An ileostomy is a surgery that makes a temporary or permanent opening called a stoma. A stoma is a pathway from the lowest part of the small intestine, called the ileum, to the outside of your abdomen. This helps solid waste and gas exit the body without passing through the colon or the rectum.
An ileostomy is a procedure in which the lumen of the ileum, part of the small bowel, is brought through the abdominal wall via a surgically-created opening called a stoma. The purpose of an ileostomy is to evacuate stool from the body via the ileum instead of the usual route via the anus. This activity reviews the indications, contraindications, and potential benefits of the ileostomy and highlights the role of the interprofessional team in the management of patients with a stoma.
An ileostomy is when the lumen of the ileum (small bowel) is brought through the abdominal wall via a surgical opening (created by an operation). This can either be temporary or permanent, an end or a loop. The purpose of an ileostomy is to evacuate stool from the body via the ileum rather than the usual route of the anus. The output from an ileostomy consists of loose or porridge-like stool consistent with that expected to pass through the small bowel (as it is the large bowel that is responsible for making the stool more solid dependent upon water absorption). The output from an ileostomy can vary but typically ranges from 200 to 700 ml per day, and an Ileostomy is typically formed on the right side of the abdomen.
Anatomy and Physiology
An ileostomy is formed from a section of the ileum which is part of the small intestine. The small intestine begins at the pylorus of the stomach and is composed of three adjoining sections: the duodenum proximally, jejunum, and the ileum distally. The jejunum and ileum are intraperitoneal structures whereas the duodenum has a retroperitoneal component to it. The jejunum and duodenum are attached to the small bowel mesentery which are peritoneal folds containing blood vessels, lymphatics, and nerves. The small intestine is approximately 6 to 7 meters in length with a varying luminal diameter between 3 and 5 cm. It has multiple functions including food digestion, secretion of enzymes and proteins, and nutrient absorption [rx]. The wall of the intestine consists of the mucosa, the submucosa, muscularis propria (the muscular layer), the subserosa, and finally the serosa [rx]. The ileum terminates at the ileocaecal junction in a valve at the superior aspect of the caecum before it goes on to form the ascending colon. The caecum can be identified at this point of the bowel where the tinea converge.
The anatomy of the anterior abdominal wall is important to be aware of when forming the trephine incision for the ileostomy. The layers encountered are the skin, subcutaneous fat, Scarpa’s and Camper’s fascia, anterior rectus sheath, muscle, posterior rectus sheath (if above the arcuate line), and the peritoneum. The muscles include the external and internal obliques, the transverse abdominis, and the rectus abdominis. The obliques and transverse abdominis attach at varying levels to the lower ribs and the iliac crests, whereas the rectus abdominis arises from the costal margin and xiphoid process before extending down to the symphysis pubis. The abdominal muscles are wrapped in fascia but also have dense tendons called aponeuroses that converge at the midline to form the linea alba.
An ileostomy should be brought through the rectus muscle and sheath to reduce the risk of laterparastomal hernia formation, which occurs when the abdominal content pushes through the weakness created by the incision.
Indications
There are different indications for forming an ileostomy but essentially arrive at the same result of diverting stool out of the body without it ever entering the colon.
A loop ileostomy is when a distal loop of the ileum is brought out to the skin with 2 lumens draining into the stoma bag and is commonly used as a temporary diversion of stool usually to protect a distal anastomosis such as a colonic anastomosis in segmental colonic resections. The reason to protect such distal anastomoses is to reduce the risk of an anastomotic leak from when stool passes through the joint of the two ends of the bowel [rx]. Once the distal anastomosis has healed, both limbs of the loop ileostomy can be joined back together thereby restoring continuity to the gastrointestinal tract, which allows stool to pass through into the colon. With loop ileostomies, the proximal limb is the one that passes out the stool, and the distal limb usually acts as a mucous fistula, draining out the secretions produced within the mucosal lining from the lumen to the caecum. However, the distal limb does not drain out colonic secretions if the ileocaecal valve is competent, and therefore, does not decompress the colon. This is important to note if there is a colonic obstruction as then the patient would be at risk of perforation from a large bowel obstruction. This is because the colon is unable to decompress either proximally or distally to the obstructing source, causing secretions and flatus to build up under tension in an essentially closed loop of the bowel. At a later date, usually between three and six months, this temporary ileostomy can be “reversed” or re-joined back together to re-establish continuity of the bowel.
An end ileostomy is when there is nothing distal to the proximal emptying limb, in other words, there is no bowel to be re-attached to this “end” at a later stage. The formation of an end ileostomy is usually considered following permanent removal of the entire colon, and therefore the patient manages their stoma for the rest of their life.
In brief, the indications for forming an ileostomy include:
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To defunction the rest of the bowel in order to protect a distal anastomosis
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To evacuate stool from the body if the entire colon has been removed such as in colorectal cancer, Crohn’s disease, ulcerative colitis, and familial adenomatous polyposis
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Relieve bowel obstruction
Contraindications
There are no absolute contraindications to ileostomy formation, but the relative ones include:
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Short mesentery disables the ileum from being exteriorized through the abdominal wall to the skin without tension. This, unfortunately, is more common in obese patients.
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Carcinomatosis that prevents full mobilization of the ileum
The ileostomy should be formed as distal as possible to allow enough bowel length for absorption of nutrients.
A high output ileostomy can lead to electrolyte disturbances (particularly important to monitor for and treat in patients with renal impairment), as well as malabsorption leading to malnutrition.
During ileostomy formation, it is important to spout the stump to get the effluent away from contact with the skin.
An ileostomy should be sited away from scars, skin creases, and bony prominences to allow placement of the stoma appliance and avoid leakage.
Equipment
The equipment required can be split into the operative stage and the maintenance stage. In the operative stage, the formation of the trephine ileostomy involves the utilization of many instruments that are discussed below in the technique section. The maintenance stage is based on stoma education and how the patient manages their ileostomy. This includes the use of stoma bags, perhaps extra adhesive fixings such as spray, powder, paste, and rings, as well as belts, adhesive removal spray, wet wipes, and waste disposal bags.
Preparation
This includes both physical and psychological elements of preparation; the stoma nurses are again invaluable here to help support the patient through this process. Physical preparation varies somewhat on the nature of the operation involved and whether it is an emergency procedure or a planned elective operation.
Points to consider include
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Shaving of hair on the abdominal wall
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Body mass index (BMI) of patients having a planned ileostomy in an elective setting: They may be asked to lose weight prior to the operation to not only improve their anesthetic suitability but also reduce the distance the small bowel mesentery has to traverse to be bought to the skin without being under tension.
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Previous operative scars/deformities of the abdominal wall. A previous operation increases the extent of adhesions
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The presence of herniae
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Also in a planned setting, one would consider the effect of smoking and diabetic control on wound healing
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Most importantly would be the positioning of the stoma site, which is usually on the right side of the abdomen at the lateral edge of the rectus muscle, at a level where the patient can see it, access it easily, and not have it interfering with belts or skin folds. It should also ideally avoid the coastal margin and umbilicus.
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A nasogastric tube in cases of obstruction/perforation or if anticipating a postoperative ileus
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Adequate fluid and electrolyte resuscitation.
Technique
Ideally, the site would be marked pre-operatively with indelible ink or an “X” scored into the skin. This is so that the site can still be seen at the end of a long operation when the antiseptic prep or blood may have distorted the skin. If a laparotomy has been formed then the linea alba, which is the cut edge of the abdominal wall, is grasped with Kocher clamps or Littlewood clamps and retracted toward the midline to approximate the two wound edges together. As this will be the anatomically correct position of closure of the abdominal wall, it will also help identify where the ileostomy will be sited once the wound is closed. If a loop ileostomy is being made laparoscopically, then under vision the ileum can be grasped with a pair of Johan atraumatic graspers and bought towards the anterior abdominal wall to sit in a position where it is not under tension.
A 2.5 to 3 cm circle or ellipse of skin is excised using monopolar diathermy (it may be helpful to lift the skin upward using an Alice clamp or Littlewood clamp). The tissue is then dissected down through the subcutaneous fat to the anterior fascial sheath of the rectus muscle, which is then opened through a cruciate incision. The rectus muscle is spread or retracted medially; however, caution must be taken to avoid injuring the epigastric vessels that run deeply in the center of this muscle. Once the muscle is retracted, the posterior sheath is seen underlying this which is usually closed attached to the peritoneum on its under-surface. Another cruciate incision is made to the posterior sheath, and then two Kelly clips are used to grasp the peritoneum and lift it up. Using dissection scissors, a cut is made in the peritoneum between the two clips which will gain access into the peritoneal cavity. The surgical defect is stretched to allow two fingers to traverse through it thus ensuring enough room for the small bowel to be bought up to form the ileostomy. The next step is to gently pass the selected segment of terminal ileum (which has been checked to have enough length, mobilization, and is tension-free) through the trephine that you just formed. If a loop ileostomy is being formed, it is the loop of ileum that is bought up through the abdominal wall defect to the skin. If an end ileostomy is being formed, then it is simply the stapled off the end of ileum that is bought up. The ileum should be positioned such that the proximal limb is cephalad and is at 12 o’clock. It should also protrude approximately 5 cm above the skin before a seromuscular absorbable stay suture (e.g., 3.0 monocryl or vicryl rapide) is placed on the skin to prevent the ileum from slipping back inside. This then allows you to perform your final checks (checking orientation, controlling hemostasis, washout, rectus sheath catheters, drains) prior to closing up the abdomen and protecting the wounds with dressings before focussing on the ileostomy formation. It is considered common practice to close any abdominal wounds prior to the formation of the ileostomy so as to prevent fecal contamination of the wound with stool from the ileum.
Loop Ileostomy Formation
The distal limb is opened transversely for two-thirds of its diameter in a position about halfway up from the skin level. Submucosal bleeding can be controlled with bipolar cautery. Interrupted absorbable sutures are placed at the 3, 9, and 12 o’clock position taking seromuscular bites at the lumen of the proximal limb as well as approximately 4 cm down the loop before taking a subcuticular bite of the skin at the trephine skin edge. The positions here are away from the supplying mesentery. A Langenbeck retractor can then be used to help evert the lumen so that the limb is now spouting. The interrupted sutures are then tied in place using square knots. The distal limb is also everted similarly, however, will be less spouted as there is less protrusion of the distal limb above skin level. Interrupted absorbable sutures are applied circumferentially around both limbs, taking care not to compromise the vascular supply of the mesentery.
End Ileostomy
The formation of the trephine is the same here as mentioned above. Once you pull the stapled end of the ileum through the abdominal wall defect and apply the stay suture, you still proceed to carry out the usual checks and close the wounds as previously mentioned. Then taking the monopolar diathermy, you excise the staple line from the ileal end and discard it. Some surgeons may choose to cut the staple line off using dissecting scissors. However, this increases the risk of bleeding from the cut edges of the bowel which can be troublesome at times to control. Once the staple line has been excised, open up the lumen and then apply the 3 interrupted absorbable sutures at the 3, 9, and 12 o’clock position taking seromuscular bites. Again using a Langenbeck retractor, evert the mucosa of the lumen so that the limb is now spouting. The interrupted sutures are then tied in place using square knots.
Before the Procedure
Always tell your provider what medicines you are taking, even medicines, supplements, or herbs you bought without a prescription.
Before your surgery, talk with your provider about the following things:
- Intimacy and sexuality
- Pregnancy
- Sports
- Work
The 2 weeks before your surgery
- Two weeks before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), Naprosyn (Aleve, Naproxen), and others.
- Ask your provider which drugs you should still take on the day of your surgery.
- If you smoke, try to stop. Ask your provider for help.
- Always let your provider know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.
The day before your surgery
- You may be asked to drink only clear liquids such as broth, clear juice, and water after some point.
- Your provider will tell you when to stop eating and drinking.
- Your provider may ask you to use enemas or laxatives to clear out your intestines.
On the day of your surgery
- Take the drugs you were told to take with a small sip of water.
- You will be told when to arrive at the hospital.
After the Procedure
You will be in the hospital for 3 to 7 days. You may have to stay longer if your ileostomy was an emergency operation.
You may be able to suck on ice chips on the same day as your surgery to ease your thirst. By the next day, you will probably be allowed to drink clear liquids. You will slowly add thicker fluids and then soft foods to your diet as your bowels begin to work again. You may be eating again 2 days after your surgery.
What should I expect during surgery?
You will receive general anesthesia before the surgery. The procedure may be done with:
- A surgical incision, which is a large cut in the abdomen
- Laparoscopic surgery, which involves less invasive small incisions. This method reduces pain and recovery time.
- Bleeding inside the small intestine or from the stoma
- Damage to nearby organs
- Infection
- Not being able to absorb enough nutrients from food
- Intestinal blockage caused by scar tissue
How long will it take to recover from surgery?
Most patients stay in the hospital for up to 1 week after the procedure. Complete recovery from an ileostomy may take up to 2 months. During this time, you will have limits on what you can eat while the small intestine heals.
If the ileostomy is temporary, you may need a reversal, or closure, surgery after the small intestine has healed. This surgery usually takes place about 12 weeks later.
Ileostomy care
Emptying your ileostomy bag – Once you have recovered from surgery, you will need to empty the ileostomy bag several times per day. You will not be able to control when stool and gas move into the pouch. It is best to empty it when the bag is less than half full.
Ileostomy pouches come in many sizes and shapes, but there are 2 main types:
- One-piece pouches attach directly to the skin barrier.
- Two-piece pouches include a skin barrier and a pouch that can detach from the body.
Most pouches are drained through an opening in the bottom. Ask your health care team about which type of ileostomy pouch you will receive and instructions on how to empty it.
Draining waste with a catheter – If you have a continent ileostomy, the surgeon will leave a tube in the pouch so the waste can drain continuously, called an indwelling catheter. This will last for about 3 to 4 weeks. Once the indwelling catheter is removed, you will need to drain the pouch several times a day. This frequency will decrease over time.
Caring for your skin – The skin surrounding the stoma is called peristomal skin. It will always look red and may bleed occasionally, which is normal. However, bleeding should not continue for long.
It is important to make sure your pouch is correctly connected to your stoma. A pouch that fits poorly can irritate your skin. You should also keep this area clean and dry. If this skin appears wet, weepy, bumpy, itchy, or painful, it may be infected. Contact your healthcare team.
Ileostomy concerns
High stool output – During the first few days after surgery, you may have a larger than normal stool output. As your body gets used to the stoma and ileostomy, this amount will decrease. If it does not decrease after a few days, call your health care team. Passing large amounts of stool means you may be losing too many fluids. This could lead to an imbalance in your electrolyte levels. Electrolytes are minerals that help regulate the body.
Managing gas – Just like with stool, you will also need to release gas from your ileostomy pouch. The way you do this depends on the type of pouch. Some pouches have a filter that deodorizes and vents gas. This prevents the bag from becoming too stretched, coming off of the abdomen, or bursting.
Amounts of gas deposited into the pouch will vary based on the type of ileostomy and your diet. Foods and drinks such as beans, onions, milk, and alcohol can cause excess gas. Swallowing air can also increase the amount of gas in your small intestine. This happens when you chew gum or drink through a straw. You may have a lot of gas right after surgery. But this should decrease as your body heals. Your health care team can provide information on food and lifestyle choices to help reduce gas.
Whole pills or capsules in the stool – Coated pills and extended-release capsules may come out intact in your pouch. This can mean that the medication was not fully absorbed in your body. Tell your health care team if this happens. They may be able to prescribe liquid or gel medications for you to take instead.
Stoma obstruction – Sometimes your stoma may become blocked by a piece of undigested food and scar tissue. This means that stool and gas cannot pass through into the pouch. An obstruction may cause abdominal pain or swelling or nausea or vomiting.
You may be able to remove the blockage at home. This can be done by avoiding solid foods and drinking more fluids, including warm drinks like tea. You can also try massaging your abdomen around the stoma or drawing your knees to your chest and rocking side to side. If these tips do not work, call your health care team right away.
Complications
These can be classified as immediate, early, or late or as procedure-specific and general complications. It is important to note that complications following the creation of an intestinal stoma are experienced by 20% of the patients. General complications vary depending on the type of operation being undertaken for an ileostomy to be necessary. Procedure-specific complications include the following [rx]:
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Stenosis
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Ischemia/Necrosis
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Hemorrhage
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Infection/Abscess
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A parastomal hernia
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Retraction/Prolapse
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Electrolyte imbalance due to the high output of the effluent from the ileostomy
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Dehydration
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Renal impairment
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Hematoma/Seroma
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Obstruction
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Fistula formation
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Skin irritation
Some of the main problems that can occur after an ileostomy or ileo-anal pouch procedure are described below.
Obstruction
Sometimes the ileostomy does not function for short periods of time after surgery.
This is not usually a problem, but if your stoma is not active for more than 6 hours and you experience cramps or nausea, you may have an obstruction.
If you think you may have an obstruction, contact your GP or stoma nurse for advice.
They may recommend:
- avoiding solid foods for the time being
- drinking plenty of fluids
- massaging your tummy and the area around your stoma
- lying on your back, pulling your knees up to your chest and rolling from side to side for a few minutes
- taking a hot bath for 15 to 20 minutes to help relax the muscles in your tummy
In persistent or severe cases, you may be advised to go to your nearest accident and emergency (A&E) department as there’s a risk your bowel could burst (rupture).
Dehydration
You’re at an increased risk of becoming dehydrated if you have an ileostomy because the large intestine, which is either removed or unused if you have an ileostomy, plays an important role in helping absorb water from food waste.
This makes it important to make sure you drink enough fluids to keep your urine a pale yellow colour to prevent complications of dehydration, such as kidney stones and even kidney failure.
Rectal discharge
People who have an ileostomy but have an intact large intestine often experience a discharge of mucus from their rectum.
Mucus is a liquid produced by the lining of the bowel that acts as a lubricant, helping the passage of stools. It’s still produced even though it no longer serves any purpose.
The mucus can vary from a clear “egg white” to a sticky, glue-like consistency.
If there’s blood or pus in the discharge, contact your GP as it may be a sign of infection or tissue damage.
Many people find the most effective method of managing rectal discharge is to sit on the toilet each day and push down as if passing a stool.
This should help remove any mucus located in the rectum and prevent it building up.
Contact your GP if you find this hard to do or it’s not helping, as you may need further treatment.
Vitamin B12 deficiency
Some people who have had an ileostomy will experience a gradual decrease in their levels of vitamin B12.
Vitamin B12 plays an important role in keeping the brain and nervous system healthy.
This decrease is thought to occur because the part of the intestine removed during the procedure is responsible for absorbing some vitamin B12 from the food you eat.
In some people, the fall in vitamin B12 levels can cause a condition called vitamin B12 anaemia, which is also sometimes known as pernicious anaemia.
Symptoms of vitamin B12 anemia include:
- unexplained fatigue (extreme tiredness) and lethargy (lack of energy)
- breathlessness
- feeling faint
- irregular heartbeats (palpitations)
- headache
- hearing sounds coming from inside the body rather than from an outside source (tinnitus)
- loss of appetite
If you have had an ileostomy and experience any of these symptoms, contact your GP. They’ll be able to arrange a blood test to check your vitamin B12 levels.
It’s important not to ignore these types of symptoms. If vitamin B12 deficiency is left untreated, it can cause more serious problems with your nervous system, such as memory loss and damage to the spinal cord.
If a diagnosis of vitamin B12 deficiency or anemia is confirmed, treating the condition is relatively straightforward and involves taking regular vitamin B12 supplements in the form of injections or tablets.
Stoma problems
Some people with an ileostomy experience problems related to their stoma, such as:
- irritation and inflammation of the skin around the stoma
- narrowing of the stoma (stoma stricture)
- a section of the bowel pushing through the opening in the skin (stoma prolapse)
- an internal part of the body, such as an organ, pushing through a weakness in the muscle or surrounding tissue wall (parastomal hernia)
- the stoma sinking below the level of the skin after the initial swelling goes down (stoma retraction)
- the stoma may get longer with time as more of the bowel pushes itself out of the abdomen (prolapse)
If you think you may have a problem with your stoma, contact your GP or stoma nurse for advice.
Skin irritation can usually be treated with topical treatments, such as a spray, but you may need to have further surgery to correct physical problems related to your stoma.
Phantom rectum
The phantom rectum is a complication that can affect people with ileostomies.
The condition is similar to a phantom limb, where people who have had a limb amputated feel it’s still there.
People with phantom rectum feel like they need to go to the toilet, even though they do not have a working rectum. This feeling can continue many years after surgery.
Some people have found sitting on a toilet can help relieve this feeling.
Pouchitis
Pouchitis is when an internal pouch becomes inflamed. It’s a common complication in people with an ileo-anal pouch.
Symptoms of pouchitis include:
- diarrhea, which is often bloody
- abdominal pains
- stomach cramps
- a high temperature (fever)
Speak to your GP if you have symptoms of pouchitis.
The condition can usually be successfully treated with a course of antibiotics.
LIVING WITH AN ILEOSTOMY
- Work – With the possible exception of jobs requiring very heavy lifting, an ileostomy should not interfere with work. People with ileostomies are successful business people, teachers, carpenters, welders, etc.
- Sex and Social Life – Physically, the creation of an ileostomy usually does not affect sexual function. If there is a problem, it is almost always related to the removal of the rectum. The ileostomy itself should not interfere with normal sexual activity or pregnancy. It should not prevent one from dating and continuing relationships and friendships. UOAA Affiliated Support Groups are available for emotional support to couples.
- Clothing – Depending on stoma location usually one is able to wear similar clothing as before surgery, including swimwear.
- Sports and activities – With a securely attached pouch one can swim and participate in practically all types of sports. Caution is advised in heavy body contact sports and a guard or belt can be worn for protection. Travel is not restricted in any way. Bathing and showering may be done with or without the pouch in place.
- Diet – For guidance, follow your nurse or doctor’s orders at each stage of your post-op adjustment. Individual sensitivity to certain foods varies greatly. You must determine, by trial, what is best for you. See our guide for special considerations for those with an ileostomy including absorption and blockages. A good practice for all is to chew your food thoroughly and always hydrate properly.
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