or urine to the exterior which is collected in an external appliance.Natural openings: Nostrils, mouth, anus.Intestinal stoma = opening of the intestinal tract onto abdominal wallViscus:  large interior organ in any of the great body cavities, especially those in the abdomen.

STOMA

Types of stoma•Duration (Temporary or Permanent )•Anatomical location:

•CNS: ventriculostomy•Respiratory: tracheostomy•GIT: ileostomy, colostomy

•Reconstruction: End Loop Double Barrel(Mickulicz) Bishop-Koop(distal ileostomy with end to

side ileas anatomosis) Santulli(proximal ileostomy with end-to-side

anastomosis)

Permanent stoma

● Necessary when there is no distal bowel segment remaining after resection or when for some reason the bowel cannot be re-joined

● Usually below the belt line● Permanent colostomy: left

iliac fossa (LIF)● Permanent ileostomy: right

iliac fossa(RIF)

Temporary stoma

• Relieve complete distal large bowel obstruction causing proximal dilatation

Indication of Stoma1. Feeding

– Percutaneous endoscopic gastrostmoy (PEG)

2. Lavage– Appendectomy

3. Decompression4. Diversion

– Protection/defunction of distal bowel anastomosis● Previous contaminated bowel● Iliorectal anastomosis

– Urinary diversion following cytectomy

5. Exteriorization – Perforated or contaminated bowel (distal abscess or fistula)– Permanent stoma (APR of rectum)

Site of abdominal Stoma

● Preparation of patient undergoing Stoma

1. Psychosocial and physical preparation2. Explanation if indication and complication3. Request help of Clinical Nurse Specialist in

Stoma care pre-operatively, who will mark the site.

4. Marking the stoma site (Pt standing up)– Pt able to see the stoma well– 5 cm from the umbilicus (spino-umbilical line away from all

bony prominence)– Away from scar & skin creases– Away from bony points or waistline of clothes– Easily accessible to Pt (not under a large fold of fat)

5. The stoma within rectus abdominis sheath

● Examination of Stoma● Inspection1. Site2. Types of stoma3. Surrounding skin4. Covering of surrounding

skin5. Loop6. Stoma functioning7. Stoma discharge

– Colour– Type– Amaount

● Palpation1. General abdominal

palpation2. Stoma?

● Percussion– Shifting dullness

● Auscultation– Bowel sound

● End examination– PR exam

● Complication of Stoma● General(d/t u/l dz)

– Stoma diarrhea● Water&electrolyte

imbalance● Hypokalemia

– Nutritional disorders– Stones

● Gallstone● Renal stone

– Psychosexual– Residual disease

● Crohn’s disease● Parastomal fistula

● Specific – Skin excoriation– Prolapse/gangrene/

necrosis of distal end– Bleeding– Retraction– Parastomal hernia– Fistula formation– Stenosis of orifice

● Cause constipation

1.Local: skin excoriation, dermatitis, candidiatis, ischaemia,

2.Structural: retracted, prolapse, stenosis, parastomal hernia (support corset)

3.Systemic:dehydration,electrolyte imbalance, malabsorption

INTESTINAL STOMA

PERMANENT1. End colostomy2. End ileostomy3. Hartsmann’s

procedure(End colostomy + rectal stump)

TEMPORARY1. Loop transverse

colostomy• emergency

procedure: large bowel obstruction

• defunctioning stoma• bowel rest: pericolic

abscess, anorectal fistula

ILEOSTOMYessential in the management of neonates with certain types of distal intestinal obstructione.g: long segment Hirschsprung disease, complex meconium ileus, gastroschisis with atresiaIleostomies are commonly placed to divert bowel contents in neonatal necrotizing enterocolitis, ulcerative colitis, familial polyposis

Ileostomy effluent:Liquid.Contains activated digestive enzymes.Discharged almost continuously.Appearance: sprout of mucosa

-Elevate the ileostomy opening 2-3 cm from skin to ensure the effluent passes directly into a stoma bag with minimal contact with skin.-Ileum is exerted on itself to form a spout.

End Ileostomy

Loop Ileostomy

ColostomyA colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the exterior, where it can be collected in an external applianceIndication :

Imperforate anus, Hirschsprung disease, Abdomino-perineal resection of a low rectal anal canal tumour diverticular disease.

Colostomy

By anatomy :•Transverse colostomy•Descending colostomy•Sigmoid colostomy

By function :•Decompressing•Diversion

By construction :• End• Loop• Double barrel

COLOSTOMY●Type:

Temporary (loop colostomy) Permanent (end colostomy)

●Indications: Diverticular disease Colorectal cancer

●Appearance: Flush with the skin (#) Mucosa sutured to skin

●Location: Permanent at LIF Temporary at LIF or right hypochondrium

●Effluent: intermittent and solid

Colostomies are sutured flush with skin.Allowed to pout slightly to prevent retraction after weight gain

End Colostomy

Double-barrel colostomyWhen creating a double-barrel colostomy, the surgeon divides the bowel completely.(2 stoma besides each other and separate from each other)Each opening is brought to the surface as a separate stomaProximal-end = end stoma (secrets stool), needs a drainage bag.Distal-end= mucous fistula (secretes mucus)Temporary stoma

Hartmann’s Procedure

Surgical diversion of urinary system Done for baldder Ca, urinary incontinence and neuropathic bladdersFormation of urostomy

Needs ileal conduit, a segment of viable ileum mad like a tube where 1 end is open (used as stoma) and another end is closed( used as reserve). Ureters are implanted into this isolated segment of small bowel tubeThe open-end of conduit is everted to create a similar spout as ileostomy and allows diversion of urine from kidneys to outside the abdomen and collected by stoma bag

Urostomy

Loop stoma – temporary stoma

VASCULAR COMPROMISE● Ischaemia due to operative tissue trauma● Intestinal necrosis due to ligation of arterial

supply/inadequate collateral arterial circulation● Venous outflow obstruction > venous

congestion >necrosis of stoma

Stoma careParents, as well as older children, must be carefully taught and reassured before leaving the hospital and on subsequent follow-up visits.Properly fitted appliances should remain in situ for several days (change every 3 days).There are two basic types of pediatric appliances:

the one-piece pouching system in which the adhesive skin barrier is already attached to the pouch

the two-piece system in which the adhesive skin barrier is separate from the pouch.

Candidiasis remains a common problem in the parastomal skin, and local antifungal medication should be used at the earliest sign of irritation.With skin excoriation, the area is exposed to air and a synthetic barrier is applied. A hairdryer can be useful.application of silver nitrate may be necessary to control granulation tissue around the mucosa-skin interface in the early stages.

Colostomy bags and appliances