Introduction

Get a useful overview of the key issues in stoma surgery in this section. There is a quick reference to the anatomy and organ systems involved, the common complications that your patients may encounter after surgery and tips and tools to help. 

 


Anatomy and physiology

The digestive system The digestive system The digestive system is one of the body's major organ systems. The digestive tract handles the digestion and processing of food. More about the digestive system
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Anatomy and physiology of the digestive and urinary systems

Digestive system

 
The digestive tract stretches some nine metres from the mouth to the anus and is divided into different sections. Each section processes food in a specific way to prepare it for the next section of the digestive tract, until the waste finally leaves the intestinal tract as faeces.

Functions of the digestive system:

  • Mechanical and chemical breakdown of food into basic nutrients
  • Absorption of nutrients into the blood
  • Processing and elimination of waste

A number of organs work alongside the digestive tract, producing fluids and enzymes to aid indigestion:

  • Salivary glands in the mouth
  • Acid fluids in the stomach
  • Liver and gallbladder
  • Pancreas

 

The gastrointestinal tract comprises:

  • Mouth
  • Oesophagus
  • Stomach
  • Small intestine – jejunum & ileum
  • Large intestine – colon
  • Rectum
  • Anus

 

The intestinal wall consists of several layers

 

The small intestine is approximately 5–7 m long in adults. It is divided into three main parts:

  • Duodenum
  • Jejunum
  • Ileum

The jejunum and ileum are connected to the abdominal wall by the mesentery. The mesentery contains arteries, veins and lymph vessels that ensure the transport of oxygen and nutrients to and from the small intestine.

 

The large intestine is approximately 1–2 m long in adults. It is divided into six parts:

  • Ascending colon
  • Transverse colon
  • Descending colon
  • Sigmoid colon, the S-shaped structure
  • Rectum: final part of the digestive tract. Stool collects in the rectal ampulla. A filled ampulla initiates the urge to empty the bowels
  • Anus, terminal opening of the digestive system
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The urinary system The urinary system The urinary system is another of the body's major organ systems. The urinary tract is involved in fluid and electrolyte balance, and the excretion of urine. More about the urinary system
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The urinary system

The urinary system

The overall function of the urinary system is to produce and drain urine, removing waste products and regulating the blood's fluid balance. The entire urinary system is located behind the digestive tract.

 

The urinary system consists of:

  • Two kidneys
  • Two ureters
  • Bladder
  • Urethra

The kidneys are two bean-shaped structures that continuously filter the blood, removing waste products and excess water, and balancing fluids and electrolytes. This filtering process results in the production of urine.

 

The ureters are ducts that carry urine from the kidneys to the bladder.

 

The bladder has a dual function. It is both a reservoir that stores urine and a pump that expels urine from the body. The muscle in the bladder wall pushes the urine out.

 

The urethra is a duct connecting the bladder to the outside of the body.

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Before stoma surgery

Stoma marking How to mark a stoma before operation A well-placed stoma can make a big difference to patients’ quality of life. A good stoma site is easy for the patient to see, allows for secure pouching and freedom of movement - essential to avoid complications. How to mark a stoma site
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How to mark a stoma before operation

Stoma markingA preoperative marking to select the optimal location of the stoma site is important for patient quality of life. A favourable site can help reduce potential problems such as leakage, fitting issues, skin irritation, pain and psychological/emotional health.

When marking the stoma site, it’s important to consider the dynamics of the body as it changes according to factors such as different positions and scar formation. Creases and folds near the stoma should be avoided. In addition, the lifestyle and activity level of the patient will influence where the stoma should be located.

Before marking the site, consider these four factors:

  1. Physical condition:
    Constitution, current weight and recent weight changes, manual dexterity and eyesight
  2. Social activities:
    Occupation, physical positions at work, sports, hobbies, clothing preferences, cultural and religious aspects
  3. Areas to avoid:
    Bony prominences, skin folds, scars from previous operations, the umbilicus, belt line and skin areas that have been irradiated and are highly sensitive (atrophic)
  4. Visibility:
    The site should be placed in an area that the patient can see and reach. If not, the patient cannot perform stoma self-care, and will need help from other people when changing the appliance

Having a stoma alters body functions and body image. But if health care professionals - such as stoma care nurse and surgeon - work together to give end-users competent care, the chances of a good outcome for the patient are greatly increased.

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Different stoma types Different stoma types There are three types of stoma, each created for different purposes. Keep reading to find out where they are typically placed and what they are for. The three different stoma types
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Three different types of stoma

The three types of stoma are:

- Colostomy
- Ileostomy
- Urostomy

 

Formation of a stomaColostomy

In a colostomy operation, part of the colon is brought to the surface of the abdomen to form the stoma. A colostomy is usually created on the left-hand side of the abdomen. Stools in this part of the intestine are solid and, because a stoma has no muscle to control defecation, will need to be collected using a stoma pouch.

 

There are two different types of colostomy surgery: End colostomy and loop colostomy.

 

End colostomy
If parts of the large bowel (colon) or rectum have been removed, the remaining large bowel is brought to the surface of the abdomen to form a stoma. An end colostomy can be temporary or permanent. The temporary solution is relevant in situations where the diseased part of the bowel has been removed and the remaining part of the bowel needs to rest before the ends are joined together. The permanent solution is chosen in situations where it is too risky or not possible to re-join the two parts of the intestine.

 

Loop colostomy
In a loop colostomy, the bowel is lifted above skin level and held in place with a stoma rod. A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. In this way, a loop stoma actually consists of two stomas (double-barrelled stoma) that are joined together. The loop colostomy is typically a temporary measure performed in acute situations. It can also be carried out to protect a surgical join in the bowel.

 

Ileostomy

In an ileostomy operation, a part of the small bowel called the ileum is brought to the surface of the abdomen to form the stoma. An ileostomy is typically made in cases where the end part of the small bowel is diseased, and is usually made on the right-hand side of your abdomen.

 

Stools in this part of the intestine are generally fluid and, because a stoma has no muscle to control defecation, will need to be collected in a pouch.

 

There are two different types of ileostomy surgery:

End ileostomy

End ileostomy

An end ileostomy is made when part of the large bowel (colon) is removed (or simply needs to rest) and the end of the small bowel is brought to the surface of the abdomen to form a stoma. An end ileostomy can be temporary or permanent.

The temporary solution is relevant in situations where the diseased part of the bowel has been removed and the remaining part needs to rest before the ends are joined together. The permanent solution is chosen in situations where it is too risky or not possible to re-join the two parts of the intestine.

Loop ileostomy

Loop ileostomy

In a loop ileostomy, a loop of the small bowel is lifted above skin level and held in place with a stoma rod. A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. In this way, a loop ileostomy actually consists of two stomas that are joined together.

The loop ileostomy is typically temporary and performed to protect a surgical join in the bowel. If temporary, it will be closed or reversed in a later operation.

 

UrostomyUrostomy

If the bladder or urinary system is damaged or diseased and your patient is unable to pass urine normally, there is a need for a urinary diversion. This is called a urostomy, an ileal conduit or a Bricker bladder.

An isolated part of the intestine is brought onto the surface of the right-hand side of the abdomen and the other end is sewn up. The ureters are detached from the bladder and reattached to the isolated section of the intestine. Because this section of the intestine is too small to function as a reservoir, and there is no muscle or valve to control urination, your patient will need a urostomy pouch to collect the urine.

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Complications with a stoma

Peristomal skin disorders Peristomal skin issues are the most common complications for people with a stoma, accounting for a third of visits to stoma care nurses. Most frequent cause is chemical irritation due to leakage. Tools to help accurate assessment and appropriate treatment
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Peristomal skin disorders

Monitoring of peristomal skin, already during the post-operative phase, is essential to ensure that the skin remains healthy, and, if it is affected by a skin disorder, that appropriate and consistent treatment can be initiated immediately.

 

The Ostomy Skin Tool is developed together with stoma care nurses on the Global Advisory Board to ensure accurate assessment of peristomal skin.

 

It consists of two parts; the DET score and the AIM guide:

  • DET score (Discolouration, Erosion, Tissue overgrowth) – provides a standardised and validated way to score the peristomal skin through objective observations.
  • AIM guide (Assessment, Intervention, Monitoring)  - provides categorisation of the peristomal skin disorder according to its cause and offers guidance on care. The guide is based on a thorough literature review.

 

The tool is designed to help you to:

  • Assess peristomal skin at the time of assessment based on the validated DET score
  • Identify the most suitable appliance and peristomal skin care routine
  • Provide you and your colleagues with a common language for describing peristomal skin conditions 

 

Please contact Customer Care if you need further information on the Ostomy Skin Tool.

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Early complications following stoma surgery As with any operation, complications may occur directly following stoma surgery. Common early complications
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Early complications following stoma surgery

BleedingBleeding

  • Earliest complication

  • Usually stops spontaneously

Use soft materials wringed in cold water to stop the bleeding. In case of continuous bleeding, it might be necessary to ligate/tie off the bleeding vessel.

 

OedemaOedema

  • Can occur after surgery

  • Usually clears after 1–2 weeks
  • To manage the appliance, use a mouldable ring or paste

Make incision/slices in the adhesive to ensure flexibility and prevent cutting the mucosa.

NecrosisIschemia/necrosis

  • Poor or interrupted blood supply due to surgical complications
  • Must be observed closely
  • If vital tissue is observed the necrotic tissue will be discharged. If not, a re-operation is needed

SeparationSeparation

  • Separation characteristics:
    • Partial or complete
    • Shallow or deep
  • Two treatment options:
    • Open drainage by fitting the appliance to the outer rim of the separation
    • Moist wound healing of the separation under the adhesive.

FistulaFistulae

  • A fistula is a channel that develops spontaneously between two normally unconnected structures
  • Spontaneous fistulae are formed secondary to either intrinsic internal disease or external trauma. Irritable bowel syndromes such as Crohn’s disease is a common cause
  • Treatment is either conservative or surgical

 

Conservative treatment:

  • Ensure fluid and electrolyte balance
  • Control sepsis with antibiotics
  • Total parental nutrition to decrease fistula output
  • Drain fistula

 

 

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Complications later on Complications may also occur in the long term following stoma surgery. Common late complications
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Late complications following stoma surgery

Stoma retractionStoma retraction

  • A retracted stoma lies below skin level, commonly caused by too short a section of intestine used

Management:

  • Convex adhesive, mouldable ring or paste
  • If excess weight/obesity is the case, weight loss should be encouraged
  • Irrigation if it is a colostomy
  • Further surgical procedure may be necessary.

HerniaHernia

  • A bulge around the stoma can be a true, sliding or “false” hernia
  • True hernia – a loop of the intestine moves through the hole in the abdominal wall
  • Sliding hernia – a segment of the intestine used to create the stoma becomes looped into the subcutaneous fatty tissue
  • “False” hernia – increased abdominal pressure produces a bulge in the side of the body due to a weakened abdominal wall – this is the most common cause.

Stoma prolapseStoma prolapse

  • The section of intestine used to create the colostomy is almost turned inside out and pushed forward

  • It can be treated by gently pushing the prolapsed segment back into the abdomen
  • If oedematous, use ice to reduce blood flow and sugar to reduce the oedema
  • Surgical repair might be needed

StenosisStenosis

  • The stoma is oedematous, mushroom shaped and glistening
  • Faeces is expelled in the form of a thin strip; the blockage is due to tightened tissue around the stoma
  • Can be treated by dilation of the intestine
  • If at skin level, local surgery may be necessary

GranulomasGranulomas

  • Granulomas at the mucosa are seen in the transition between the stoma and the skin
  • Causes include chemical or mechanical irritation
  • Can be treated by covering raised areas with silver nitrate
  • Diathermy (electrical heating)
  • Laser treatment
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Regulated by the Care Quality Commission (CQC)

 

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