Stoma Examination and viva for practical examination PG general surgery
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I now have comprehensive material from multiple authoritative surgical textbooks. Let me compile the complete PG surgery examination guide on stoma.
Stoma - Examination & Viva Guide for PG General Surgery
Definition
A stoma (Greek: "mouth") is a surgically created opening in the abdominal wall that brings a portion of the bowel (or urinary tract) to the surface to divert the contents of the gut (feces/urine) - Bailey & Love's Short Practice of Surgery, 28th Ed.
A stoma may serve as:
- A definitive procedure (permanent stoma)
- A temporary diversion to protect a distal anastomosis or allow healing
- A salvage from a failed/complicated prior surgical intervention
Classification
By Duration
| Type | Characteristics |
|---|---|
| Temporary | Protects anastomosis, diverts fecal stream; intended for reversal |
| Permanent | Required when continuity cannot be restored (e.g., APR, total colectomy with incontinence) |
By Bowel Used
| Stoma | Bowel segment | Output character |
|---|---|---|
| Ileostomy | Ileum | Liquid/semi-liquid, caustic, high volume |
| Colostomy | Colon | Varies - ascending = liquid; descending/sigmoid = formed, less irritant |
| Urostomy/Ileal conduit | Ileum (urinary diversion) | Urine |
By Configuration
| Type | Description | Common use |
|---|---|---|
| End stoma | Single barrel; bowel divided, proximal end brought out | APR (end colostomy), Hartmann's procedure |
| Loop stoma | Loop of bowel with supporting rod; two openings (afferent/efferent) | Temporary diversion; easier to close |
| Double-barrel | Both limbs brought out as separate stomas | Emergency; significant inflammation/sepsis |
| End-loop | Loop mobilized, distal limb stapled/oversewn | Alternative to loop; useful with limited mesentery |
| Ghost ileostomy | Loop marked but not opened, sutured subfascially | "Safety net" if anastomotic leak occurs post-op |
Viva point: A transverse loop colostomy should be avoided - it is large, prone to prolapse, placed in the belt line (mid-upper abdomen), making pouching difficult. - Sabiston Textbook of Surgery
Sites and Siting
Ideal Stoma Site Criteria (must know for viva)
- Within the rectus abdominis muscle (reduces hernia and prolapse risk)
- At the infraumbilical fat mound - ideally where patient can see it
- Away from bony prominences (ASIS, costal margin), umbilicus, scars, skin folds, belt line
- Assessed in three positions - lying, sitting, standing - to avoid creases that appear only in certain postures
- Right iliac fossa (RIF) - ileostomy site
- Left iliac fossa (LIF) - sigmoid colostomy site
- Should be marked preoperatively by the stoma nurse (enterostomal therapist)
Stoma Aperture Construction
- Disk of skin 1.5-2 cm diameter excised at marked site
- Subcutaneous fat incised to anterior rectus fascia
- Rectus muscle split (not cut) with a curved clamp
- Posterior fascia opened sharply into peritoneum
- Final aperture = two fingerbreadths (adequate for bowel + mesentery to pass without tension)
- Larger aperture needed in obese patients or obstructed mesentery
Viva Q: Why is the stoma brought through the rectus muscle? - To reduce risk of parastomal hernia and prolapse by the muscular support it provides. - Fischer's Mastery of Surgery, 8th Ed.
Types in Detail
Ileostomy
Brooke Ileostomy (standard end ileostomy technique):
- Stump brought 4-5 cm above skin level
- Four sutures placed at 90° to each other incorporating: cut end of ileum + seromuscular layer at level of anterior rectus fascia + subcuticular skin edge
- Sutures tied to produce stomal eversion (the "spout" or "rose bud" appearance)
- Additional simple sutures complete the maturation
- Purpose of spout (2-3 cm protrusion): caustic ileostomy effluent is delivered directly into the pouch, away from skin, reducing excoriation
Loop Ileostomy:
- Segment of distal ileum brought through abdominal wall defect as a loop
- Rod/bridge may be placed to prevent retraction
- Enterotomy created, stoma matured
- Can also be divided loop - linear cutting stapler across distal limb flush with skin, then proximal limb matured - prevents incomplete diversion
Indications for ileostomy:
- Protection of low rectal or ileal anastomosis
- Total colectomy for UC (before IPAA or as permanent in cases of incontinence)
- Crohn's disease (temporary/permanent)
- Familial adenomatous polyposis (FAP) - after colectomy
- Ileostomy output guide for colectomy decision (high output = avoid)
Output: 500-1500 mL/day (liquid); contains active digestive enzymes → high risk of peristomal skin excoriation
Colostomy
End Colostomy (Hartmann-type / permanent after APR):
- Protrudes only 0.5-1 cm above skin level (effluent is formed, not caustic)
- No spout needed
- Matured with interrupted absorbable sutures
Loop Colostomy (transverse or sigmoid):
- Descending/sigmoid preferred over transverse
- Transverse loop colostomy: avoid - high prolapse rate, poor bag adhesion (belt line)
Double-barrel Colostomy (Paul-Mikulicz):
- Both proximal and distal limbs brought out
- Used in emergency situations with significant contamination or fistula
Ascending colostomy → high liquid output (like ileostomy)
Descending/sigmoid colostomy → formed stool, less skin irritation
Indications for colostomy:
- Obstructing or perforated left colon cancer (Hartmann's procedure)
- Anorectal trauma (fecal diversion)
- Recto-vaginal or recto-urethral fistulas
- Hirschsprung's disease (leveling colostomy)
- Radiation proctitis
- Perineal sepsis / Fournier's gangrene
Difference Between Ileostomy and Colostomy
| Feature | Ileostomy | Colostomy |
|---|---|---|
| Site | RIF | LIF (sigmoid) |
| Protrusion | 2-3 cm spout (Brooke) | 0.5-1 cm flush |
| Output | Liquid, 500-1500 mL/day | Semi-formed to formed |
| Output enzymes | Active - caustic | Inactive |
| Skin excoriation risk | High | Low (sigmoid) |
| Bag change | Daily or more | Every 2-3 days |
| Mesentery | Mobile, no vascular ligation needed | May need central ligation in obese |
| Odor | Less | More |
| Closure | Without formal laparotomy usually | Similar |
Preoperative Preparation (Stoma Care)
- Preoperative marking by stoma nurse/enterostomal therapist is mandatory
- Assess abdomen in sitting, standing, bending positions
- Consider clothing habits (belt position, clothing type)
- Psychological preparation and counseling (permanent stoma has major psychosocial impact)
- Optimize nutrition (malnourished patients have higher complication rates)
- Bowel preparation: role is limited in emergency settings
Complications of Stoma
Up to 30% of patients require operative revision for stoma complications. - Fischer's Mastery of Surgery
Early Complications (within 30 days)
| Complication | Cause | Management |
|---|---|---|
| Necrosis / Ischemia | Tension on mesentery; inadequate blood supply; tight aperture; hypotension | Use transparent pouch for inspection; clear tube + flashlight to assess level; necrosis below fascia = re-exploration + new stoma; above fascia = expectant ± revision |
| Retraction | Tension, obesity, mesenteric edema | Convex skin barrier; stoma belt; local revision or relocation if persistent |
| Mucocutaneous separation | Tension, infection, poor technique, ischemia | Minor: allow to heal by secondary intention; Major: revision |
| High output (ileostomy) | Short bowel; Crohn's activity | Dietary modification; loperamide; codeine; IV fluids; octreotide in refractory cases |
| Peristomal skin excoriation | Effluent contact (especially ileostomy) | Correct appliance; barrier creams; convex skin barrier |
Late Complications (after 30 days)
| Complication | Features | Management |
|---|---|---|
| Parastomal hernia | Most common late complication; bowel through fascial defect beside stoma | Conservative (support belt); surgical - Sugarbaker repair or keyhole repair with mesh; laparoscopic/robotic preferred |
| Prolapse | Bowel telescopes outward; more common in loop stomas (efferent limb) and transverse colostomy | Manual reduction; surgical revision if recurrent/incarcerated |
| Stenosis | At skin or fascial level; from ischemia, Crohn's, scar, inadequate aperture | Gentle dilatation (short-term); surgical revision; assess for Crohn's/malignancy in late onset |
| Skin irritation / Dermatitis | Contact dermatitis, candidiasis, psoriasis | Correct appliance fitting; antifungals if candida; barrier creams |
| Bleeding | From mucosa (trauma), varices (portal hypertension - "caput medusae" around stoma) | Minor: conservative; variceal: local measures, TIPS |
| Fistulation | Crohn's disease; deep suture | Examination; Crohn's work-up; surgical revision |
Stoma Necrosis - Assessment Method
- Use clear tube (test tube) + flashlight inserted into stoma
- If mucosa viable = pink/red above fascia level → conservative
- If black/cyanotic extending below fascia → re-exploration required
Stoma Reversal (Closure)
Prerequisites for closure:
- Anastomosis healed - confirm with contrast enema (Gastrografin) and flexible endoscopy
- Patient nutritionally optimized
- No active sepsis or disease
- Cancer patients: defer until completion of adjuvant chemotherapy
- Generally performed 8-12 weeks after index surgery
Technical considerations:
- Elliptical incision around stoma
- Bowel dissected free of subcutaneous tissue and fascia
- Hand-sewn or stapled anastomosis; return bowel to peritoneal cavity
- Stoma site closure: purse-string leaving small opening, or skin closure over Penrose drain
- Mesh reinforcement of fascial defect at time of closure reduces risk of incisional/parastomal hernia
Complications of reversal:
- Anastomotic leak
- Wound infection (contaminated field)
- Incisional hernia at stoma site
Parastomal Hernia - Management (High-yield Viva)
Repair techniques:
- Sugarbaker repair - mesh placed without fenestration; intestine lateralized between mesh and abdominal wall; lower recurrence rate but requires bowel redundancy
- Keyhole repair - mesh fenestrated to allow stoma passage; more natural bowel course but higher recurrence (fenestration enlarges over time)
- Stoma relocation - move stoma to opposite side + mesh repair of original defect
Open vs. Laparoscopic/Robotic:
- Laparoscopic/robotic preferred: fewer wound complications (incisions remote from contaminated stoma site)
- Open: more wound morbidity but technically less demanding
High-Output Ileostomy
Definition: Output > 2000 mL/day
Causes: Short bowel syndrome, Crohn's, post-op ileus resolution, bacterial overgrowth, medications
Complications: Dehydration, hyponatremia, hypomagnesemia, metabolic acidosis, renal failure
Management:
- Restrict hypotonic fluids
- Oral rehydration solution (high sodium - >90 mEq/L)
- Loperamide (slows transit)
- Codeine phosphate
- Proton pump inhibitor (reduces GI secretions)
- Octreotide (severe/refractory)
- Nutritional support - parenteral if needed
Stoma Appliances
One-piece system: Skin barrier and pouch integrated - simpler, less bulky, for established stomas
Two-piece system: Separate skin wafer + pouch that clicks on - allows pouch change without disturbing skin
Closed-end pouch: For colostomy (formed stool) - disposed after single use
Open-end/drainable pouch: For ileostomy (liquid output) - drained periodically, changed every 1-3 days
Convex wafer: Used in retracted stoma to push skin in and direct effluent into pouch
Irrigation of Colostomy
- Used for sigmoid/descending colostomy only (formed stool, adequate length of colon)
- 500-1000 mL warm water instilled via cone irrigation set into stoma
- Promotes bowel evacuation at a predictable time; patient can go "bag-free" between irrigations
- Not suitable for ileostomy (liquid, unpredictable output) or transverse/ascending colostomy
Stoma and Quality of Life
- Permanent stoma has significant psychological, sexual, and social impact
- Stoma care nurse (enterostomal therapist) role: preoperative education, site marking, postoperative appliance training, complication management, emotional support
- Support groups, counseling, and regular follow-up mandatory
- Body image disturbance is a recognized complication - address proactively
Key Viva Questions & Model Answers
Q: What are the components of an ideal stoma?
A: Correct site (within rectus, visible, away from bony prominences and folds), adequate blood supply without tension, appropriate protrusion (ileostomy 2-3 cm spout; colostomy flush), proper aperture size (2 fingerbreadths), secure mucocutaneous union.
Q: Why does an ileostomy have a spout but a colostomy does not?
A: Ileal effluent is liquid and contains active proteolytic enzymes - highly caustic to skin. The spout delivers effluent directly into the pouch bag, protecting peristomal skin. Colonic effluent (especially sigmoid) is formed and less irritating, so flush maturation is adequate.
Q: What is the most common late complication of stoma?
A: Parastomal hernia. Incidence up to 30-50% at 5 years for end colostomy.
Q: How do you assess viability of a necrotic-appearing stoma?
A: Insert a transparent/clear test tube into the stoma lumen and inspect with a flashlight. Assess the level of ischemia relative to the fascia. Above fascia = conservative; below fascia = re-operation required.
Q: What is a Hartmann's procedure?
A: Resection of the rectosigmoid with end colostomy (LIF) and closure of the rectal stump as a blind pouch. Done in emergency setting (perforated sigmoid cancer, diverticular perforation with peritonitis) when primary anastomosis is unsafe.
Q: What is the 'ghost ileostomy'?
A: A loop of ileum is prepared and marked but not exteriorized - it is sutured beneath the anterior abdominal wall. Acts as a safety net. If anastomotic leak occurs postoperatively, the ghost ileostomy can be quickly converted to a functioning stoma without full re-laparotomy.
Q: What is Turnbull-Blowhole colostomy?
A: Decompressive loop colostomy (without formal laparotomy) used in toxic megacolon - particularly in pregnancy or in patients too unstable for major surgery. Skin is incised over the dilated loop, which is then opened and fashioned as a stoma.
Q: What is the difference between Sugarbaker and keyhole repair for parastomal hernia?
A: Sugarbaker repair - mesh without fenestration, intestine lateralized between mesh and abdominal wall; lower recurrence. Keyhole repair - mesh with central fenestration for stoma; higher recurrence because the fenestration tends to enlarge over time. Both carry risks of obstruction, mesh erosion, and bowel ischemia.
Summary Table: Ileostomy vs Colostomy
| End Ileostomy | Loop Ileostomy | End Colostomy | Loop Colostomy | |
|---|---|---|---|---|
| Common site | RIF | RIF | LIF | Transverse/sigmoid |
| Protrusion | 2-3 cm (spout) | 2-3 cm | 0.5-1 cm | Flush/minimal |
| Output | Liquid | Liquid | Formed | Semi-formed |
| Permanent/Temp | Both | Usually temp | Both | Usually temp |
| Reversal | Formal laparotomy usually | Often without laparotomy | Hartmann reversal | Without formal laparotomy |
| Prolapse risk | Low | Moderate (efferent limb) | Low | High (transverse) |
Sources: Bailey & Love's Short Practice of Surgery (28th Ed.) | Sabiston Textbook of Surgery | Schwartz's Principles of Surgery (11th Ed.) | Fischer's Mastery of Surgery (8th Ed.) | Maingot's Abdominal Operations
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Management of parastomal hernia PG level
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