Comment on stoma

Stoma Examination comment on type of surgerythatthepl had undergone

Surgical seer Midline

Inspection eg laparotomy

Stoma drainage bag content

vapour

Stoma sprouted I flushed

pink I ischemia bluish or edematous

prolapse refraition

Surrounding skin f base skin excoriation

parastomal hernia
fistula
press
I

mulocutaneous separation abscess

Palpation Surrounding tenderness parastomal abscess

Weargloves tell examiner that want to open the baseplate

you

usually examiner will say no need just proceed

4 if open it's transparent stomabag comment

Lumen patency needto insert index fingertofeel
guns

j Number of
Typeof stoma
content bleeding Skin extoriation

EndthePEwith Full Git examination

Suspect and

opening

branches

g 3

I J
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Stoma examination (by Dr Ikhwan Sani)

1. Stoma examination

● Part of abdominal examination

● Position: supine position

● Exposure: supposed to be from nipple to knee, but for patient’s

modesty, I expose from xiphisternum to pubic symphysis

● Inspection (bag → content → stoma → skin)

● Drainage bag located at left lower quadrant of the abdomen

● The drainage bag is transparent and I can see a stoma behind

the drainage bag

● The drainage bag is not transparent so I could not know

the content. Will confirm by palpation later

● Content of drainage consists of faecal matter which is semi-solid

● Yellowish effluent usually for ileostomy

● Semi-solid faeces for colostomy

● Stoma bag is distended with gas & vapour is seen

● And I can see a single lumen stoma on my inspection

● The stoma is created flush with the skin (flat and even with

the skin)

● Presence of a spout or flush with the skin

● Spout = ileostomy

● Stoma flush with the skin = colostomy

● Stoma looks healthy, pink, dark=gangrene, pale=ischemia

● No prolapse, no retraction of stoma

● No bleeding point

● No skin excoriation seen around the stoma

● No scar on the abdomen

● Wear gloves, prepare gauze and yellow bag, open the drainage bag

● After I opened the bag,

● Content of drainage bag

● I see a single lumen stoma created flushed to the skin

● Stoma looks healthy, pink, no gangrene

● No bleeding point

● No skin excoriation seen around the stoma

● Ask patient to cough

● Look for parastomal hernia

● 2 types of parastomal hernia: revealed and concealed

● Revealed hernia is protruded even without coughing

● Concealed hernia is expulsion seen on coughing

● Palpation

● (from outside to inside - less contaminate the skin with stoma

content)
● Pak cik ade rase sakit mane mane?

● Palpate the skin around the stoma with two fingers for
tenderness (infection parastomal abscess)


● Palpate the stoma to see contact bleeding
● Put gel and insert little fingers into the lumen to confirm whether

is a single or double lumen stoma

● If 2 lumen try to separate them

● If cannot be separated, it is a loop stoma

● if able to be separated, it is a double barrel stoma

● Any stenosis

● Auscultation

● For bowel sound on the abdomen as the evident of functioning

stoma (+ drainage bag content)

● Complete the examination with

● Digital rectal examination

● If end colostomy for post-APR: absence of anus

● If Hartmann procedure: anus still patent

● If paediatric patient: assess anal tone (Hirschsprung

disease) and anal patency (imperforate anus)

● Look at urine I/O chart, BUSE

● To detect fluid electrolyte imbalance

2. What is a stoma?

● Stoma is a surgically created opening that connects a hollow organ to

another hollow organ or a hollow organ to the external environment

3. Not only for drainage and diverting, stoma can also be an input port eg

feeding jejunostomy and tracheostomy

4. How to classify stoma?

● According to the location (stoma is created on a mobile part of the

bowel)

● Left lower quadrant - sigmoid colostomy

● Right upper quadrant - proximal transverse colostomy

● Right lower quadrant - cecostomy (rarely done nowadays due to

high complication such as perforation)

● Right lumbar or iliac fossa - ileostomy

● According to design
● End colostomy

● Double barrel colostomy

● Loop colostomy

● Based on function

● Temporary
● Double barrel colostomy

● Loop colostomy

● Permanent

● Usually end colostomy


5. Cecum, transverse colon and sigmoid colon are mobile so suitable to have
stoma

● Ascending and descending colon are not suitable because they are

fixed to the posterior abdominal wall by lateral peritoneal fold /

paracolic gutter / Todt fascia

6. If a stoma located at left iliac fossa, but spouting of mucosa, with a laparotomy
scar?

● Think ileostomy! Because patient may have adhesions

post-laparotomy, causing difficulty to bring out and create the ileostomy

on RIF, thus mobilise the bowel and do it on LIF

7. Why is transverse colostomy done in the Right hypochondriac region?

● Colostomy is anchoring by hepatic flexure

● Can prevent stoma prolapse

● Less impact of peristaltic movement as the distance from stoma to the

flexure is short

● The longer the distance, the higher risk of stoma prolapse

8. Criteria of location to bring out the stoma

● Able to be seen and easily accessible by patient especially in obese

patient - mark stoma site on patient lying and standing

● Unless nephrostomy at the back

● Away from bony prominence - ASIS

● Away from waist line or belt area in male

● Avoid skin crease

● Avoid surgical scar - risk of wound contamination + infection

● Away from old surgical scars - risk of hernia

● Must have enough bowel mobilisation - to prevent tension over the

stoma which leads to decreased vascularity and finally stoma necrosis

9. Indicators of a functioning stoma

● Abdomen not distended - no intestinal obstruction

● Presence of vapour / distended with gas

● Content drained out into the bag

● Bowel sound present

10. Indications of stoma

● Temporary

● Emergency procedure (Eg: Hartmann’s procedure done in the

case of Rectosigmoid Ca presented with intestinal obstruction)

● Defunctioning a distal anastomosis aka Covering stoma (Eg:

Trephine transverse loop colostomy done after left

hemicolectomy+primary end to end anastomosis in the case of

colorectal Ca)

● Defunctioning an inflamed sigmoid in diverticular disease /

Crohn disease (Eg: Trephine transverse loop colostomy)


A loop of colon is brought to the surface of the body and may be supported by a rod

which is removed after about 5 days. The bowel wall is partially cut to produce 2
openings (afferent and efferent limb). The afferent limb leads to functioning part of

the colon (which stool and gas pass out) and the efferent limb leads to
non-functioning part of the colon.

● Defunctioning the rectum or anus (Eg: Loop sigmoid colostomy

was currently done in the case of rectal cancer/

incontinence/perianal abscess/pelvic fracture)

● Diversion (Eg: in acute IO due to advanced rectal Ca, trephine

sigmoid colostomy done to divert faeces and relief bowel

obstruction, then arrange patient for radiotherapy to shrink

tumours, then only subject patient for surgery)

**Trephine colostomy is a type of loop colostomy without laparoscopy or open

laparotomy. It is a minimally invasive procedure done only in emergency situations.

Commonly created as proximal trephine transverse colostomy or trephine sigmoid

colostomy.

**Ileo-colic anastomosis usually won’t need covering stoma because small bowel
has rich blood supply → faster healing → less risk of anastomotic risk. However,

anastomosis btw large bowel usually needs covering stoma because large bowel

has poor blood supply.

● Permanent

● End colostomy (after Abdominal Perineal Resection follows

rectal Ca or anal Ca)

● End Ileostomy (after panproctocolectomy follows Familial

Adenomatous Polyposis)

11. Common causes of stoma

● Paediatrics: (All are temporary)

● Hirschsprung disease

● Short segment rectosigmoid 80%

● Long segment 10%

● Total colonic 5%

● Total colonic with small bowel involvement 2%

● Necrotizing enterocolitis

● Imperforate anus

● Anorectal swelling - trauma

● Worry of soiling - diversion to promote healing

● TB colitis lead to TB peritonitis as anastomosis cannot be done

immediately

● Adult

● Hartmann procedure
● IO to divert faeces

● Covering stoma to rest bowel after dissection (defunctioning)

● Perineal injury - perianal abscess, severe pelvic fractures


● Permanent stoma
● APR

● Rehabilitation patient

● Advanced ca
● Immobilize patient

12. Complications of stoma

● Early complication

● Stoma gangrene

● due to poor blood supply

● Parastomal abscess

● Stenosed stoma

● Due to inadequate cutting on the rectus sheath

● Skin excoriation due to digestive enzyme

● Treat with zinc oxide and frequent dressing

● Late complication

● Prolapsed stoma (> 4cm protrusion from skin)

● Retracted stoma

● Parastomal hernia

● Disuse atrophy of distal part of stoma

● Distal lumen became smaller

● Due to faecal diversion

13. Presence of midline laparotomy scar + single lumen stoma, how to

differentiate it is a Hartmann procedure or abdominal perineal resection?

● Inspect the anus

● Closed anus → Abdominoperineal excision

● Patent anus → Hartmann

14. In bowel resection, when can we anastomose immediately without a

defunctioning stoma?
● For colocolic anastomosis, a covering/defunctioning stoma is done

● As blood supply in large intestine is not as good as in small

intestine
● So give time for healing

● Loopogram done to look at anastomotic site

● See any stricture

● If healthy, then can close back / reverse the stoma

● For ileocolic anastomosis, then no need a covering stoma