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General Surgery
Intestinal Stomas
Built from Maingot's Abdominal Operations
What’s inside
12 sections · 178 slides
Overview
- Scope of this topic
Stomas in general
Definitions, who needs one, and the problems every stoma shares
- Definition of an intestinal stoma
- Names for each type of stoma
- Family of stomas on the abdominal wall
- Sources of data on stomas
- 15,000
- Complications recorded in the registry
- 92%
- Sexual function after proctectomy for cancer
- Improvements in care and falling stoma numbers
- Problems shared by every stoma
- Peristomal varices and drug precautions
- Preoperative marking and counselling
- Steps in siting a stoma before surgery
Colostomy
Where in the colon, where on the abdomen, and for what purpose
- Indications for a colostomy
- Colostomy types by anatomic location
- Physiology of the right and left colon
- Effluent from a proximal versus a distal colostomy
- Choosing the colostomy site on the abdominal wall
- Colostomy classified by function
The decompressing colostomy
Blow-hole stoma, tube cecostomy and loop-transverse colostomy
- Indications for a decompressing colostomy
- Alternatives to a decompressing stoma
- Strengths and weaknesses of a decompressing stoma
- Three types of decompressing stoma
- When a cecostomy or blow-hole colostomy is chosen
- Technique of the blow-hole stoma
- Decompressing and maturing the blow-hole stoma
- Sequence of a blow-hole stoma
- Blow-hole stoma: siting the incision and the first suture layer
- Blow-hole stoma: second suture layer and opening the colon
- The completed blow-hole stoma
- Postoperative course of a blow-hole stoma
- Technique of tube cecostomy
- Tube cecostomy with a mushroom-tipped catheter
- Tube cecostomy weighed up
- Loop-transverse colostomy: purpose and limits
- Siting a loop-transverse colostomy
- Delivering the loop through the abdominal wall
- Loop-transverse colostomy from site choice to matured stoma
- Maturing the loop and its early care
- Divided end-loop colostomy
- Deciding when to close a temporary colostomy
- Technique of colostomy closure
- Colostomy closure: freeing the colon from the abdominal wall
- Colostomy closure: stapled and hand-sutured repair
The diverting colostomy
End colostomy, mucus fistula, and life with irrigation
- Indications for a diverting colostomy
- Degree of diversion by a loop colostomy
- Retraction and the vented distal limb
- Options for the distal bowel at an end colostomy
- Choosing between a closed stump and a mucus fistula
- Marking the site for an end colostomy
- End colostomy: site, colonic mobilisation and maturation
- Mobilising the colon for an end colostomy
- Making the opening in the abdominal wall
- Maturing the end colostomy
- The first appliance
- Colostomy irrigation and what it offers
- Principle, drawbacks and risks of irrigation
- Patients unlikely to succeed with irrigation
- Technique of colostomy irrigation
Colostomy complications
Stricture, necrosis, hernia, prolapse and perforation
- Everyday colostomy problems and registry data
- Gas, odour and bleeding
- Origin of the term stoma maturation
- Causes and repair of colostomy stricture
- Colostomy necrosis: causes and assessment
- How a paracolostomy hernia develops
- Why the hernia forms where it does
- Management of parastomal hernia
- Colostomy prolapse
- Treating colostomy prolapse
- Colostomy perforation
Ileostomy
End, loop, divided end-loop and loop-end stomas, and their closure
- What an ileostomy is and who needs one
- Why ileostomy construction must be more precise
- Types of ileostomy
- Choosing the ileostomy site
- Confirming the site and preparing the patient
- Choice of abdominal incision
- Ileostomy site, abdominal wall opening and ileal blood supply
- Mobilising the distal ileum
- Preserving the blood supply of the stoma
- Preserved arcade and the ileum drawn through the wall
- Making the abdominal wall opening
- Sizing the opening and delivering the ileum
- Fixing the mesentery and checking the ileostomy blood supply
- Everting the ileostomy into a spout
- Three-point sutures that evert the ileostomy
- The first appliance and early skin care
- Loop ileostomy: purpose and orientation
- Marking the loop of ileum before delivery
- Delivering the loop and the question of a twist
- The obese patient and the supporting rod
- Opening and maturing the loop ileostomy
- Loop ileostomy matured over a supporting rod
- Divided end-loop ileostomy
- Divided end-loop ileostomy: transection and delivery
- Working spout beside a small recessive opening
- Divided end ileostomy for extra length
- Loop ileostomy closure: timing and technique
- Loop ileostomy closure: mobilising and cleaning the loop
- Loop ileostomy closure: suture and stapled repair
- Closing a divided end-loop ileostomy
- Divided end-loop closure: excising the stoma site
- Functional end-to-end stapled closure
- Loop-end ileostomy: when it is needed
- Technique of the loop-end ileostomy
- Loop-end ileostomy: preserved mesentery and inverted end
- Loop-end ileostomy: mesenteric fixation and rod support
- Mucus from the recessive limb
Living with an ileostomy
Appliances, output, dehydration, blockage and skin
- Parts of an ileostomy appliance
- Outcomes with a well-built ileostomy
- 1500 mL
- How ileostomy dysfunction used to happen
- How ileostomy dysfunction was solved
- Appliance seal problems and chemical dermatitis
- The appliance that seals to mucosa
- Dehydration after ileostomy
- Food bolus obstruction
- Managing a blocked stoma
- Algorithm for relieving a blocked ileostomy
- High ileostomy output
- Paraileostomy fistula and stoma injury
The continent ileostomy
An internal pouch with a nipple valve, and how to rescue it
- What a continent ileostomy is
- Selecting patients for a continent ileostomy
- Continent ileostomy weighed up
- Origin of the Kock pouch
- Four components of a continent ileostomy
- Measurements of the S-shaped pouch
- Continent ileostomy: dividing the ileum and shaping the S-pouch
- Suturing the pouch
- Making the nipple valve
- Stapling the nipple valve in place
- Intussuscepting and stapling the nipple valve
- The mesh collar and pouch suspension
- Fixing the pouch and completing the stoma
- Mesh collar, pouch fixation and the finished stoma
- Draining the pouch after surgery
- Complications of the continent ileostomy
- Rescuing a failed nipple valve
- Rescuing a slipped nipple valve: excision and pouch rotation
- Rebuilt nipple valve with the mesh collar in place
- Completed pouch and stoma after revision
The urinary conduit
Bowel used as a pipe for urine, and what goes wrong with it
- What a urinary conduit is
- Indications for a urinary conduit
- Principles of conduit construction
- Technique of ileal conduit construction
- Ileal urinary conduit from segment isolation to ureteral stents
- The conduit stoma and its appliance
- Complications: a leaking appliance
- Infection, odour and stones
- Revision and relocation of a conduit stoma
Fistulas and the laparoscopic approach
Unplanned openings, and making or closing a stoma through keyholes
- The unplanned intestinal fistula
- Laparoscopic stoma creation and its evidence
- Indications for a laparoscopic stoma
- Advantage in near-obstructing rectal cancer
- Trephine versus laparoscopic stoma creation
- Laparoscopic technique: access and exploration
- Laparoscopic technique: delivering the bowel
- Confirming orientation for an end stoma
- Early discharge and stoma teaching
- Laparoscopic stoma closure
- Two strategies for Hartmann reversal
- Planning before a Hartmann reversal
- Restoring continuity after an ileostomy
Summary
What to carry away from intestinal stomas
- Key points: siting and construction
- Key points: choosing the operation
- Key points: complications and follow-up
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition