Editing Intestinal Segments and Urinary Diversion (section)

== Abdominal Stoma ==

* '''Two types of stomas may be made on the anterior abdominal wall:''' '''flush with the skin and those that protrude.'''
** '''The flush stoma is preferable for the continent type of diversion in which intermittent catheterization is carried out and over which a small dressing is placed.'''
** '''The stoma that protrudes is preferable when a collection device is worn'''. A properly protruding stoma worn with an appliance results in a lesser incidence of stomal stenosis and a better appliance fit with fewer peristomal skin problems.
* '''The site of the stoma should be selected preoperatively. This is done by marking the stomal site with the patient in the sitting position, as well as in the supine position'''
* '''All stomas should be placed through the belly of the rectus muscle'''
** '''If''' '''the stoma is placed lateral to the rectus sheath, a parastomal hernia is likely to occur'''.
** The stoma should be brought through a circular incision made at the predetermined site.
** Paraplegics, often with abdominal prolapse and wheel-chair existence pose a special problem for stomal site selection. A right lower quadrant site often results in a stoma that is difficult for the patient to see, with the stoma and appliance squeezed between the abdomen and thigh. For this reason, '''in the paraplegic patient, the stoma should always, if possible, be placed in the upper abdomen''' [SASP 2014]
* '''Nipple Stoma: “Rosebud”'''
** Summary of Steps:
*** A Babcock clamp is placed through the opening, and the bowel is grasped and brought out for a distance of 5 to 6 cm to make a nipple of about 2 to 3 cm in length. Two 3-0 chromic sutures are placed through the seromuscular layer of the bowel and the peritoneum on the anterior abdominal wall. Alternatively, the serosa may be sutured to the fascia with two 2-0 chromic sutures. The mesentery is aligned in its normal anatomic direction before the serosa is sutured to the peritoneal wall. The ileum is usually curved in a concave manner toward the mesentery. If the curvature is severe, the mesentery may be partially incised 1 cm from the bowel wall. Thus a portion of mesentery is preserved along the entire length of the bowel. This should straighten the curve in the bowel significantly if not completely. Four 3-0 chromic sutures are placed in quadrants through the full thickness of the bowel edge and through the seromuscular layer of the bowel 3 to 4 cm from the cut edge and then through the subcuticular skin layer. Sutures should not traverse the full thickness of the skin but should be placed through the subcuticular and subdermal layers only.
*** When the sutures are tied, the bowel is everted and forms a nipple. A more secure nipple may be made by performing multiple myotomies through the seromuscular layer of the bowel above the skin line before construction of the nipple. The myotomies adhere serosa to serosa and reduce the risk of stomal retraction. This is particularly appropriate for patients who are obese
* Flush Stoma [Further details in Campbell’s]
* '''Loop End Ileostomy''' [Further details in Campbell’s]
** '''Easier to perform than the ileal end stoma in the patient who is obese'''
* '''Complications of Intestinal Stomas'''
** '''Early complications of abdominal stomas include:'''
**# '''Stomal stenosis (most common)'''
**#* '''Leaving a catheter through the superficial portion of stoma nightly may reduced the need for operative revision of stomal stenosis'''
**#* '''Most likely cause of elongated dilated conduit with hydronephrosis and hyperchloremic acidosis'''
**# '''Stomal retraction'''
**# '''Stomal prolapse'''
**# '''Parastomal hernia'''
**#* More common with loop than end-on stomas
**#* '''Most effective management is relocation of the stomal site to the other side of the abdominal wall''' and by closure of the hernia.
**# '''Bowel necrosis'''
**# '''Bleeding'''
**#* '''Bleeding that is extremely difficult to manage may be a result of cirrhosis and varices. In this situation, life-threatening bleeding from the stoma or conduit may occur. To stop the bleeding, portal decompression may be required'''
**# '''Dermatitis'''
**# '''Obstruction'''