Colostomy
Content
Stoma dr. Citra Roshian
Pembimbing : dr. Tommy Ruchimat, Sp.B-KBD
Anatomi Abdomen
Fisiologis
Lambung motorik
Reservoir Mencampur Pengosongan lambung
Pencernaan & sekresi Pencernaan protein Sintesis dan pelepasan gastrin Sekresi faktor intrinsik Sekresi mukus
Usus Halus Pencernaan
Absorbsi Nutrisi
Dibantu oleh enzim dan hormon
Cairan Elektrolit
Usus Besar
Mengabsorbsi
cairan dan elektrolit Reservoir massa faeses Dengan bantuan bakteri sintesis vitami
The physiology of the colon should be taken into account when considering stoma construction. The right side of the colon absorbs water and has irregular peristaltic contractions. Stomas made from the proximal half of the colon usually expel a liquid content. The left colon serves as a conduit and reservoir and has a few mass peristaltic motions per day . The content is more solid, and in many cases the stoma output can be regulated by irrigation. Proximal colostomies should be avoided , as they will combine the worst features of both a colostomy and an ileostomy: liquid, high-volume, foul-smelling effluent. The left colon should be used for a colostomy if possible; the distal transverse colon is also a reasonable choice.
Lokasi Stoma yang baik
Lokasi Stoma
The most common indication is cancer of the rectum. Colostomy is an opening of the large intestine, no sphincteric control better on the abdominal wall than in the perineum (maintanence). A distal colorectal anastomosis in an elderly patient with a poorly functioning anal sphincter may result in what is essentially a "perineal colostomy." In these cases, it often behooves the surgeon to construct a good colostomy rather than to restore intestinal continuity to an incontinent anus. Colostomies are also constructed as treatment for obstructing lesions of the distal large intestine and for actual or potential perforations.
Colostomy
End sigmoid Descending
Emergency / elektif
Sementara / permanent
Kanker rektum (abdominoperineal reseksi) Tujuan hygiene (tetraplegia / inkontinensia alvi) Diversi faeses Obstruksi Perforasi Kasus trauma
Type by Anatomic Location
Type of colostomy categorized by the part of the colon used in its construction. The most common type : "end-sigmoid" colostomy. However, if the inferior mesenteric artery is transected during an operation for cancer of the rectum, the blood supply to the sigmoid colon is no longer dependable, and it should not be used for stoma construction. "end-descending" colostomy is preferable to an endsigmoid colostomy. Other types of colonic stomas include the transverse colostomy and cecostomy.
Type by Function More important than the anatomy of the colon is the function that the colostomy is intended to perform. There are two considerations: (1) to provide decompression of the large intestine (2) to provide diversion of the feces.
Types of Decompressing Stomas
(1)
(2) (3)
There are three types of decompressing stomas: the so-called "blow-hole" decompressing stoma constructed in the cecum or transverse colon, a tube type of cecostomy, and a loop-transverse colostomy.
"blow-hole"
a tube type of cecostomy
a loop-transverse colostomy
Loop colostomy
Diverting Colostomy
A diverting colostomy is constructed to provide diversion of intestinal content. It is performed because the distal segment of bowel has been completely resected (as during abdominoperineal resection), because of known or suspected perforation or obstruction of the distal bowel (e.g., obstructing carcinoma, diverticulitis, leaking anastomosis, or trauma), or because of destruction or infection of the distal colon, rectum, or anus (e.g., Crohn's disease or failed anal sphincter reconstruction).
Diverting stomas
Loop ileostomy
Loop ileostomy
End ileostomy
Construction of an End Colostomy
An end, completely diverting, colostomy usually is located in the left lower quadrant, where the site is chosen preoperatively by placing a vertical line through the umbilicus and another line transversely through the inferior margin of the umbilicus and by affixing a disk the size of a stoma faceplate to designate the stoma opening through the rectus muscle and on the summit of the infraumbilical fan fold. An alternative location is through the midline fascia, not necessarily at the umbilicus. Although this site initially seems esthetically unappealing, it allows construction of a stoma with a lower incidence of symptomatic hernia formation because of the ability to tightly close the linea alba around the stoma.
End Colostomy
Once a site is chosen, the patient should be evaluated in multiple body configurations to verify the adequacy of the stoma site. A common mistake is to choose the site with the patient supine and then find when the patient rises to a standing or sitting position that the chosen site is completely obscured by fat folds, scar tissue, or a protruding skeletal structure. The location should be adjusted up or down, even considering the use of upper quadrants of the abdomen if necessary, to allow proper fixation of an appliance and easy access by the patient. The site usually is marked with ink in the patient's room and then is scratched into the skin with a needle in the operating room after induction of anesthesia. This is totally painless for the patient and does not leave a permanent tattoo should colostomy not be needed.
An end colostomy most often is constructed after removal of the rectum for low-lying malignancy. The entire left colon is mobilized on its mesentery, and depending on mobility of the colon and thickness of the abdominal wall, may require mobilization of the splenic flexure. If the patient has received neoadjuvant pelvic radiotherapy and/or the inferior mesenteric artery is transected at its origin at the aorta, the entire sigmoid colon should be removed because of concerns regarding ischemia and a descending colostomy created.
If the colostomy is to be brought through the left lower quadrant, an opening in the abdominal wall is made at the previously marked site by excising a 3-cm disk of skin. The undesirable oval configuration of a stoma is avoided by placing traction clamps in the dermis, the fascia, and the peritoneum. These clamps are held in alignment when the opening is made through the abdominal wall. This duplicates the configuration of the abdominal wall when the abdomen is closed and should allow construction of a desirable circular stoma.
The fat, fascia, muscle, and posterior peritoneum are then incised longitudinally. No fat is excised. The opening is then dilated to allow passage of two fingers, and the closed end of the colon is pulled through the abdominal wall. There, mesentery of the colon can be sutured to the lateral abdominal wall with a running suture, although the complication of small bowel obstruction due to torsion of the small bowel mesentery around the colon mesentery has not been proven to be reduced by this maneuver. After the wound is closed and protected, attention is directed to completing the colostomy. The stoma is completed by excising the staple or suture line and by placing chromic catgut sutures between the full thickness of colon and skin. If the stoma is constructed because of inflammatory bowel disease or radiated bowel, a spigot configuration is utilized by applying principles similar to those for ileostomy construction. This facilitates a good appliance seal for anticipated high-volume, liquid effluents .
If the colostomy will be brought through the midline, no fixation of the mesentery is necessary. The intended midline colostomy is brought through the abdominal incision, and the entire incision is closed, with the sutures adjacent to the colostomy being tied last. At least a few interrupted sutures are placed on either side of the colostomy even if a running closure of the abdominal wall is used. As the last sutures are tied, the colon is pulled through the abdominal wall, and the surgeon's finger is placed adjacent to the stoma as a spacer to avoid compromise of the blood supply to the stoma. The skin is closed and the wound is protected as attention is directed to the colostomy, where either the staple line is excised or the clamp is removed, and full thickness of colon is sutured to full thickness of skin with interrupted absorbable sutures.
Once the stoma construction is complete, an appliance is applied in the operating room. The simplest is a one-piece appliance with a skin barrier that can be cut to the appropriate size of the stoma. This same appliance can be used for colostomy and ileostomy. The pouch is allowed to fall to the patient's side, because in the postoperative period, the patient will be supine rather than upright the majority of the time. The appliance, which need not be sterile, is held in place with the skin adhesive of the appliance and is secured with strips of nonallergenic tape placed in "picture-frame" fashion. The remaining wound dressing is applied. Tincture of benzoin should never be used to maintain adhesion of an appliance to the skin because it has a high risk of initiating contact dermatitis. If colostomy function does not begin within 4 or 5 days, the stoma can be irrigated with small volumes (250 mL) of normal saline to initiate stoma function. The enterostomal therapy nurses are involved early in the care of the stoma and in teaching the patient and family to provide long-term care of the colostomy. In most cases, the patient is taught the technique of stoma irrigation, and then each individual decides in the more distant postoperative course if she or he wishes to irrigate the stoma or not.
Perawatan stoma
Waktu yg tepat untuk mengganti kantung Frekuensi mengganti kantung Proteksi kulit peristoma Kontrol bau & gas Management diare Pencegahan & management gangguan cairan & elektrolit Pencegahan & management konstipasi Irigasi stoma
Komplikasi
Metabolik problems Parastoma abses, ulcerasi, hernia Striktur Volvulus Caput medusae
Pembimbing : dr. Tommy Ruchimat, Sp.B-KBD
Anatomi Abdomen
Fisiologis
Lambung motorik
Reservoir Mencampur Pengosongan lambung
Pencernaan & sekresi Pencernaan protein Sintesis dan pelepasan gastrin Sekresi faktor intrinsik Sekresi mukus
Usus Halus Pencernaan
Absorbsi Nutrisi
Dibantu oleh enzim dan hormon
Cairan Elektrolit
Usus Besar
Mengabsorbsi
cairan dan elektrolit Reservoir massa faeses Dengan bantuan bakteri sintesis vitami
The physiology of the colon should be taken into account when considering stoma construction. The right side of the colon absorbs water and has irregular peristaltic contractions. Stomas made from the proximal half of the colon usually expel a liquid content. The left colon serves as a conduit and reservoir and has a few mass peristaltic motions per day . The content is more solid, and in many cases the stoma output can be regulated by irrigation. Proximal colostomies should be avoided , as they will combine the worst features of both a colostomy and an ileostomy: liquid, high-volume, foul-smelling effluent. The left colon should be used for a colostomy if possible; the distal transverse colon is also a reasonable choice.
Lokasi Stoma yang baik
Lokasi Stoma
The most common indication is cancer of the rectum. Colostomy is an opening of the large intestine, no sphincteric control better on the abdominal wall than in the perineum (maintanence). A distal colorectal anastomosis in an elderly patient with a poorly functioning anal sphincter may result in what is essentially a "perineal colostomy." In these cases, it often behooves the surgeon to construct a good colostomy rather than to restore intestinal continuity to an incontinent anus. Colostomies are also constructed as treatment for obstructing lesions of the distal large intestine and for actual or potential perforations.
Colostomy
End sigmoid Descending
Emergency / elektif
Sementara / permanent
Kanker rektum (abdominoperineal reseksi) Tujuan hygiene (tetraplegia / inkontinensia alvi) Diversi faeses Obstruksi Perforasi Kasus trauma
Type by Anatomic Location
Type of colostomy categorized by the part of the colon used in its construction. The most common type : "end-sigmoid" colostomy. However, if the inferior mesenteric artery is transected during an operation for cancer of the rectum, the blood supply to the sigmoid colon is no longer dependable, and it should not be used for stoma construction. "end-descending" colostomy is preferable to an endsigmoid colostomy. Other types of colonic stomas include the transverse colostomy and cecostomy.
Type by Function More important than the anatomy of the colon is the function that the colostomy is intended to perform. There are two considerations: (1) to provide decompression of the large intestine (2) to provide diversion of the feces.
Types of Decompressing Stomas
(1)
(2) (3)
There are three types of decompressing stomas: the so-called "blow-hole" decompressing stoma constructed in the cecum or transverse colon, a tube type of cecostomy, and a loop-transverse colostomy.
"blow-hole"
a tube type of cecostomy
a loop-transverse colostomy
Loop colostomy
Diverting Colostomy
A diverting colostomy is constructed to provide diversion of intestinal content. It is performed because the distal segment of bowel has been completely resected (as during abdominoperineal resection), because of known or suspected perforation or obstruction of the distal bowel (e.g., obstructing carcinoma, diverticulitis, leaking anastomosis, or trauma), or because of destruction or infection of the distal colon, rectum, or anus (e.g., Crohn's disease or failed anal sphincter reconstruction).
Diverting stomas
Loop ileostomy
Loop ileostomy
End ileostomy
Construction of an End Colostomy
An end, completely diverting, colostomy usually is located in the left lower quadrant, where the site is chosen preoperatively by placing a vertical line through the umbilicus and another line transversely through the inferior margin of the umbilicus and by affixing a disk the size of a stoma faceplate to designate the stoma opening through the rectus muscle and on the summit of the infraumbilical fan fold. An alternative location is through the midline fascia, not necessarily at the umbilicus. Although this site initially seems esthetically unappealing, it allows construction of a stoma with a lower incidence of symptomatic hernia formation because of the ability to tightly close the linea alba around the stoma.
End Colostomy
Once a site is chosen, the patient should be evaluated in multiple body configurations to verify the adequacy of the stoma site. A common mistake is to choose the site with the patient supine and then find when the patient rises to a standing or sitting position that the chosen site is completely obscured by fat folds, scar tissue, or a protruding skeletal structure. The location should be adjusted up or down, even considering the use of upper quadrants of the abdomen if necessary, to allow proper fixation of an appliance and easy access by the patient. The site usually is marked with ink in the patient's room and then is scratched into the skin with a needle in the operating room after induction of anesthesia. This is totally painless for the patient and does not leave a permanent tattoo should colostomy not be needed.
An end colostomy most often is constructed after removal of the rectum for low-lying malignancy. The entire left colon is mobilized on its mesentery, and depending on mobility of the colon and thickness of the abdominal wall, may require mobilization of the splenic flexure. If the patient has received neoadjuvant pelvic radiotherapy and/or the inferior mesenteric artery is transected at its origin at the aorta, the entire sigmoid colon should be removed because of concerns regarding ischemia and a descending colostomy created.
If the colostomy is to be brought through the left lower quadrant, an opening in the abdominal wall is made at the previously marked site by excising a 3-cm disk of skin. The undesirable oval configuration of a stoma is avoided by placing traction clamps in the dermis, the fascia, and the peritoneum. These clamps are held in alignment when the opening is made through the abdominal wall. This duplicates the configuration of the abdominal wall when the abdomen is closed and should allow construction of a desirable circular stoma.
The fat, fascia, muscle, and posterior peritoneum are then incised longitudinally. No fat is excised. The opening is then dilated to allow passage of two fingers, and the closed end of the colon is pulled through the abdominal wall. There, mesentery of the colon can be sutured to the lateral abdominal wall with a running suture, although the complication of small bowel obstruction due to torsion of the small bowel mesentery around the colon mesentery has not been proven to be reduced by this maneuver. After the wound is closed and protected, attention is directed to completing the colostomy. The stoma is completed by excising the staple or suture line and by placing chromic catgut sutures between the full thickness of colon and skin. If the stoma is constructed because of inflammatory bowel disease or radiated bowel, a spigot configuration is utilized by applying principles similar to those for ileostomy construction. This facilitates a good appliance seal for anticipated high-volume, liquid effluents .
If the colostomy will be brought through the midline, no fixation of the mesentery is necessary. The intended midline colostomy is brought through the abdominal incision, and the entire incision is closed, with the sutures adjacent to the colostomy being tied last. At least a few interrupted sutures are placed on either side of the colostomy even if a running closure of the abdominal wall is used. As the last sutures are tied, the colon is pulled through the abdominal wall, and the surgeon's finger is placed adjacent to the stoma as a spacer to avoid compromise of the blood supply to the stoma. The skin is closed and the wound is protected as attention is directed to the colostomy, where either the staple line is excised or the clamp is removed, and full thickness of colon is sutured to full thickness of skin with interrupted absorbable sutures.
Once the stoma construction is complete, an appliance is applied in the operating room. The simplest is a one-piece appliance with a skin barrier that can be cut to the appropriate size of the stoma. This same appliance can be used for colostomy and ileostomy. The pouch is allowed to fall to the patient's side, because in the postoperative period, the patient will be supine rather than upright the majority of the time. The appliance, which need not be sterile, is held in place with the skin adhesive of the appliance and is secured with strips of nonallergenic tape placed in "picture-frame" fashion. The remaining wound dressing is applied. Tincture of benzoin should never be used to maintain adhesion of an appliance to the skin because it has a high risk of initiating contact dermatitis. If colostomy function does not begin within 4 or 5 days, the stoma can be irrigated with small volumes (250 mL) of normal saline to initiate stoma function. The enterostomal therapy nurses are involved early in the care of the stoma and in teaching the patient and family to provide long-term care of the colostomy. In most cases, the patient is taught the technique of stoma irrigation, and then each individual decides in the more distant postoperative course if she or he wishes to irrigate the stoma or not.
Perawatan stoma
Waktu yg tepat untuk mengganti kantung Frekuensi mengganti kantung Proteksi kulit peristoma Kontrol bau & gas Management diare Pencegahan & management gangguan cairan & elektrolit Pencegahan & management konstipasi Irigasi stoma
Komplikasi
Metabolik problems Parastoma abses, ulcerasi, hernia Striktur Volvulus Caput medusae
