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 Resuscitation
Rapid segmental 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
