INTRODUCTION

Proper construction of an ileostomy is a fundamental and essential skill for all surgeons operating in the abdomen. It can be performed either as a separate operation or as a part of a larger procedure and can be created using a traditional open incision or laparoscopic techniques.¹ Depending upon the indication, an ileostomy may be constructed in a variety of ways. Because both ends of the small bowel are accessible on the surface of the skin, loop ileostomies are generally easier to close and intended to be temporary stomas. However, a recent study of patients undergoing surgery for rectal cancer showed that approximately 19% of these “temporary” stomas will never be reversed.² End ileostomies may be either permanent or temporary depending upon the remaining bowel anatomy, but generally require a laparotomy to restore bowel continuity. An “end-loop” ileostomy is generally used when there is difficulty reaching through the abdominal wall (Fig. 22-1).

Figure 22-1 An end-loop ileostomy. The mesentery to the bowel is not divided, enabling the bowel to be brought through a thick abdominal wall without the risk of ischemia.

(Adapted from Wu JS. Ileostomy. Oper Tech Gen Surg 2003;5:257–263.)

Ileostomies have a significant impact on the quality of life of patients, with up to 80% experiencing some change in their lifestyle after the creation of a stoma.³ The degree of social impact appears to be related to the number of stoma care problems.⁴ Regardless of the indication for the procedure or the technique used, surgeons must adhere to several basic principles in order to minimize postoperative stoma-related complications.

INDICATIONS

OPERATIVE STEPS

OPERATIVE PROCEDURE

Site Selection

Poorly Fitting or Leaking Stoma Appliance

• Consequence

Breakdown of the skin surrounding the ileostomy. Approximately 28% of patients with an ileostomy would prefer the stoma to be relocated, and the percentage is higher in patients undergoing an emergency procedure (37%) than in those undergoing elective surgery (23%).³ Thirty percent to 61% of patients experience excoriation of the skin around the stoma, and 22% to 57% of patients experience leakage^4–6 (Fig. 22-2).

Grade 1 complication

Figure 22-2 The site for this ileostomy was not marked prior to the operation. In the operating room, it looks to be in good position. However, postoperatively, when the patient is seated the ileostomy is low, making care difficult.

• Repair

Patient education and changing the type of appliance may be effective. In extreme cases, laparotomy with stoma relocation may be necessary.

• Prevention

Ideally, the stoma should be placed through the rectus muscle centered on a flat area or on the crest of a fat roll away from scars, creases, or bony prominences. The site should be chosen prior to the operation after examining the patient in the supine and sitting positions. Marking the patient preoperatively in the proper site can significantly reduce skin problems in the immediate postoperative period.⁷

Selection of the Bowel Segment and Preparation of the Bowel

High-Output Stoma

• Consequence

Electrolyte imbalances or dehydration potentially leading to acute renal failure. A prospective analysis of 60 patients undergoing restorative colectomy with a defunctioning ileostomy showed that ileostomy output peaked at postoperative day 4 and that the critical period for acute dehydration was from 3 to 8 days after the operation. During this time, ileostomy output is increasing, but oral intake is still limited.⁸ Overall, dehydration occurs in 5% to 20% of patients with ileostomies.^6,9

Grade 1 complication

• Repair

Replacement fluids should be given while monitoring standard parameters of resuscitation. Serum electrolytes should be checked and replaced as needed. Loperamide has been shown to decrease ileostomy output by 22%.¹⁰ Bismuth subgallate, lomotil, tincture of opium, and codeine sulfate have also been shown to reduce ileostomy output.¹¹

• Prevention

During surgery, every effort should be made to preserve the distal small bowel and use the most distal portion of the small bowel for the ileostomy. Postoperatively, ileostomy output should be carefully measured and recorded. On discharge, patients should be instructed and taught to continue to track the stoma output.

Stoma Retraction

• Consequence

Leakage around the stoma, leading to peristomal skin irritation. Retraction of a loop ileostomy can result in incomplete defunctionalization of the distal bowel.^6,12 Stoma retraction occurs in up to 17% of ileostomy patients followed for 20 years.¹³

Grade 3 complication

• Repair

Stoma revision may be accomplished by a local procedure at the ileostomy site, but the majority of cases will require a laparotomy.

• Prevention

Stoma retraction is caused by tension on the bowel or loss of the distal stoma from necrosis. Retraction often is associated with a high body mass index.¹⁴ In obese patients, an end-loop ileostomy should be considered. Some data indicate a higher rate of retraction in contaminated stoma cases, although this is not specific for ileostomies.¹⁵

Necrotic/Ischemic Stoma

• Consequence

Superficial necrosis of the stoma, resulting in stenosis or retraction of the stoma. If the ischemic segment extends below the fascia, peritonitis can result. A simple bedside test can be performed to assess the depth of necrosis (Fig. 22-3).

Grade 2/3 complication

Figure 22-3 To determine the depth of ischemia or necrosis of a stoma, a test tube is gently inserted into the stoma opening. A penlight is used to help visualize the mucosa. If the ischemia extends below the fascial level, an urgent laparotomy is required.

• Repair

Superficial necrosis can be observed. If it results in stenosis or difficulty fitting the appliance, the stoma will need to be revised. If the ischemic segment extends below the fascia, an emergent laparotomy is required.

• Prevention

Mesenteric tension or excessive trimming of the mesentery may result in an ischemic stoma. The last vascular arcade of the small bowel mesentery should be preserved. Again, consideration should be given to constructing an end-loop ileostomy, especially in obese patients.

Stoma Stenosis

• Consequence

Difficulty fitting the appliance, stoma leakage, and noise while passing flatus (Fig. 22-4).

Grade 2/3 complication

Figure 22-4 Ischemia at the distal end of the ileostomy or tension on the mesentery of the bowel can lead to stenosis. This will make it difficult for the patient to properly fit the appliance.

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