Overview on Stoma Care

Haryono Yarman
April 25, 2019

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 Topics to be Discussed

1. Introduction
2. Perioperative Preparations
3. Operative Considerations
4. Follow up
5. Summary

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 Introduction
• Stoma is derived from the Greek :
stomat = mouth
• Gastrointestinal stomas = artificial
connections of the gut to the skin

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 Introduction
 OSTOMY = anastomosis between an endothelially
lined organ & the skin

 A frequent part of emergent colon surgery

 Almost any abdominal procedure carries some risk of

requiring a colostomy or ileostomy

 Ability to create a healthy, well functioning,

easily manageable colostomy is essential for all surgeons

Cataldo TE, End Sigmoid/Descending Colostomy in Cataldo PA, MacKeigan,

Intestinal Stomas,Principles,Techniques, and Management, 2004
 STOMA

Jejunostomy Gastrostomy
 Introduction
 Stoma should be free of complication :
 Retraction,
 Stricture,
 Prolaps

 Temporary :
 many are in place for months to years
 every stoma should be created as :
if it was the only mode of defecation for life !
 Introduction
• Stoma will frequently be a significantly life altering
event

• Whenever possible, it is best to have the patient &

family well educated prior to surgery

• Preoperative evaluation & marking by a qualified ETN

will greatly improved patient satisfaction & funtional
result

Cataldo TE, End Sigmoid/Descending Colostomy in Cataldo PA,

MacKeigan, Intestinal Stomas, Principles,Techniques, and Management,
2004
 Ostomates’ Quality of life

• 1 goal of any Surgical Procedure is to improve

the patient’s QoL :

– Successful treatment of the underlying disease

– Patient’s adaptation to the stoma

Thorson AG , Preoperative Considerations , in Cataldo PA, MacKeigan JM ,

Intestinal Stomas : Principles , Techniques , and Management , 2nd Ed , 2004
 Stoma & QᴑL
• There are circumstances when construction of an ostomy
leads to significant improvement in QoL &
may be Lifesaving

• Patients with a good functioning stoma can expect :

- to live a normal life
- very few lifestyle restrictions.

• In contrast, a patient develops complications related to

their stoma :
impact on their physical & mental health can be irreparable
•
Introduction
USA 2004 : I million ostomates
• Most have normal life
Bad QoL
 The Surgeons & ET Nurses
Preoperative care

• Successful postop management of the

patient undergoing ostomy surgery begins
with Comprehensive Preoperative Care

Erwin-Toth P , Hocevar B , Stricker L J , Wound, Ostomy, and Continence /

Enterostomal Therapy (WOC/ET) Nursing in Fazio VW et al. (eds.), Atlas of
Intestinal Stomas, Springer Science+Business Media, 2012
 The Surgeon & ET Nurse
Preoperative care
• Counseling & Stoma Site Selection are key services the
WOC/ET Nurse provides to patients & their families

• Information regarding basic ostomy function & self-care,

lifestyle issues, body image, and sexuality
 help prepare the patient for living with an ostomy

• Optimum stoma placement and stoma construction

are essential in obtaining :
a reliable, secure pouching system seal after surgery.

• Even in an emergency situation, basic counseling &

stoma site marking should be completed

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Education

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 The Ideal location for ileostomy

• In the RLQ
• Through the rectus muscle,
• Sufficiently away from the
midline incision
• The infra-umbilical fat
mound over the rectus
muscle sheath is generally
an ideal location because it
is away from the umbilicus,
skin creases, or bony
prominences
• Stocchi L, in Fazio VW et al.
(eds.), Atlas of Intestinal
Stomas, 2012
 Operative Considerations
• The Best Functional Outcome :
as in all Intestinal Surgery, is the result of following
the principles :
1. Tension-free Construction
2. Adequate Blood Supply
3. Minimal Tissue Manipulation

– Cataldo TE in Cataldo PA, MacKeigan JM , Intestinal Stomas : Principles ,

Techniques , and Management , 2nd Ed , 2004

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Preoperative Siting

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To create an ileostomy
 To Create an Ileostomy
1 2 3

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 Postoperative Management

• Apply transparent pouch in OR :

• No leak
• Surgeon’s responibility

• Rehabilitate the patient in collaboration

with ET Nurses
 Post- operative Patient Care,
Education, & Counseling
• The role of the WOC/ET Nurse complements the care
rendered by other members of the healthcare team
• Patients’ Education :
– is an important part of the patient’s rehabilitation
– Proper selection of the pouching system
– Adjustment to an ostomy is optimized with secure,
reliable, & odor proof pouch
– This is best achieved with a well-sited,
well constructed, budded stoma.
– Consideration of visual acuity, manual dexterity, and
patient preference should be included in the selection
of the pouching system
 Post- operative Patient Care,
Education, & Counseling
• Wound care is an integral part of modern WOC/ET nursing
practice :
– create a physiologic environment to promote healing,
– enhance patient comfort,
– improve patient outcomes in a costeffective manner
• Principles of topical wound care include :
– Removal of nonviable tissue in well-vascularized wounds,
– Non-cytotoxic cleansing of the wound bed,
– Identifying and eliminating infection,
– Filling dead space without over packing
• A holistic approach to patient care is essential
 addresses the needs of the entire patient and not just the
stoma.
 Post- operative Patient Care,
Education, & Counseling
• Pouch security and maintenance of peristomal skin integrity provide
a foundation for long-term success for the patient’s rehabilitation f

• Ostomy surgery is not a handicapping procedure.

• The past 50 years have seen the practice of

colorectal surgeons and WOC/ET nurses evolve.
What has remained is the partnership between
the 2 Health Care Professionals to improve
the QoL of the patients.
Erwin-Toth P , Hocevar B , Stricker L J , Wound, Ostomy, and Continence /
Enterostomal Therapy (WOC/ET) Nursing in Fazio VW et al. (eds.), Atlas of Intestinal
Stomas, Springer Science+Business Media, 2012
 Stoma related complications

• Unfortunately, Significant Morbidity is

associated with stoma creation

• The rate of stoma-related complications :

20% - 70%
 Time of Complications
Early Complications Late Complications

Within the first 30 days of

the stoma creation
1. Ischemia/necrosis, 1. Parastomal hernia,
2. Retraction, 2. Prolape,
3. Mucocutaneous 3. Retraction,
separation, 4. Varices
4. Parastomal abscess.
 The Most common
Stoma-related complications
1. Herniation,
2. Retraction,
3. Necrosis,
4. Infection, Colostomy
5. Prolapse,
6. Stenosis,
7. Fistula,
8. Small Bowel Obstruction (SBO)

• ( Harris et al found in 345 ostomates )

Krishnamurty DK, Blatnik J, Mutch M, Stoma Complications, Clin Colon
Rectal Surg 2017;30:193–200
FROM THE OSTOMATES VIEW

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 Ostomates’ Rights
1. Receive preoperative counseling to ensure that they are fully aware of the
benefits of the operation and the essential facts about living with a stoma.

2. Have a well-constructed stoma, placed at an appropriate site, and with full

and proper consideration to the comfort of the patient.

3. Receive experienced and professional medical support and stoma nursing

care in the preoperative and postoperative period both in hospital and in
their community.

4. Receive support and information for the benefit of the family, personal
caregivers and friends to increase their understanding of the conditions
and adjustments which are necessary for achieving a satisfactory
standard of life with a stoma.

5. Receive full and impartial information about all relevant supplies and
products available in their Country.

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 Ostomates’ Rights
6. Have unrestricted access to a variety of affordable ostomy products.

7. Be given information about their National Ostomy Association

and the services and support which can be provided.

8. Be protected against all forms of discriminations

9. Receive assurance that personal information regarding their ostomy

surgery will be treated with discretion and confidentiality to maintain
privacy; and that no information about their medical condition will be
disclosed by anyone possessing this information, to an entity that
engages in the manufacture, sales or distribution of ostomy or related
products; nor shall it be disclosed to any person that will benefit,
directly or indirectly, because of their relation to the commercial
ostomy market without the expressed consent of the ostomate.

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 Some differences to be considered

Western people Indonesian people

• Small rectus abdominis muscle
• Lack of well trained nurses
• Lack of good stoma & wound
appliances
•  stoma in rectus m ;
close to laparotomy
wound,
will contaminated the
wound,
Infection  Problem

• How if we make the stoma

outside the rectus muscle ?
 Summary
• The Perfect Stoma creation & the avoidance of complications
should follow the principles of :
• No tension,
• Adequate blood supply,
• Minimal tissue manipulation ,
• Well placed,
• Well fitted segment of bowel with the abdominal trephine.
• Well pre & post operativecare
• Well collaboration between the Surgeon, the Nurse & the
Ostomate & his or her relatives