StomaStoma

dr. Citra Roshiandr. Citra Roshian

Pembimbing :Pembimbing :dr. Tommy Ruchimat, Sp.B-KBDdr. Tommy Ruchimat, Sp.B-KBD

Anatomi AbdomenAnatomi Abdomen

FisiologisFisiologis

LambungLambung

motorikmotorik

Pencernaan & sekresiPencernaan & sekresi

ReservoirReservoir

MencampurMencampur

Pengosongan lambungPengosongan lambung

Pencernaan proteinPencernaan protein

Sintesis dan pelepasan gastrinSintesis dan pelepasan gastrin

Sekresi faktor intrinsikSekresi faktor intrinsik

Sekresi mukusSekresi mukus

Usus HalusUsus Halus

Pencernaan Pencernaan AbsorbsiAbsorbsi NutrisiNutrisiCairanCairanElektrolitElektrolit

Dibantu oleh enzimDibantu oleh enzim

dan hormondan hormon

Usus BesarUsus Besar

Mengabsorbsi cairan dan elektrolitMengabsorbsi cairan dan elektrolitReservoir massa faesesReservoir massa faesesDengan bantuan bakteri Dengan bantuan bakteri sintesis vitamin sintesis vitamin

The physiology of the colon should be taken into The physiology of the colon should be taken into account when considering stoma construction. account when considering stoma construction.

The right side of the colon absorbs water and The right side of the colon absorbs water and has irregular peristaltic contractions. has irregular peristaltic contractions.

Stomas made from the proximal half of the colon Stomas made from the proximal half of the colon usually expel a liquid content. usually expel a liquid content.

The left colon serves as a conduit and The left colon serves as a conduit and reservoir and has a few mass peristaltic reservoir and has a few mass peristaltic motions per daymotions per day. . The content is more solid, and The content is more solid, and in many cases the stoma output can be regulated in many cases the stoma output can be regulated by irrigation. by irrigation.

Proximal colostomies should be avoidedProximal colostomies should be avoided, as , as they will combine the worst features of both a they will combine the worst features of both a colostomy and an ileostomy: liquid, high-volume, colostomy and an ileostomy: liquid, high-volume, foul-smelling effluent. The left colon should be foul-smelling effluent. The left colon should be used for a colostomy if possible; the distal used for a colostomy if possible; the distal transverse colon is also a reasonable choice.transverse colon is also a reasonable choice.

Lokasi Stoma yang baikLokasi Stoma yang baik

Lokasi StomaLokasi Stoma

The most common indication is The most common indication is cancer of cancer of the rectumthe rectum. .

Colostomy Colostomy is an opening of the large is an opening of the large intestine, no sphincteric control intestine, no sphincteric control better on better on the abdominal wall than in the perineum the abdominal wall than in the perineum (maintanence). (maintanence).

A distal colorectal anastomosis in an elderly A distal colorectal anastomosis in an elderly patient with a poorly functioning anal patient with a poorly functioning anal sphincter may result in what is essentially a sphincter may result in what is essentially a "perineal colostomy." In these cases, it often "perineal colostomy." In these cases, it often behooves the surgeon to construct a good behooves the surgeon to construct a good colostomy rather than to restore intestinal colostomy rather than to restore intestinal continuity to an incontinent anus. continuity to an incontinent anus.

Colostomies are also constructed as Colostomies are also constructed as treatment for obstructing lesionstreatment for obstructing lesions of the of the distal large intestine and for actual or distal large intestine and for actual or potential perforations.potential perforations.

ColostomyColostomy End sigmoidEnd sigmoid

Descending Descending

Emergency / elektifEmergency / elektif Sementara / permanentSementara / permanent

Kanker rektum (abdominoperineal reseksi)Kanker rektum (abdominoperineal reseksi)

Tujuan hygiene (tetraplegia / inkontinensia Tujuan hygiene (tetraplegia / inkontinensia alvi)alvi)

Diversi faesesDiversi faeses

ObstruksiObstruksi

PerforasiPerforasi

Kasus traumaKasus trauma

Type by Anatomic LocationType by Anatomic Location Type of colostomy categorized by the part of the Type of colostomy categorized by the part of the

colon used in its construction. colon used in its construction. The most common type : The most common type : "end-sigmoid" "end-sigmoid"

colostomycolostomy. . However, if the inferior mesenteric artery is However, if the inferior mesenteric artery is

transected during an operation for cancer of the transected during an operation for cancer of the rectum, the blood supply to the sigmoid colon is no rectum, the blood supply to the sigmoid colon is no longer dependable, and it should not be used for longer dependable, and it should not be used for stoma construction. stoma construction.

"end-descending" "end-descending" colostomy is preferable to an end-colostomy is preferable to an end-sigmoid colostomy. sigmoid colostomy.

Other types of colonic stomas include the Other types of colonic stomas include the transverse transverse colostomy colostomy and and cecostomy.cecostomy.

Type by FunctionType by Function

More important than the anatomy of More important than the anatomy of the colon is the function that the the colon is the function that the colostomy is intended to perform. colostomy is intended to perform. There are two considerations: There are two considerations:

(1)(1) to provide to provide decompressiondecompression of the of the large large intestine intestine

(2)(2) to provide to provide diversiondiversion of the feces. of the feces.

Types of Decompressing Types of Decompressing StomasStomas

There are three types of There are three types of decompressing stomas: decompressing stomas:

(1)(1) the so-called the so-called "blow-hole" "blow-hole" decompressing stoma constructed in decompressing stoma constructed in the cecum or transverse colon, the cecum or transverse colon,

(2)(2) a tube type of cecostomya tube type of cecostomy, and , and

(3)(3) a loop-transverse colostomya loop-transverse colostomy..

"blow-hole" "blow-hole"

a tube type of a tube type of cecostomycecostomy

a loop-transverse colostomya loop-transverse colostomy

Loop colostomyLoop colostomy

Diverting ColostomyDiverting Colostomy

A diverting colostomy is constructed to provide A diverting colostomy is constructed to provide diversion of intestinal contentdiversion of intestinal content. It is performed . It is performed because the distal segment of bowel has been because the distal segment of bowel has been completely resected (as during completely resected (as during abdominoperineal resection), because of known abdominoperineal resection), because of known or suspected perforation or obstruction of the or suspected perforation or obstruction of the distal bowel (e.g., obstructing carcinoma, distal bowel (e.g., obstructing carcinoma, diverticulitis, leaking anastomosis, or trauma), diverticulitis, leaking anastomosis, or trauma), or because of destruction or infection of the or because of destruction or infection of the distal colon, rectum, or anus (e.g., Crohn's distal colon, rectum, or anus (e.g., Crohn's disease or failed anal sphincter reconstruction).disease or failed anal sphincter reconstruction).

DivertingDiverting

stomasstomas

LoopLoop

ileostomyileostomy

Loop ileostomyLoop ileostomy

End ileostomyEnd ileostomy

Construction of an End Construction of an End ColostomyColostomy

An end, completely diverting, colostomy usually is An end, completely diverting, colostomy usually is located in the left lower quadrant, where the site is located in the left lower quadrant, where the site is chosen preoperatively by placing a vertical line chosen preoperatively by placing a vertical line through the umbilicus and another line transversely through the umbilicus and another line transversely through the inferior margin of the umbilicus and by through the inferior margin of the umbilicus and by affixing a disk the size of a stoma faceplate to affixing a disk the size of a stoma faceplate to designate the stoma opening through the rectus designate the stoma opening through the rectus muscle and on the summit of the infraumbilical fan muscle and on the summit of the infraumbilical fan fold. fold.

An alternative location is through the midline fascia, An alternative location is through the midline fascia, not necessarily at the umbilicus. Although this site not necessarily at the umbilicus. Although this site initially seems esthetically unappealing, it allows initially seems esthetically unappealing, it allows construction of a stoma with a lower incidence of construction of a stoma with a lower incidence of symptomatic hernia formation because of the ability symptomatic hernia formation because of the ability to tightly close the linea alba around the stoma.to tightly close the linea alba around the stoma.

End ColostomyEnd Colostomy

Once a site is chosen, the patient should be Once a site is chosen, the patient should be evaluated in multiple body configurations to verify evaluated in multiple body configurations to verify the adequacy of the stoma site. the adequacy of the stoma site.

A common mistake is to choose the site with the A common mistake is to choose the site with the patient supine and then find when the patient rises patient supine and then find when the patient rises to a standing or sitting position that the chosen to a standing or sitting position that the chosen site is completely obscured by fat folds, scar site is completely obscured by fat folds, scar tissue, or a protruding skeletal structure. tissue, or a protruding skeletal structure.

The location should be adjusted up or down, even The location should be adjusted up or down, even considering the use of upper quadrants of the considering the use of upper quadrants of the abdomen if necessary, to allow proper fixation of abdomen if necessary, to allow proper fixation of an appliance and easy access by the patient. an appliance and easy access by the patient.

The site usually is marked with ink in the patient's The site usually is marked with ink in the patient's room and then is scratched into the skin with a room and then is scratched into the skin with a needle in the operating room after induction of needle in the operating room after induction of anesthesia. anesthesia.

This is totally painless for the patient and does not This is totally painless for the patient and does not leave a permanent tattoo should colostomy not be leave a permanent tattoo should colostomy not be needed.needed.

An end colostomy most often is constructed An end colostomy most often is constructed after removal of the rectum for low-lying after removal of the rectum for low-lying malignancy.malignancy.

The entire left colon is mobilized on its The entire left colon is mobilized on its mesentery, and depending on mobility of the mesentery, and depending on mobility of the colon and thickness of the abdominal wall, colon and thickness of the abdominal wall, may require mobilization of the splenic may require mobilization of the splenic flexure. flexure.

If the patient has received neoadjuvant pelvic If the patient has received neoadjuvant pelvic radiotherapy and/or the inferior mesenteric radiotherapy and/or the inferior mesenteric artery is transected at its origin at the aorta, artery is transected at its origin at the aorta, the entire sigmoid colon should be removed the entire sigmoid colon should be removed because of concerns regarding ischemia and because of concerns regarding ischemia and a descending colostomy created.a descending colostomy created.

If the colostomy is to be brought through the If the colostomy is to be brought through the left lower quadrant, an opening in the left lower quadrant, an opening in the abdominal wall is made at the previously abdominal wall is made at the previously marked site by excising a 3-cm disk of skin. marked site by excising a 3-cm disk of skin.

The undesirable oval configuration of a stoma The undesirable oval configuration of a stoma is avoided by placing traction clamps in the is avoided by placing traction clamps in the dermis, the fascia, and the peritoneum. dermis, the fascia, and the peritoneum.

These clamps are held in alignment when the These clamps are held in alignment when the opening is made through the abdominal wall. opening is made through the abdominal wall.

This duplicates the configuration of the This duplicates the configuration of the abdominal wall when the abdomen is closed abdominal wall when the abdomen is closed and should allow construction of a desirable and should allow construction of a desirable circular stoma.circular stoma.

The fat, fascia, muscle, and posterior peritoneum are The fat, fascia, muscle, and posterior peritoneum are then incised longitudinally. No fat is excised. then incised longitudinally. No fat is excised.

The opening is then dilated to allow passage of two The opening is then dilated to allow passage of two fingers, and the closed end of the colon is pulled fingers, and the closed end of the colon is pulled through the abdominal wall. through the abdominal wall.

There, mesentery of the colon can be sutured to the There, mesentery of the colon can be sutured to the lateral abdominal wall with a running suture, although lateral abdominal wall with a running suture, although the complication of small bowel obstruction due to the complication of small bowel obstruction due to torsion of the small bowel mesentery around the colon torsion of the small bowel mesentery around the colon mesentery has not been proven to be reduced by this mesentery has not been proven to be reduced by this maneuver.maneuver.

After the wound is closed and protected, attention is After the wound is closed and protected, attention is directed to completing the colostomy. directed to completing the colostomy.

The stoma is completed by excising the staple or The stoma is completed by excising the staple or suture line and by placing chromic catgut sutures suture line and by placing chromic catgut sutures between the full thickness of colon and skin. between the full thickness of colon and skin.

If the stoma is constructed because of inflammatory If the stoma is constructed because of inflammatory bowel disease or radiated bowel, a spigot configuration bowel disease or radiated bowel, a spigot configuration is utilized by applying principles similar to those for is utilized by applying principles similar to those for ileostomy construction. This facilitates a good ileostomy construction. This facilitates a good appliance seal for anticipated high-volume, liquid appliance seal for anticipated high-volume, liquid effluentseffluents..

If the colostomy will be brought through the midline, If the colostomy will be brought through the midline, no fixation of the mesentery is necessary. no fixation of the mesentery is necessary.

The intended midline colostomy is brought through The intended midline colostomy is brought through the abdominal incision, and the entire incision is the abdominal incision, and the entire incision is closed, with the sutures adjacent to the colostomy closed, with the sutures adjacent to the colostomy being tied last. being tied last.

At least a few interrupted sutures are placed on At least a few interrupted sutures are placed on either side of the colostomy even if a running either side of the colostomy even if a running closure of the abdominal wall is used. closure of the abdominal wall is used.

As the last sutures are tied, the colon is pulled As the last sutures are tied, the colon is pulled through the abdominal wall, and the surgeon's finger through the abdominal wall, and the surgeon's finger is placed adjacent to the stoma as a spacer to avoid is placed adjacent to the stoma as a spacer to avoid compromise of the blood supply to the stoma. compromise of the blood supply to the stoma.

The skin is closed and the wound is protected as The skin is closed and the wound is protected as attention is directed to the colostomy, where either attention is directed to the colostomy, where either the staple line is excised or the clamp is removed, the staple line is excised or the clamp is removed, and full thickness of colon is sutured to full thickness and full thickness of colon is sutured to full thickness of skin with interrupted absorbable sutures.of skin with interrupted absorbable sutures.

Once the stoma construction is complete, an appliance is Once the stoma construction is complete, an appliance is applied in the operating room. The simplest is a one-piece applied in the operating room. The simplest is a one-piece appliance with a skin barrier that can be cut to the appliance with a skin barrier that can be cut to the appropriate size of the stomaappropriate size of the stoma. .

This same appliance can be used for colostomy and This same appliance can be used for colostomy and ileostomy. The pouch is allowed to fall to the patient's side, ileostomy. The pouch is allowed to fall to the patient's side, because in the postoperative period, the patient will be because in the postoperative period, the patient will be supine rather than upright the majority of the time. supine rather than upright the majority of the time.

The appliance, which need not be sterile, is held in place with The appliance, which need not be sterile, is held in place with the skin adhesive of the appliance and is secured with strips the skin adhesive of the appliance and is secured with strips of nonallergenic tape placed in "picture-frame" fashion. The of nonallergenic tape placed in "picture-frame" fashion. The remaining wound dressing is applied. remaining wound dressing is applied.

Tincture of benzoin should never be used to maintain Tincture of benzoin should never be used to maintain adhesion of an appliance to the skin because it has a high adhesion of an appliance to the skin because it has a high risk of initiating contact dermatitis. risk of initiating contact dermatitis.

If colostomy function does not begin within 4 or 5 days, the If colostomy function does not begin within 4 or 5 days, the stoma can be irrigated with small volumes (250 mL) of stoma can be irrigated with small volumes (250 mL) of normal saline to initiate stoma function. The enterostomal normal saline to initiate stoma function. The enterostomal therapy nurses are involved early in the care of the stoma therapy nurses are involved early in the care of the stoma and in teaching the patient and family to provide long-term and in teaching the patient and family to provide long-term care of the colostomy. In most cases, the patient is taught care of the colostomy. In most cases, the patient is taught the technique of stoma irrigation, and then each individual the technique of stoma irrigation, and then each individual decides in the more distant postoperative course if she or he decides in the more distant postoperative course if she or he wishes to irrigate the stoma or not.wishes to irrigate the stoma or not.

Perawatan stomaPerawatan stoma

Waktu yg tepat untuk mengganti Waktu yg tepat untuk mengganti kantungkantung

Frekuensi mengganti kantungFrekuensi mengganti kantung Proteksi kulit peristomaProteksi kulit peristoma Kontrol bau & gasKontrol bau & gas Management diareManagement diare Pencegahan & management gangguan Pencegahan & management gangguan

cairan & elektrolitcairan & elektrolit Pencegahan & management konstipasiPencegahan & management konstipasi Irigasi stomaIrigasi stoma

KomplikasiKomplikasi

Metabolik problemsMetabolik problems Parastoma abses, ulcerasi, herniaParastoma abses, ulcerasi, hernia StrikturStriktur VolvulusVolvulus Caput medusaeCaput medusae