Creation and Characteristics of Temporary Stomas
The information below describes the creation and characteristics of temporary stomas. The content was written by David E. Beck, MD, FACS, FASCRS, Clinical Professor of Surgery at Vanderbilt University for UOAA’s New Ostomy Patient Guide and revised by Linda Coulter, BSN, MS, RN, CWOCN in 2024.
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Types of Ostomies
There are several types of ostomies: loop, end, and end loop (Figure 1). In an end stoma, the end of the bowel is brought through the abdominal wall and the stoma has a single lumen or opening. A loop stoma, as described below, has two openings.
An end stoma is usually created when bowel has been removed. The other end of the bowel may be absent or left in the abdomen as a Hartmann’s pouch (closed off rectum). It may also be brought through the abdominal wall and connected to the skin. Intestinal contents don’t come out of this part of the bowel, but mucous does. Because of this it is often called a mucous fistula.
More often temporary stomas are loop stomas. A loop stoma is generally easier to create. A loop stoma has two openings. This type of stoma diverts the intestinal contents away from and protects the portion of the bowel that has been operated on. Loop stomas are usually easier to close as both ends of the bowel are close together. The indications for a temporary stoma include bowel obstructions (tumors, inflammatory disease, diverticulitis, or Crohn’s disease), leaks or fistulas, or to protect an anastomosis (i.e. new constructions, such as j-pouches or repairs like low anterior resections).
A variation of a loop stoma is an end loop stoma. In this type of stoma the end of the loop is sutured closed. This completely diverts the bowel contents and is used when it is difficult for the bowel to reach the skin.
Even if a stoma is planned to be temporary, some will become permanent. This may happen if a person’s disease progresses or other conditions develop or worsen. Some people decide they are happy with their stoma and/or they don’t want another operation. For these reasons, and to minimize any problems while the stoma is in place, it is very important to have the stoma created correctly. That is the stoma should be in a good location and should protrude adequately.
Stoma Location
It is best to pick the location of the stoma prior to surgery. A portion of the abdomen is selected that is relatively flat and not near bony prominences, scars, and folds of fat and skin. It is important that the patient can see the location. It is important to evaluate the proposed location with the patient standing and sitting because skin folds may be present in some positions, but not others. The assistance of an ostomy nurse in selecting stoma locations is often helpful.
The opening through the abdominal wall must be adequate size to allow the bowel and its accompanying blood vessels to pass through without constriction. A certain amount of bowel protrusion is desired. The amount will depend on the type of stoma and whether there is not too much stretch on the bowel and its mesentery (the tissue that supports the bowel and related blood vessels and nerves). A 2-3 cm (1 inch) protrusion is preferred for ileostomies and 0.5 – 1 cm (? inch) for colostomies. The bowel is then folded back on itself and attached to the skin with several absorbable sutures. This is referred to as stomal maturation. The edge of bowel mucosa is sutured to the dermal or inner layer of the skin. To maintain the desired protrusion, the bowel wall is sutured to the subcutaneous fat or the maturation suture also includes part of the bowel wall. Close approximation of the mucosa to the skin hastens healing. If there is a lot of tension on the bowel, which can pull the bowel back into the abdomen, surgeons will often use a plastic rod to help support the loop stoma for a few days following surgery.
Special Circumstances
A number of patient characteristics can make stoma creation challenging. One of the more common of these is obesity where excess fat is deposited in the abdominal wall and bowel mesentery. A fatty mesentery is often shorter, making it harder to reach through the abdominal wall. It also requires a larger hole in the abdominal wall in order for the bowel to pass through. A thick subcutaneous fat layer also makes it difficult for the bowel to reach the skin.
Losing weight prior to a planned surgery can help, but this is often difficult or impossible. Another option is abdominal wall modification or contouring. Diseased bowel (radiated or involved with Crohn’s disease) is also difficult to manipulate. It is preferred to use healthier bowel that is soft and pliable.
