Perioperative management - Ileostomy placement

Stomas are often created during abdominal surgeries, whether in emergency situations or elective procedures.

The indication for and type of stoma creation depend on the underlying disease and the general situation.

• Neoplastic diseases → Prevention of ileus during neoadjuvant treatment or inoperability
• To protect high-risk anastomoses (protective ileostomy) or due to the removal of sphincters after radical oncological bowel resections
• Anastomotic insufficiency
• Emergency situations such as after abdominal trauma, intestinal ischemia, ileus, or bowel perforation
• Protective placement before, for example, extensive proctological procedures (fistula surgery)
• Chronic inflammatory bowel diseases
• Functional disorders such as severe fecal incontinence, evacuation disorder
• Congenital intestinal anomalies (malformations)

In the presented example, it is an ileostomy created during an open rectal carcinoma operation.

Types of stomas:

• Temporary versus permanent stomas, possibly considering the need for complete diversion of stool passage to keep the subsequent bowel segment dry.
• End stomas (split stomas, where the bowel ends after resection are separately diverted as end stomas) versus loop stomas (resection stomas where the bowel ends after resection are sutured posteriorly and then diverted together).
• Modified split stoma where the efferent limb of a loop stoma is blindly closed at the abdominal wall level. This combines the advantages of complete diversion of stool passage with those of easy reversal without re-laparoscopy or -tomy.
• Hartmann's situation with rectal blind closure and end colostomy. Here, a re-laparoscopy or -tomy is required in any case (reconnection surgery Hartmann II).

An end stoma is usually created when, at least in the long term, reversal is not planned or possible.

If the stoma is to be temporary, a loop stoma is usually created. A small bowel stoma is typically created in the terminal ileum or, if that is not possible, in the most distal small bowel segment.

Optimal is the transrectal placement in the lower abdomen above the arcuate line. The better muscular and fascial support here is intended to prevent a parastomal hernia or prolapse.

Due to anatomical proximity, the transverse stoma is best placed in the upper abdomen, and the ileo- and sigmoidostomy in the lower abdomen.

Special situation 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 is much less common with a colostomy, and obstruction issues after reversal are also less frequent.

Ethical reasons

• Medical History
• Clinical Examination
• Laboratory
• Optional: Ultrasound (dependent on 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:

• Fasting depending on indication: For planned procedures, 6 hours of food abstinence and 2 hours of clear fluid abstinence.
• Possibly laxative measures for bowel cleansing (e.g., for rectal surgery with planned stoma)
• Marking of the ileostomy: Stoma marking

Ideally, the marking and subsequent instruction on stoma care should be performed by specially trained stoma therapists or an experienced surgeon.

1. Trial marking on the lying or already sitting patient in the area of the right rectus abdominis muscle (navel height) in a 10 × 10 cm skin area, preferably without folds, scars, or bony protrusions.
2. Verification of the intended position in motion (standing, bending).
3. The chosen site should be easily visible and accessible to the patient and compatible with the position of the pants or belt.
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!

• Single-shot antibiotic prophylaxis

The indication, the procedure of stoma placement (permanent or temporary – conventional or laparoscopic placement), further care of the stoma in the hospital and later at home, as well as psycho-social factors should be discussed with the patient. (How do I live with an artificial outlet? What do I need to consider in the future? Nutritional counseling.)

General complications in (laparoscopic) surgeries:

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

Specific complications:

Stoma complications are not uncommon and are also due to technical inadequacies such as circulatory disorders, lack of tension-free placement, or too narrow stoma canal and incorrect positioning. However, even with proper placement, not all complications are necessarily avoidable:

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

• Intubation anesthesia
• Possibly additional local infiltration

• Supine position or
• Lithotomy position – depending on indication
• both arms positioned out or
• right arm positioned alongside (open),
• left arm positioned alongside (laparoscopic)

Laparoscopic Setup:

• It is recommended that the surgeon initially stands on the left; usually, when suturing the stoma, the surgeon moves to the right.
• The assistant stands and remains on the left.
• OR nurse on the left

Open Setup:

• Surgeon on the right
• Assistant on the left
• OR nurse on the left

For Laparoscopic Ileostomy Placement:

• Laparoscopic tower
• Camera (with appropriate sterile covering)
• If the placement of an ileostomy (as shown in the film) occurs as part of a larger procedure, the trocars from the "main operation" are usually sufficient (e.g., in the context of a rectal procedure).
• For ileostomy placement as the main procedure, usually 3 trocars are sufficient (e.g., 1x 10 mm and 2x 5 mm).

For Conventional Placement:

• Vessel loop for encircling the ileum loop

Postoperative Analgesia:
Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, an increase with opioid-containing analgesics can be made.
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:

In case of contamination of the surgical site (in major surgeries) by stool, continuation of antibiotics (for 2-3 days depending on laboratory values) is recommended after local rinsing.

Professional postoperative guidance and sufficiently 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 of 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 in prophylactic, possibly weight- or disposition 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: immediate

Physical Therapy: Breathing therapy (in case of major underlying surgery)

Dietary Progression: immediate

Bowel Regulation: If necessary

Incapacity for Work: Individually adjusted – according to the indication for surgery. Jobs with greater physical strain are generally unsuitable due to the risk of prolapse and hernias.

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

Nutrition: No low-salt diet, adequate fluid intake of 2-3 liters daily, urine output should not fall below 1000 ml/24h. Thickening foods like potatoes, rice, bananas. Avoidance of fibrous foods to prevent ostomy blockage.