INTESTINAL SURGERY I
Ileostomy and colostomy
James Pine
Lynn Stevenson
Abstract
The formation of intestinal stomas, mainly ileostomy and colostomy, has
become an integral approach to the surgical management of several pathol-
ogies of the gastrointestinal tract e in both the emergency and elective pa-
tient. The basic underlying principle is that faecal flow is diverted away from
the site of the pathology, by bringing an end or a loop of bowel, through the
anterior abdominal wall. Either in a temporary capacity or permanent role
stomas can reduce morbidity and mortality associated with several condi-
tions of the gastrointestinal tract such as perforated colon, inflammatory
bowel disease, bowel obstruction and elective cancer operations, for
example a low anastomosis in an anterior resection of rectum. It has to
be appreciated though that stomas are not without their own set of compli-
cations, both in the early and late phases. Initial concerns can be due to
ischaemia of the bowel forming the stoma, stomal retraction and obstruc-
tion through to later complications such as parastomal hernia formation,
stomal prolapse and peristomal skin changes.
Keywords colostomy; end stoma; Ileostomy; loop stoma; mucus fistula;
parastomal hernia
Introduction
The word stoma is derived from the Greek, meaning ‘mouth’. It is
defined medically as a communication, natural or artificial, be-
tween the body cavity and the external environment. Surgical
procedures in which stoma are created are given the suffix-os-
tomy. Artificial stomas are formed mainly from the gastrointes-
tinal tract and intestinal stomas, such as ileostomies and
colostomies, are the most common type.
History of intestinal stomas
In the pre-anaesthetic era the formation of intestinal stomas was
uncommon. There is a case report from 1710 of a patient who
developed an intestinal stoma spontaneously secondary to a
strangulated hernia.1 The first demonstration of a surgically
constructed stoma was performed by Littre who, in 1710,
demonstrated the technique in a deceased child with imperforate
anus,2 but the first successful colostomy undertaken on a live
patient was not performed until 1793.3 The advent of anaesthetic
techniques made intestinal stoma formation more common. The
ileostomy was first advocated in ulcerative colitis in 1912 but
James Pine MBChB MD MRCS is a Trainee General and Colorectal Surgeon
at The Cumberland Infirmary, Carlisle, UK. Conflicts of interest: none
declared.
Lynn Stevenson MBChB FRCS MML is a Consultant General and Colorectal
Surgeon at The Cumberland Infirmary, Carlisle, UK. Conflicts of interest:
none declared.
SURGERY 32:4
only became widely used following the development of an
everted ileostomy technique in 1952.4,5
The formation of intestinal stomas has become an essential
tool in the surgical management of several diseases of the
gastrointestinal tract. They are used in both the emergency and
elective settings and there is little doubt regarding their impor-
tance in preventing serious complications and reducing overall
surgical morbidity and mortality.
Types of intestinal stoma
Intestinal stomas can be temporary, diverting stomas designed to
rest diseased distal bowel, protect distal anastomoses (following,
for example, low anterior resection), or to relieve obstruction.
Permanent stomas are indicated following the resection of distal
bowel when a primary anastomosis is inadvisable, for example
when gross faecal contamination or infected material is present,
when there are doubts regarding the blood supply to the affected
bowel, or if a primary anastomosis is not possible (e.g. when the
distal bowel including anus has been excised as in an
abdominoperineal resection (APER)).
There are two types of intestinal stoma: loop and end
(Figure 1). A loop, or double-barrelled, stoma is formed by
bringing a loop of bowel to the skin surface and creating a
proximal and distal opening. The faecal flow is via the proximal
opening into the stoma bag. The fact the distal end is exteriorized
enables the stoma to be more easily reversed at a later date. This
is achieved by mobilizing the bowel loop, re-anastomosing the
two bowel ends, returning the bowel into the abdomen in con-
tinuity and closing the stomal defect. This is commonly per-
formed at an optimum time between 3 and 6 months following
the original operation. Types of loop stomas used include loop
ileostomies, and transverse and sigmoid loop colostomies. Loop
colostomies often require a plastic colostomy bridge to prevent
early retraction. A loop stoma is commonly formed following
distal colonic/rectal surgery in order to protect a distal anasto-
mosis. This stoma can be a transverse loop colostomy but most
surgeons favour a loop ileostomy formed from the terminal
ileum. Williams et al. (1986) demonstrated that loop ileostomies
produced fewer odours, required fewer appliance changes and
were associated with a lower incidence of complications than a
transverse loop colostomy.6 There is also a potential risk of
damaging the marginal artery when reversing a colostomy and
therefore compromising the bowel distal to the stoma.7
End stomas are formed from the end of a proximal portion of
divided bowel. An end colostomy usually involves sigmoid colon
and is positioned in the left iliac fossa. An example of this in
emergency surgery would be following a Hartmann’s procedure.
This is an operation performed following obstruction, perforation
or ischaemia of the large bowel. The diseased segment of bowel is
resected and a proximal end of healthy, well-perfused large bowel
is used to form the end colostomy. The distal end of bowel is closed
with a stapling device and/or sutures and is left in situ in the
peritoneal cavity. Electively, end colostomies are utilized when
restoration of intestinal continuity is impossible, usually following
resection of the anus in an abdominoperineal resection of the
rectum (APER). End ileostomies are usually positioned in the right
iliac fossa. They are formed from the most distal section of healthy
ileum possible in order to maximize fluid and nutrient absorption.
212 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY I
Figure 1 End colostomy (left) and loop colostomy (right)
This minimizes the incidence of dehydration and nutritional de-
ficiencies and produces a thicker faecal consistency allowing easier
management of the ileostomy. End ileostomies are typically used
following subtotal/total colectomy for fulminant colitis in both
elective and most emergency settings.
Reversal of end stomas is possible 3e4 months after the original
procedure. It is, however, a more difficult operation when
compared to reversal of loop stomas and usually involves re-
laparotomy, although if expertise allows a laparoscopic approach
can be undertaken. The reality is that reversal is never achieved in
around 40% of end stomas following Hartmann’s procedure.8
As previously mentioned, following the formation of an end
stoma any remaining distal portion of colon is often closed over
and dropped back into the abdominal cavity. However, if there
are concerns that the distal closure may break down, releasing
intestinal content into the peritoneal cavity and inducing faecal
peritonitis, it is possible to bring the distal end to the skin as a
Figure 2 End colostomy and mucous fistula
SURGERY 32:4
mucus fistula (Figure 2). This can be at a separate site to the
proximal end (e.g. the inferior portion of a midline laparotomy)
or at the same site, forming a double-barrelled stoma.
Advantages of this technique are that it reduces the risk of
serious postoperative morbidity and may make reversal easier.
This has to be weighed against the fact the patient will have two
stomas to deal with. A compromise strategy has also been sug-
gested where the closed distal end is brought through the anterior
sheath but the skin is closed over it. Therefore, if the stump leaks
the content will drain percutaneously. Trickett et al. (2005)
reviewed rectal stump management following emergency sub-
total colectomy in inflammatory bowel disease. They demon-
strated that the subcutaneous placement of the stump, compared
to intraperitoneal placement, resulted in reduced incidence of
pelvic sepsis and a significantly shorter postoperative stay.9
Unusual stomas
Less common intestinal stomas include caecostomy for decom-
pression of colon, appendicostomy for administration of ante-
grade enemas (chronic constipation), and the use of small bowel
as an ileal conduit for reconstruction of the urinary tract
following cystectomy. Attempts have been made to create
continent stomas using plastic valves (Koch ‘continent’ ileos-
tomy). Results, however, have been poor and their use is limited.
The surgical placement of a feeding tube into proximal jejunum
for enteral feeding (feeding jejunostomy) is an important part of
a surgeon’s skill set.
Indications for intestinal stomas
Ileostomy
The indications for the different forms of ileostomy are shown in
Table 1.
Colostomy
The indications for the different forms of colostomy are shown in
Table 2.
Physiology of intestinal stomas
Ileostomy
The primary functions of the small bowel are chemical digestion of
food and absorption of the products of digestion. The absorption of
the majority of nutrients takes place in the jejunum. The ileum is
213 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY I
Indications for ileostomy
End ileostomy
Total colectomy for hereditary bowel cancer e FAPC/HNPCC
(with low rectal cancer)
Total colectomy for fulminant ulcerative colitis refractory to
medical therapy
Total colectomy for Crohn’s disease
FAPC, familial adenomatous polyposis coli; HNPCC, hereditary nonpolyposis colorectal cancer.
Table 1
specifically involved in the absorption of vitamin B12 and bile salts.
Although water is absorbed by passive diffusion throughout the
length of the small bowel, the majority of water absorption takes
place in the large bowel. Consequently, ileostomy output tends to be
soft and often liquid. The consistency of ileostomy output is deter-
mined by how distal the stoma is. The more proximal the stoma, the
less small intestinal surface area is available for water absorption.10
This has two effects. The first is to make the output increasingly
watery. The second is to increase the volume of stoma output. An
ileostomy formed from distal ileum typically has an output of be-
tween 500 ml and 700 ml per day. Stoma output of greater than 1500
ml is considered high output and places the patient at risk of dehy-
dration and electrolyte disturbances.11 Strategies to manage a high
output ileostomy include dietary adjustments (low fat, fluid
restricted) or by increasing intestinal transit time using drugs such as
codeine or loperamide.
Following resection of the terminal ileum nutritional de-
ficiencies can occur. Vitamin B12 absorption can be affected and
can result in a pernicious anaemia.12 This is easily dealt with via
intramuscular B12 therapy. Failure to absorb bile salts can also
lead to increased incidence of cholelithiasis.
In extreme circumstances, when an exceptionally long
segment of small bowel is resected or in very proximal stomas,
small bowel intestinal failure can occur. Also known as short
bowel syndrome, this is commonly defined as a length of 100 cm
or less of small bowel with the ability to absorb nutrients. These
Indications for colostomy
End colostomy
Low rectal or anal cancer where sphincter complex excision is necessary
or coloanal anastomosis inappropriate (e.g. APER/low anterior resection)
Hartmann’s procedure
Faecal incontinence
Radiation proctitis
APER, abdominoperineal resection.
Table 2
SURGERY 32:4
Defunctioning loop ileostomy
Protection of a distal rectal anastomosis
(e.g. low anterior resection)
Relieve distal obstruction (e.g. malignant/inflammatory stricture)
Emergency management of anastomotic leak
To defunction an intestinal fistula
To defunction in the presence of severe perianal sepsis
(e.g. Crohn’s, Fournier’s gangrene/necrotizing fasciitis)
Rectal trauma/sphinteric injury
Faecal incontinence
patients will need total parenteral nutrition and are often
managed at specialist referral centres.
Colostomy
As previously mentioned, the primary function of the large intes-
tine is to extract water from the indigestible material that passes
out the small bowel. Therefore the material passed through a co-
lostomy tends to be more solid than that passed through an
ileostomy, particularly the more common left-sided colostomy.
The colostomy bag tends to need emptying once a day.
Surgical formation of intestinal stomas
Principles of stoma site marking
Ideally, the principles and practicalities of living with a stoma
should be discussed with any patient with the potential to
require one in both the elective and emergency setting.
Specialist stoma nurses should be involved early on as they will
be able to counsel the patient as well as help to mark an
appropriate site for the stoma. Identifying an appropriate site
for any stoma is a critical part of the process as any error at this
point can have a significant impact on the quality of life of the
patient following surgery. The marked site should be on a flat,
smooth area of skin away from scars, skin creases and bony
prominences. It should be an area visible to the patient so that
it can be easily accessed when managing the stoma post-
operatively. When assessing for a stoma site the patient should
Defunctioning loop colostomy
Relieve distal obstruction (e.g. malignant/inflammatory stricture)
Faecal incontinence
Emergency management of anastomotic leak
To defunction an intestinal fistula
214 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY I

ideally be dressed in their normal clothes and should be with the skin. The laparotomy wound should then be dressed
assessed standing, sitting and lying down. and the stoma appliance applied to the ileostomy (see Figure 3).

Creation of stoma tract Colostomy

The stoma site should be marked preoperatively. A circular disc
of skin is excised, approximately 200 mm in diameter, over the
marked site. The subcutaneous fat is divided and retracted using
Langenbeck retractors until the anterior sheath is exposed. The
sheath should be opened with a cruciate incision to expose the
underlying rectus muscle. In the case of a midline laparotomy it
is often useful to apply slight tension to the abdominal wall by
gently retracting it medially using Littlewood’s forceps applied to
the exposed abdominal wall. Again Langenbeck retractors should
be used to separate the rectus in line with its muscle fibres until
the posterior sheath is exposed. This should also be opened to
enter the abdominal cavity, being careful to avoid damage to
underlying structures. The tract that has been created should be
gently dilated so it is wide enough to admit two fingers.
The opening in the abdominal wall is fashioned in a similar
manner as for an ileostomy. Traditionally, a colostomy is formed
in the left iliac fossa and an ileostomy in the right iliac fossa.
The portion of colon to be exteriorized should be identified.
For an end colostomy, stapling devices are often used to divide
the bowel prior to stoma formation. The selected bowel should
be brought through the stoma trephine using Babcock’s forceps,
ensuring the colon is twist-free. It should be under no tension
and have a good blood supply. If either of these factors are in
doubt further mobilization may be necessary or a different

Ileostomy
The segment of ileum to be used to form the stoma should be
identified. In the case of an end stoma this will be a proximal end of
divided bowel, in a loop ileostomy this will be a predetermined
loop usually marked proximally and distally (often with a suture)
to avoid confusion when the loop is exteriorized. The identified
area should be checked to ensure a good blood supply.
A Babcock’s forcep should be passed down the stoma tract
and used to gently grasp the identified portion of bowel. This can
then be carefully brought to the skin surface via a combination of
gentle traction and by delivering the ileum through the abdom-
inal wall from within the abdomen. The exteriorized bowel
should again have its blood supply assessed. It is also vital that
the stoma is not under too much tension and that the section of
bowel is twist-free. A Babcock forcep is left on the segment of
bowel to secure its external position. Before proceeding to close
the abdominal wall the orientation of the intraperitoneal small
bowel and mesentery should be confirmed to be in its correct
anatomical position. The abdominal wall and the skin of the
laparotomy incision can be closed and covered with a large
sterile swab.
The ileostomy can now be opened and matured. In an end
ileostomy this is achieved using three triangulated sutures placed
on the anti-mesenteric border and either side of the small bowel
mesentery. These sutures each take a bite of the edge of small
bowel mucosa, the serosa of the small bowel at skin level and
subcuticular tissue in the adjacent tissue. Each suture is placed,
clipped and cut. They should then be tied in turn; the very pro-
cess of doing this should evert the stoma forming a spout. Oc-
casionally, the eversion can be facilitated using Babcock’s
forceps to carefully grasp the small bowel mucosa and apply
gentle traction. Once the spout has been formed, further sutures
can be placed between the free edge of small bowel mucosa and
the subcuticular portion of the skin. When forming a loop
ileostomy the loop of small bowel is brought to the surface as Figure 3 Formation of end ileostomy (a) Site of stoma marking. (b) Divi-
previously described, marked in some way to identify proximal sion of distal ileum with GIA stapler. (c) Cruciate incision in anterior rectus
and distal portions. The ileum is opened transversely at the level sheath following excision of circle of skin. (d) Splitting of rectus muscle.
of the skin with the distal portion. The ileostomy spout is (e) Ensuring opening accommodates two fingers. (f ) Gentle delivery of
end of ileum through abdominal wall with Babcock forceps. (g) Eversion
matured from the proximal end in a similar manner to an end
of the end ileostomy with Langenbeck forceps and suturing to abdominal
ileostomy. The distal end of the loop ileostomy is sutured flush wall. (h) Completed end ileostomy.

SURGERY 32:4 215 Ó 2014 Elsevier Ltd. All rights reserved.

 INTESTINAL SURGERY I
segment of bowel should be utilized. Once the identified portion
of bowel is brought to the surface any other laparotomy wounds
should be closed in layers and protected with a sterile dressing.
The exteriorized colon can then be opened using diathermy to
excise the staple line or, in a loop colostomy, divide the bowel in
a transverse plane. The colostomy is formed flush to the skin. It
is secured in place with multiple interrupted 3/0 absorbable su-
ture, taking bites of colonic mucosa/serosa and adjacent sub-
cuticular tissue. The stoma appliance can then be secured.
Trephine stoma
In patients requiring a stoma but not a laparotomy, the formation
of a trephine stoma is a surgical option. This involves making a
small local incision at the site of the stoma, identifying an
appropriate portion of bowel and using it to mature a stoma in
the original incision. This technique is useful when defunction-
ing obstructed patients not suitable for formal laparotomy
(trephine colostomy). It can be difficult to orientate the bowel.
Identifying the caecal pole and working back down the terminal
ileum is a useful technique for trephine ileostomy. For a trephine
colostomy air insufflations through the anus can help identify the
distal end.
Laparoscopic stoma
A minimally invasive approach to stoma formation can be used
to create a defunctioning stoma. The small bowel is seen under
direct vision and mobilized as appropriate. A healthy segment
approximately 12e15 cm from the ileocaecal valve is identified
and delivered to the abdominal wall. A trephine stoma is created
as described previously, with the major advantage being that
once the bowel is delivered to the skin surface pneumo-
peritoneum can be re-established and the orientation of the
bowel checked.
Closure/reversal
Reversal of a loops stoma simply involves excising the existing
stoma, dissecting the associated bowel from the abdominal wall,
performing an anastomosis (either stapled or hand sewn) and
returning the anastomosed bowel to the abdominal cavity. The
stoma tract is closed at the level of the abdominal wall and at the
skin.
Reversal of an end stoma is more complex as one end of the
bowel is often within the peritoneal cavity, or stitched to the lap-
arotomy wound as a mucus fistula. Consequently, a laparotomy
through the old scar has to be performed to adequately mobilize
the two ends of bowel to be anastomosed. This type of reversal is
associated with a high complication rate.
Complications of intestinal stomas
Complications of intestinal stomas occur in around 34% of pa-
tients.13 A significant proportion of these will require revisional
surgery. The complications vary depending on type of stoma.
Patient-related factors, such as cardiovascular morbidity and
obesity, increase the likelihood of a stomal complication.7
Early
Ischaemia and necrosis of a stoma is an early complication. It is
more common following colostomy formation than ileostomy,
although can occur in both. Incidence ranges from 2.3% to
SURGERY 32:4
17%.14 Impairment of blood supply can occur for a number of
reasons. The exteriorized portion of bowel can be skeletonized to
an excessive degree, damaging the blood supply to the distal end.
In obese patients a large abdominal pannus can cause stomal
ischaemia. If the parietal opening through which the stoma
passes is too tight this can also precipitate ischaemia. It is
essential in the early postoperative period to perform daily
assessment of any formed stoma looking for ischaemia. If there
are concerns, mucosal inspection with a bright light is required.
It can be difficult to differentiate between necrosis and haema-
toma. Tactile assessment of the stoma can be helpful; if it is
warm then the blood supply is intact. A stoma that is necrotic
proximal to the fascial opening requires mandatory revisional
surgery. Early stomal ischaemia can lead to stenosis as a later
complication.
Stomal retraction occurs in up to 17% of ileostomies.15 It is
often the consequence of insufficient length of intestine or
inadequate mobilization at the time of operation. Stomal
ischaemia and necrosis can also lead to retraction. Retraction can
make a stoma more difficult to manage. In ileostomy the loss of a
functioning spout can predispose to peristomal skin irritation and
cellulitis that, in turn, can lead to abscess formation and fistulae
(see below). If the stomal retraction is causing significant prob-
lems to the patient then surgical re-siting may be necessary.
Twisting of the stoma will present in the early postoperative
period as small bowel obstruction. The ‘twist’ may be a conse-
quence of failure to orientate the stoma appropriately at the time
of surgery or could be related to a volvulus of small bowel
around the ileostomy. Volvulus can be potentially avoided by
suturing the cut edge of mesentery to the peritoneum, closing any
lateral space. If a mechanical small bowel obstruction is sus-
pected then CT would be the imaging modality of choice. If
confirmed by scan surgical exploration is indicated.
Late
The most common late complication associated with a stoma is
parastomal herniation. This is often as a consequence of an
excessively large fascial opening. They occur in approximately
30% of stomas and in up to 50% of colostomies.1,7 Symptoms
include pain, skin problems and leakage due to ill-fitting stomal
appliance. They can also cause intestinal obstruction. Repair can
be attempted with either a sutured repair or by utilizing mesh. A
high recurrence rate is seen following sutured repair.
Stomal prolapse may occur because of an excessive length of
redundant intra-abdominal bowel or large fascial opening. It is
rarely seen in ileostomy, less common with an end colostomy
and most commonly seen in loop colostomy (particularly trans-
verse). Some surgeons suggest that intra-abdominal fixation of
the stoma can prevent this complication. Mild, non-progressive
prolapses do not require intervention. Gentle pressure to
reduce oedema and prolapse can be tried, and an osmotic poul-
tice may be useful. Ulcerated, irreducible or recurrent prolapse
warrant surgical intervention. Restoration of intestinal continuity
is often the best strategy but if that is not possible re-siting the
stoma or converting a loop into an end stoma may be tried.
Bowel obstruction can be a complication of intestinal stomas.
This may be due to stenosis of the stoma and may be managed by
irrigation and dilatation. Often the obstruction is secondary to
adhesions and will resolve with conservative management.
216 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY I
Failure of the obstruction to settle mandates exploratory
laparotomy.
Ileostomy-specific
Complications more associated with ileostomies include peri-
stomal skin irritation/ulceration and problems with high output.
Irritation of the skin surrounding the ileostomy is often seen due
to the liquid, caustic nature of the bilious small intestine content.
The skin irritation is usually due to two factors: a chemical derma-
titis from the stoma effluent and desquamation of the skin as a
consequence of frequent changes of the stoma appliance. Methods
of combating this problem include good quality predischarge
training in stoma care and the use of well-fitting stoma appliances
and skin barrier creams. The formation of peristomal abscesses is an
infrequent occurrence. They inevitably require surgical drainage.
Following treatment it is not uncommon for intestinal peristomal
fistulas to develop. In patients with Crohn’s disease, formation of a
fistula is almost invariably associated with disease recurrence.
Treatment requires resection of the peristomal disease and re-siting
of the stoma.
Initial ileostomy output is often high volume and care must be
taken to ensure adequate hydration. Treatment involves ensuring
adequate patient hydration and nutrition, using medications to
attempt to thicken effluent and slowing intestinal transit.
Following the resumption of diet the ileostomy effluent thickens.
Over time the small bowel adapts to increase water absorption
and reduce output. High output ileostomies can also be the
consequence of too proximal a stoma. In persistent high output
stomas restoration of intestinal continuity at the earliest oppor-
tunity is indicated. A
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Acknowledgement
The illustrations were drawn by Cara Baker MRCS PhD, Specialist
Registrar in Surgery at St Richard’s Hospital, Chichester, UK.
217 Ó 2014 Elsevier Ltd. All rights reserved.