Perioperative management - Colostomy (sigmoidostomy) creation, double-barreled, laparoscopic

The indication for colostomy placement is made in approximately 70% of cases due to malignant tumors of the colon, rectum, anus, or bladder. The placement is either protective (e.g., to spare a vulnerable anastomosis or in planned neoadjuvant radiochemotherapy, as well as to protect wound healing, e.g., in pressure ulcers) or definitive (e.g., in inoperable rectal carcinoma). The placement can be performed conventionally open (usually as part of the treatment of the underlying disease) or laparoscopically (especially before definitive operations).

Indications include:

• Rectal carcinoma
• Anal carcinoma
• Sigmoid diverticulitis
• Crohn's disease, ulcerative colitis
• Anal fistulas, anal abscesses
• Injuries (e.g., impalement injuries, pelvic fractures, iatrogenic)
• Anal atresia
• Pressure ulcer
• Neurological diseases
• Fecal incontinence
• Decompression stoma
• Protective stoma
• Rectovaginal-vesical fistula
• Anastomotic insufficiency

For a colonic stoma, any part of the colon can be used in principle, with the transverse colon and sigmoid colon being most commonly advanced.

Optimal is the transrectal placement in the lower abdomen above the arcuate line. The superior muscular and fascial support at this site is intended to prevent the development of a parastomal hernia or prolapse.

Due to anatomical proximity, the placement of a transverse colostomy is recommended in the upper abdomen, and for ileostomy and sigmoidostomy, placement in the lower abdomen is recommended.

Special situation of protective stoma in colorectal carcinoma:

In low anterior resection with TME, a protective stoma is generally indicated, with an ileostomy being preferable to a colostomy. An ileostomy is easier and less complicated to reverse. Parastomal hernias and stoma prolapses occur less frequently. However, fluid loss syndrome occurs much less frequently with a colostomy, and obstruction problems after reversal are also less common.

Ethical reasons

• Medical history, clinical examination, laboratory
• Optional: Sonography (dependent on the examiner)

Imaging usually available due to underlying conditions (indication), e.g., CT or contrast X-ray (gastrointestinal passage), MRI, rectoscopy, histology. Therefore, additional preoperative diagnostics are usually not required.

Preparatory Measures:

6-12 hours preoperative fasting for planned procedures (anesthesia-dependent)

Possibly laxative measures for bowel cleansing

Perioperatively, a single-shot antibiotic, e.g., with a 2nd generation cephalosporin, is advisable.

Marking of the colostomy: Stoma marking

Ideally, the marking and subsequent instruction for stoma care should be carried out by specially trained stoma therapists or surgical staff specifically trained for this purpose.

1. Trial marking on the lying or already seated patient in the area of the rectus abdominis muscle in a 10 × 10 cm skin area, preferably without folds, scars, or bony prominences.
2. Verification of the intended position in motion (standing, bending).
3. The chosen site should be easily visible and accessible to the patient; the position of the waistband and belt should also be considered.
4. Determination of an alternative marking is recommended in case of intraoperative complications.
5. Covering the marking with a skin-friendly adhesive tape.

The position of the stoma significantly influences handling and care, and thus the patient's quality of life!

The indication, the procedure of stoma creation (permanent or temporary? Planned conventional or laparoscopic creation?), the further care of the stoma (initially in the hospital, later at home), as well as psycho-social factors should be discussed with the patient. (How do I live with an ostomy? What should be considered in the future? if necessary, nutritional counseling.)

General complications:

• General surgical risks (bleeding, rebleeding, thrombosis, embolism, HIT)
• if necessary, conversion to open technique in case of intraoperative complications
• Subcutaneous emphysema
• Post-laparoscopic shoulder pain syndrome
• Wound healing disorder
• Postoperative ileus
• Adhesions

Specific complications:
Stoma complications are overall common and often result from avoidable technical inadequacies such as circulatory disorders, lack of tension-free placement, or too narrow stoma canal and incorrect positioning. However, even with proper placement, complications are unavoidable:

• Parastomal hernia
• Stoma prolapse
• Stenosis of the stoma
• Stoma fistula
• Retraction (recession below skin level)
• Peristomal inflammation

The procedure is performed under intubation anesthesia.

The following points should be differentiated:

• Ascending stoma/Transverse stoma/Descending stoma/Sigmoid stoma
• Permanent vs. temporary stoma
• Open or laparoscopic placement

Depending on the indication, surgical technique, and required side, positioning is either supine with arms positioned alongside or with the arm on the side of the colostomy extended.

The following points must be differentiated:

• Ascending stoma/Transverse stoma/Descending stoma/Sigmoid stoma
• Permanent vs. temporary stoma

Depending on the indication, surgical technique, and required side, the OR setup is as follows:

Laparoscopic setup

• Surgeon and assistant on the opposite side (!)
• Scrub nurse on the side of the planned stoma placement
• Laparoscopy tower opposite the surgeon.

Open setup

• Surgeon on the side of the planned stoma placement
• Assistant on the opposite side
• Scrub nurse on the side of the surgeon

For laparoscopic procedures:

• Laparoscopic tower
• Trocars

For open procedures:

• standard retraction systems

Postoperative Analgesia:

Adequate pain management (e.g., alternating Metamizole and Ibuprofen three times daily, with an additional morphine analog like Targin twice daily for more severe pain). Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management). Follow the link to the current guideline Treatment of Acute Perioperative and Post-Traumatic Pain.

Medical Follow-up:

If the surgical site or subcutaneous tissue is contaminated with stool, continuation of antibiotics may be recommended.

Professional postoperative guidance and adequately organized post-discharge follow-up are prerequisites for good quality of life.

Long-term follow-up, both nursing and medical, should be ensured for every ostomy patient. Contact with self-help groups (e.g., ILCO: Self-help association of people with an ostomy, the name ILCO is formed by the initials of Ileum (small intestine) and Colon (large intestine)) can alleviate patients' fears about living with an ostomy from the perspective of those affected.

Thrombosis Prophylaxis:

In the absence of contraindications, due to the moderate to high risk of thromboembolism, low molecular weight heparin should be administered prophylactically, possibly in a weight- or risk-adapted dosage, until full mobilization is achieved. Note: Kidney function, HIT II (history, platelet control) Follow the link to the current guideline Prophylaxis of Venous Thromboembolism (VTE).

Mobilization:

Mobilization is possible immediately.

Physical Therapy:

The indication for physical therapy depends on the primary procedure; respiratory therapy may be advisable.

Dietary Progression:

Dietary progression can generally occur immediately.

Bowel Regulation:

Bowel regulation may be necessary.

Incapacity for Work:

Individually adjusted according to the surgical indication. Work involving significant physical strain is generally unsuitable due to the risk of prolapse and hernia.

Ostomy Care:

Learning emptying/cleaning techniques. Training of partners. Ensuring good ostomy care at home, e.g., through mobile nursing services. Support from patient organizations (e.g., ILCO).

Ostomy irrigation for distal colostomy (descending or sigmoid): Regular bowel irrigation through the ostomy with subsequent emptying of bowel contents. For irrigation, body-temperature tap water in an amount of 15 ml/kg body weight (i.e., 1-1.5 liters) is introduced into the bowel using a commercially available bag and accessories. Ideally, this results in a stool-free interval of 24-48 hours. During this time, the ostomy can be managed with a cap or mini-bag, thus increasing freedom of movement. Simultaneous evacuation of intestinal gases prevents bloating for 8-10 hours.