Indikasi, Teknik pembuatan

stoma, dan Reanastomosis

KOLEGIUM ILMU BEDAH INDONESIA

ileostomi Kolostomi
 Indications for ileostomy

 Ulcerative colitis (Colitis ulcerosa) (Colon, bloody slimy

multiple diarrhorea, 10-17/day)

 Crohn's disease (inflammation of small/big colon) diarrhoea, fatigue, weight loss,

abdominal pain, anaemia)

 Familial polyposis (>100 adenoids, malignant after 10yrs)

 Fistulas

 Traumas

 Obstruction

 Irradiation damages
Different types of ileostomies
Permanent ileostomy

 End ileostomy

Temporary ileostomies
End ileostomy

loop ileostomy
 End ileostomy

Newly operated ”Perfect” ileostomy

Sutures are pulling the skin Normal colour and size
Separation (beginning) Nice round shape
Skin slightly macerated Surrounding skin normal
Post-op oedema
 Loop ileostomy

Oral: 3-4 cm (everted) Oedema

Anal: skin level
 Characteristics of ileostomy

 Relatively young, usually less than 45 years

 Life expectancy longer after operation

 Impossible to live without caring devices, and

moreover, skin problems are very common

 Physiological impact is big

 Colostomy

 Created :
- to be permanent or temporary

- electively, emergently, or incidently due to

unexpected event during surgery
 Reasons for creating a
colostomy
 Rectal cancer

 Cancer of the colon

 Diverticulitis

 Trauma

 Congenital abnormalities

 Radiation injuries

 Chronic severe obstipation

 Anorectal incontinence
 Characteristics of colostomy

 Relatively old, age > 60 years

 Life expectancy after operation is variable

depending on the stage of disease when diagnosed

 Possible to live without caring devices due to regular

stomal discharge behavior

 Less impact on physiological functions

 Different types of colostomies

Permanent colostomies
 sigmoid colostomy

Temporary colostomies
sigmoid colostomy a.m. Hartmann

loop transverse colostomy

divided transverse colostomy

 End Sigmoid Colostomy
Cataldo TE, End Sigmoid/Descending Colostomy in Cataldo PA, MacKeigan,
Intestinal Stomas,Principles,Techniques, and Management, 2004

 Most frequent diversions in sigmoid perforation.

Diminished with the increasing frequency single stage resection for
acute diverticulitis.
If distal anastomosis or surgical site requires proximal fecal
diversion : loop or end loop ileostomy is growing in popularity

 An elective & permanent end sigmoid colostomy :

- part of abdominoperineal resection ( Miles’ proc ) for distal
rectal cancer
- for improving hygiene in : - paraplegic
- permanent fecal incontinence
 Sigmoid
Colostomy
Rectal amputation Sigmoid colostomy
+ sigmoid colostomy a.m. Hartmann
 Colostomy

Newly operated ”Perfect” Ostomy

Skin looks fine Normal colour and size
Aseptic post-op inflammation Nice round shape
Post-op oedema Surrounding skin normal
 COLON & RECTAL TRAUMA

Surgical options :
1. Primary repair
- Direct closure
- Segmental resection & primary anastomosis

1. Colostomy
- proximal end colostomy or ileostomy
* with distal mucous fistula
* or distal closure ( Hartman’s procedure )
- loop colostomy of the injured segment
- diverting colostomy proximal to suture repair

Ciesla DJ, Burch JM, Colon and Rectal Injuries in Asensio JA, Trunkey DD, Current Therapy of Trauma and Surgical
Critical Care, 2008
 COLON & RECTAL TRAUMA

 Patient selection based on :

1. the location
2. degree of injury
3. physiologic state of the patient
Degree of Injury
AAST Colon injury scale, 2007
Grade* Type of injury Description of injury ICD-9 AIS-90

I Hematoma Contusion or hematoma without devascularization 863.40-863.44 2

Laceration Partial thickness, no perforation 863.40-863.44 2

II Laceration Laceration <50% of circumference 863.50-863.54 3

III Laceration Laceration > 50% of circumference without 863.50-863.54 3

transection

IV Laceration Transection of the colon 863.50-863.54 4

V Laceration Transection of the colon with segmental tissue loss 863.50-863.54 4

Vascular Devascularized segment 863.50-863.54 4

*Advance one grade for multiple injuries up to grade III. *863.41,863.51-ascending;863.42, 863.52-transverse;863.45,863.53-
descending; 863.44,863.54-rectum.
From Moore et al. [6]; with permission
AAST Rectum injury scale, 2007
Grade* Type of injury Description of injury ICD-9 AIS-90

I Hematoma Contusion or hematoma without devascularization 863.45 2

Laceration Partial-thickness laceration 863.45 2

II Laceration Laceration < 50% of circumference 863.55 3

III Laceration Laceration > 50% of circumference 863.55 4

IV Laceration Full-thickness laceration with extension into the perineum 863.55 5

V Vascular Devascularized segment 863.55 5

*Advance one grade for multiple injuries up to grade III.

From Moore et al. [6]; with permission
(http://www.aast.org/Library/dynamic.aspx?id=1472)
 COLON & RECTAL TRAUMA

 Simple, non destructive injury, that do not require

segmental resection (AAST CIS I-III) :
primary suture repair.
 Destructive colon injury
 More complex choices.

1) 1st consideration : physiologic state

2) Primary repair : optimal treatment.

Injury proximal to middle colic artery : right colectomy &
ileocolostomy anastomosis

3) Ileocolostomy :
- a robust anastomosis under emergent condition
- low associated leak rate
 for almost all injuries proximal to MCA
 Destructive colon injury

 Distal to MCA :
Procedure of choice :
- primary repair
- segmental resection & colocolostomy
 The result = / better than colostomy ,
with respect to postop complication
(contemporary retrospective & prospective
randomized study)
 Risk Factors for Suture Line Failure

1. Blood loss
2. Concomitant solid organ injury
3. Mechanism of injury
4. Delayed repair
5. Patient age
6. Subjective evaluation :
- degree of bowel edema
 placement & tension of anastomotic
sutures uncertain & healing unpreditable
 Consider Colostomy
 End
Proximal colostomy
and
ostomy Hartman’s
Distal Yes procedure
Yes
closure
Demage control:
Control bleeding
Rapid segmental
Resuscitation
Persistent
resection using GIA ICU 24-72 edema
stapler hours
High
Yes
risk
for
leak
No
Hyphotermia Yes
Acidosis
Coagulopathy
Injury distal to No Resection
middle colic and
artery colocolost
omy
Yes
No
No
Destructive
injury
Resection and
ileocolostomy

No Primary
suture repair
 Resection +
end colostomy
Yes
Destructive injury

Yes

No

Visualized Primary
rectal injury repair

No

Loop colostomy + presacral

drainage
SURGICAL TECHNIQUE
End ileostomy
 Loop colostomy

www.themegallery.com
Loop end colostomy
REANASTOMOSIS

Timing of Procedures
Preoperative Assessment

Preparation

Operative Technique
 Timing Of Procedure

 Hemodinamik Stabil

 Tidak infeksi

 Status Gizi baik

 Timing of Procedure

 8-12 minggu untuk penutupan loop stoma

 12-24 minggu untuk penutupan end ostomy

 8-12 minggu pada kasus trauma

 12-24 minggu pada kasus Malignancy, IBD, TBC

 Pre Operative Assessment

 Anamnesa: Waktu, Etiologi, gejala, hasil PA,

premorbid, Rekam medis.
 Pemeriksaan Fisik:
Keadaan umum
Status lokalis; Abdominal, Perineal, Stoma.
 Laboratorium;
Umum
Khusus (premorbid, tumor marker)
 Pre Operative Assessment

 Imaging

 Anatomi : Distal Colografi, Endoscopy, Foto

Abdomen 3 posisi, USG, CT-Scan, Endo-US

 Physiology: Straining Test, Squeeze Test, Anorectal

Manometri, Defecografi
 Preparation

 ASA Classification: DM dan penggunaan steroid

jangka panjang merupakan independent predictors
pada operatif morbidity pasien dengan stoma.

 Deficits Physiology: Anemia, dehidrasi, gangguan

elektrolit, dan malnutrisi harus dikoreksi

 Antiplatelet dan Anticoagulants medications

 Personal higiene

 Pencukuran daerah operasi

 Preparation

 Fisik
 Mental
 Penunjang
Persiapan yang baik akan mempengaruhi tingkat
keberhasilan operasi disamping faktor-faktor lain
seperti usia, status nutrisi, penyakit kronis, dsb.
 Informed Concent
 Preparation

Diit
 Low residu
 Supplement vitamin K dan C
 Clear liquids sehari sebelum pembedahan

Persiapan colon
 Laxative sebelum operasi
 Antibiotik untuk mengurangi bakteri yg ada di colon
 Operative Technique

 Intraperitoneal atau Extraperitoneal

 Approach:

Open; laparotomy (end ostomy, divided)

Parastoma (Loop stoma, Double barrel)

Laparoscopy assisted Stoma Closure.

Operative Technique
Operative Technique
 Komplikasi

 Anastomosis leak, Fistula dan Abses (0-10%)

 Stricture dan Perdarahan Intestinal (<1%)
 Bowel Obstruction (1-5%)
 Stoma site herniation (<1%)
 Wound Infection (0,5-5%)
 Penyebabnya multifaktor:
(Umur, Underlying Condition, Ostomy Type, Timing
and Technique of Closure, Wound Management)
 Hal-hal yang harus diwaspadai

 Sphincter Injury
 Persistent or Recurrent Tumor
 Longer Strictures (IBD)
 Radiation Injury
 Proctocolitis
 Summary

 Preoperative Assessment Appropriate

 Suitable Operative Technique
 Intensive Post Operative Care