Iatrogenic opening in the colon communicating with the exterior, serving some or all the functions of the anus, diverting faeces and flatus to get collected in an adhesive bag.
It replaces anus as the distal opening of GI Tract.
It diverts faecal stream away from a distal anastomosis or pathology.
It serves as a vent, decompressing the colon.
It allows emergency colonic surgeries in absence of bowel preparation.
Anatomical (Based on the site)
Decompressing Venting Colostomy
For an emergency decompression of a massively distended colon Usually done for a distal obstruction
Diverts the colonic contents from a distal pathology or surgical reconstruction
Distal segment brought out as mucus fistula or left as a blind stump intraperitoneally.
Morphological Loop colostomy
A loop of colon is exteriorized and the continuity of colon is maintained usually at the posterior aspect so that small fraction of colon contents gets emptied distally.
The colon terminates as a stoma on the anterior abdominal wall.
Devine's double barrel colostomy
Modification of loop colostomy in which the last few centimeters of the afferent and efferent segments are sutured together inside the abdomen.
Complete separation of the afferent and efferent loops.
i)Mucous fistula: Venting of a transected distal segment of colon.
ii)Hartmann's colostomy: The distal stump is closed & left intraperitoneally.
iii)Perineal colostomy: Obsolete because no sphincter action and bag cannot be attached.
Temporary or permanent colostomy
Temporary: Done with an expectation of re-establishing colonic continuity. Permanent: No anticipation of re-establishing colonic continuity.
Depending upon the stoma
Stoma 1/more centimeters above skin surface
Skin level colostomy:
Follows immediate maturation of colostomy (colocutaneous sutures). A colostomy may be done on an elective or emergency basis.
Term used for exteriorization of colon.,
It usually follows injuries too large for primary suturing but not too extensive or associated with massive fecal contamination to be an indication for defunctioning colostomy.
A loop with the lesion is exteriorized followed by excision and a double barrel temporary colostomy.
Ideal requirements of a colostomy
Should have a single stoma, which passes formed stools and is sited at such a spot so as to be comfortable for application of a bag and irrigation.
Should be easy to construct and restore the continuity of bowel. Should permit definitive procedure without interference with the stoma.
Should be constructed without tension.
The paracolostomy gutter should be obliterated. The stoma viability must be confirmed.
Selection of site and type of colostomy
a)Right colon : Usually not chosen because of
Fluid contents Large diameter Ineffective (alternative Hemicolectomy)
b)Transverse colon : Good mobility due to mesocolon.
Good for loop colostomy.
c)Descending colon : Suitable for end colostomy due to semisolid contents, reduced peristalsis.
d)Sigmoid colon : Good mobility and formed tools make it suitable for both loop and end colostomy.
Type of Colostomy
If permanent then stoma site depends upon patient comfort, occupation and lifestyle.
If complete defunction required then a double barrel, spectacle or end colostomy with a mucus fistula or a Hartmann's procedure is preferred.
Operative techniques for colostomy Pre operative preparation
Emergency: On table bowel wash may be given Elective: Bowel preparation is required.
Site of stoma
2-3" below and lateral to midline from costal margins
4 cm lateral to midline at a level midway between xiphistemum and umbilicus.
2-3 inch below and lateral to the umbilicus on the spinoumbilical line
Note - In elective colostomies, the site of stoma is decided on a trial basis using an adhesive water filled colostomy bag.
Steps of surgery (loop colostomy)
After a written preinformed consent & preoperative preparation the surgery is performed under general anaesthesia with the patient in the supine position.
The abdomen is opened via a right/left paramedian incision centered at the umbilicus, and retracted with a Doyen's refractor.
The transverse colon is located by lifting the greater omentum upward and forward and is identified by its transverse course, taenia coli, transverse mesocolon, appendices epiploicae.
At the proposed site of stoma, a disc of skin and subcutaneous tissue, 2-3" in diameter is removed & the anterior sheath is opened via a cruciate incision & the incision is deepened till the peritoneum after splitting the rectus muscle fibres.
The omentum at the anterior aspect of the colon is separated and a loop of transverse colon is brought out of this gap.
An avascular window is created in the transverse mesocolon and a rubber catheter is passed around the segment with the ends clamped with a hemostat.
This loop is pulled out through the colostomy incision and the adequacy of the incision is confirmed by passing index finger in the incision-with the loop in situ.
The loop is secured on the abdomen wall by a glass or a plastic rod and seromuscular sutures to the abdominal wall fascia.
The stoma is opened immediately (or 24 hours later in Wangensteen's method) via a longitudinal incision to give a wider lumen and avoid post operative stricture) and sutured by mucocutaneous sutures (immediate maturation of colostomy)
The patency of the lumina is confirmed by passing finger in them and a colostomy bag is applied.
Abdomen is closed in layers.
The loop can also be secured to the abdominal wall by a skin bridge.
Delayed opening of stoma secures the loop by adhesions and prevents fecal contamination of the peritoneum.
Resection and the stomy can be done through same incision or separately.
The resection is done using a crushing clamp or GI stapler and the colon is brought out through the colostomy incision made earlier.
This segment is secured to the abdominal wall by seromuscular sutures to the peritoneum.
Suturing to the parietal peritoneum obliterates the lateral space besides the bowel.
The distal segment may be brought out similarly as a mucus fistula (if long) or is left inside (if short) The crushing clamp is removed with the segment of the bowel and mucocutaneous suturing is done with or without eversion of stoma & colostomy bag is applied.
Formation of stoma
Stoma flush with the skin (as mentioned above)
Everted stoma (to decrease skin contamination)
Double barrel stoma
Paul Mickuliz's method: without a spur, colonic margins sutured directly to skin incision after opening in a longitudinal axis. Paul's tube is used for drainage.
Lilienthals's artificial sphincter: Proximal end axially rotated to give a sphincter effect.
Post operative care
Immediate Care Of the patient
TPR, BP, urine output monitoring
Antibiotics, analgesics, anti-inflammatory drugs
IV fluids (5% Dextrose)
Oral sips started if peristalsis returns, flatus passed and no abdominal distention.
Semisolids started 24 hours later.
Of the stoma
Notice color change (normal-pink)
Look for edema, bleed, and purulent discharge
Local tenderness, erythema of surrounding skin
Glass rod removed on day 6.
Long term management
Of the patient
Diet: Increased roughage, fluids restricted, avoid gas forming foods (peas, tomato, onion, cream)
Bismuth kaolin mixture, Diphenoxylate to decrease frequency of stools.
Training abdominal muscles to avoid constant use of colostomy bag.
Rehabilitation in social, occupational & personal life
Of the stoma
Bag changed in first 24 hours thence on third day and weekly thereafter.
On removal of bag, the surrounding skin is washed with savlon and spirit, dried and skin protective cream is applied before reapplying the bag. LumenA5atency is always confirmed by passing a gloved finger.
Zinc-aluminum kaolin paste in petroleum base
Tincture benzoin (but may cause irritation)
Healex/stomadhesive — contains synthetic butanes (forming a layer on drying)
Application of glycerin suppository if edema
Vaseline gauze application over exposed colostomy to prevent drying.
Charcoal filter for adsorbing gas & absorbent pack for mucus.
Absorbent (gamgee) dressing if increase in output.
It is installation of fluid through stoma into colon.
Before any diagnostic or surgical procedures.
To regulate and condition the colon to evacuate at a fixed time (24-48 hourly), thus avoiding constant use of the bag.
It is useful especially for sigmoid colostomy as in transverse colostomy there is unpredictability regarding the volume & nature of output.
Started on 10th day postoperative preferably by a soma therapist.
1000-1500 ml warm water via a lubricated tube over 10-15 min and removal over 20-30 min. Colostomy bag
Ideally should be transparent, odour & leak proof, drainable (with reusable plastic clamps), flexible and wide mouthed.
It can be non disposable (India rubber, obsolete) or disposable (Polyethylene), with or without self-adhesive and skin protectors (stomadhesive or karaya gum).
May be provided with a roll-on type abdominal belt.
Applied initially diagonally to facilitate recumbent drainage.
Emptied when 2/3' full and rinsed with warm soapy water if reusable.
Guidelines for stoma formation
Avoid skin fold, scar, bony prominence, incisions, belt lines
Use rectus muscle for stoma
Stoma should be brought out straight
Avoid trimming of fat & appendices epiploicae.
Primary maturation preferred.
Place mucus fistula away from proximal colostomy.
Confirm viability of the segment before forming stoma.
Before closing a colostomy
90 days must have passed.
Patient ambulatory and in good state of nutrition.
No local / systemic infection
Pathology overcome / anastomosis secure.
Proximal & distal colograms & proctoscopy done.
Sphincter functions assessed by manometry.
Bowel cleansing done and Neomycin, Metronidazole given.
Under local/GA, with a slight head low using traction sutures a rim of skin along with the stoma is removed avoiding damage to the bowel wall, without opening the peritoneum.
If the two loops are locally approximable, then extraperitoneal closure done, with a drain in situ.
If not, then peritoneum is opened and on intraperitoneal closure is done by resection anastomosis.
Adequacy of lumen is confirmed and Lord's procedure of anal dilatation done to faciliatate drainage.
In case of a double barrel colostomy, the spur is crushed with a Paul Mickuliczs' clamp (first day = 15 min, second day = 1/2 hr, third day = 1 hr, then till it falls off).
Local abscess or fistula
Ventral hernia or peritonitis in case of intraperitorieal closure
Diarrhea (in case of ileocolic fistula) following crushing of spur
Complications of colostomy
Treatment & prevention
Diarrhoea Initially it is normal Infection -Diet, Metronidazole, Kaolin bismuth, diphenoxylate
Herniation Too large an opening, Stoma lateral to rectus - Reduce & refashion locally. Prevent by tacking sutures and using small opening
Local skin care
Stenosis -Superficial necrosis/ small opening/ischaemia
Prolapse leading to strangulation gangrene -Poor fixing of mesentery.Manual reduction. Refashion if permanent! recurrent.
Prevent by sero-muscular sutures & high opening in pelvic colon.
Skin irritation & maceration -Improper location & technique Action of contents on skin. Skin protectives; Refashion if resistant to treatment. Locate the stoma properly & evert it. ‘
Necrosis leading to stenosis & retraction - Vascular compromise to pressure, stretch or trimmingRefashion the stoma. Avoid tension & trimming while forming stoma. Confirm viability of segment.
Gangrene Vascular compromise -Conserve if mucosal. Resection & refashion if deep
Evisceration - Large opening.Reduction & Refashion
Fecal impaction - Disimpaction & r/o stenosis.
Retraction Inadequate mobilization, short mesentery
Refashion. Prevent by glass rod/catheter and seromuscular sutures to fascia.
Perforation - Administration of enema or ulceration. Laparotomy, peritoneal wash & suturing or RA & refashion.
Bleeding - Local trauma.Adjust the bag and evaluate endoscopically.
Intestinal obstruction Adhesions / primary pathology Refakion
Failure - Occlusion of afferent loop/proximal ileus Enema, glycerin, electrolyte balance
Fistula - Infection.Open & pack the fistula, Antibiotics, Refashion.
Recurrence of pathology -Refashion ,
Others types of colostomy
End loop colostomy
Two ends of transected colon brought out of the same incision and proximal opened as end colostomy and distal colon opened partially as a small mucus fistula and sutured to the proximal bowel.
Advantage: Easy to construct, one bag required, extraperitoneal closure, less bulky & distal colon can be easily studied using a contrast.
Mobilisation of the segment of colon beneath a flap of peritoneum from the site of transection to the site of stoma. Advantage: Eliminates complications like prolapse, retraction, herniation.