Perioperative management - Colostomy (sigmoidostomy), loop, laparoscopic construction

In approx. 70% of cases colostomy is performed for cancer of the colon, rectum, anus, or bladder. The stoma is either protective (e.g., to protect a vulnerable anastomosis or in planned neoadjuvant radiochemotherapy, and to protect wound healing, e.g., in decubital ulcers) or permanent (e.g., inoperable rectal cancer). Construction may be through open surgery (usually as part of the treatment of the underlying disease) or laparoscopic operation (especially before definitive surgery).

Indications include:

• Rectal cancer
• Anal cancer
• Sigmoid diverticulitis.
• Crohn disease, ulcerative colitis
• Anal fistula, anal abscess
• Injuries (e.g., impalement injuries, pelvic fractures, iatrogenic)
• Anal atresia
• Decubitus ulcer
• Neurological disease
• Fecal incontinence
• Decompression ostomy
• Protective stoma
• Rectovaginal/rectovesical fistula
• Anastomotic failure

• Ethical reasons

• Medical history, clinical examination, lab panels
• Optional: Ultrasonography (user dependent)

Image material usually available due to the underlying diseases (indication), e.g., CT or contrast-enhanced radiographs (upper GI series), MRI, rectoscopy, histopathology. Therefore, most cases do not require additional preoperative diagnostic work-up.

Preparatory measures:

• in planned surgery preoperative fasting for 6-12h (depending on anesthetist)
• possibly laxative measures for intestinal cleansing (however, fast track surgery requires only limited or no intestinal cleansing)

Colostomy site marking:

• Stoma site marking

Ideally, the stoma should be marked and the subsequent instructions for stoma care given by intrastromal therapy nurses or specially trained surgical staff.

1. Trial marking, with the patient supine or already sitting, within the left rectus abdominis in a 10×10cm skin area, preferably without folds and creases, scars and bony prominences.
2. Evaluating the planned site with the patient supine, standing and stooping.
3. The selected site should be easily accessible to the patient and within his/her visual field and away from the natural beltline.
4. To allow for intraoperative complications marking a secondary location is recommended.
5. Dressing the markings with sensitive skin bandages.

The site of the ileostomy deeply affects its management and thus the patient’s quality of life!

Discuss with the patient the indication and actual construction of the stoma (permanent or temporary? Conventional or laparoscopic construction?), subsequent stoma care (initially in hospital, later at home) as well as psychosocial factors. (How do I live with a stoma? What do I have to consider in the future? Nutritional advice, if necessary)

General complications:

•     General surgical risks (bleeding, secondary bleeding, thrombosis, embolism, HIT)
•     In case of intraoperative complications possibly conversion to open technique
•     Skin emphysema
•     Postlaparoscopic shoulder pain syndrome
•     Secondary healing
•     Postoperative ileus
•     Adhesions

Special complications:

Stoma complications are common and in part may arise from avoidable technical deficiencies, e.g., inadequate blood supply, tension on the stoma, excessively narrow abdominal wall trephine, and poor choice of stoma site. But even in correct construction, complications cannot always be prevented:

•     Peristomal hernia
•     Prolapse
•     Stricture
•     Fistula
•     Retraction (below skin level)
•     Peristomal inflammation