Perioperative management - Ileostomy, construction of

Usually (in about 70% of cases), the issue of ileostomy construction arises in the treatment of underlying abdominal malignancy (colon, rectum, bladder) either to stave off possible ileus in neoadjuvant or palliative radiochemotherapy and/or to prevent postoperative complications (anastomotic stenosis or failure).

Also in:

• Crohn disease, ulcerative colitis
• Familial adenomatous polyposis (FAP)
• Malformations
• Intestinal ischemia
• Protective ileostomy in major intestinal operations
• Protective ileostomy before, e.g., extensive proctological procedures (fistula surgery)
• Anastomotic failure
• Palliation in inoperable underlying disease with impending ileus

Ethical reasons

• Medical history
• Clinical examination
• Lab panel
• 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:

• Fasting if indicated: For planned procedures 6 hours for solids and 2 hours for clear fluids
• If necessary, laxative measures for intestinal cleansing (e.g., in rectal surgery with planned stoma)
• Stoma site location Stoma site marking

Ideally, the stoma should be marked and the subsequent instructions for stoma care given by specially trained stoma nurses or an experienced surgeon.

1. Trial marking, with the patient supine or already sitting, within the right rectus abdominis (level of the umbilicus) in a 10×10cm skin area, preferably without folds and creases, scars and bony prominences.
2. Check of the planned site with the patient in motion (standing, stooping down).
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!

The indication for and technique of stoma construction (permanent or temporary - open or laparoscopic procedure), later stoma management in the hospital and at home as well as psychosocial factors should be discussed with the patient. (How do I live with a stoma? What do I have to heed in the future? Nutritional advice.)

General complications in (laparoscopic) surgery:

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

Special complications:
Stoma complications are not uncommon and may partly arise from 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, not all complications can be prevented for certain:

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