Ileostomy - Indications, Types, and Contraindications

Introduction

Some surgical procedures are not intended to remove a diseased or damaged part of the body but to create alternatives to the natural process. For example, creating an opening in the stomach to bypass the normal excretion passage through the anus and divert the route of the stool. This procedure is called an ileostomy, and the stool and other waste fluids come out from the patient’s body through this opening. A pouch or bag is attached to this opening or stoma that collects the waste material.

An ileostomy can be temporary or permanent, depending on the need. A temporary ileostomy is done for a few weeks or months, and the normal excretion process is reversed. Permanent ileostomy remains a lifetime. Every day, up to 600-700mL of waste is excreted through the stoma after ileostomy.

What Is Ileostomy?

An ileostomy is a surgical procedure in which an opening is created to connect a part of the ileum with the outer surface abdomen.

What Is Ileum?

It is the longest and last part of the small intestine. It is generally 3.5 meters long and is responsible for absorbing vitamin B12 and nutrients from the food.

What Are the Anatomical Considerations for Ileostomy?

The small intestine in the human body is six to seven meters long and has three parts or sections: the duodenum, jejunum, and ileum. The duodenum is present at the backside of the peritoneum (retroperitoneal). The jejunum and ileum are present within the peritoneum (intraperitoneal). The ileum ends at a junction with the caecum. The small intestine has different linings: mucosa, submucosa,muscularis propria, subserosa, and serosa. The muscle attachments include various muscles such as oblique muscles (internal and external) and abdominis muscles (transverse and rectus). These muscles are attached to the lower or last ribs at different levels.

When Is Ileostomy Indicated?

It is needed:

• To excrete the stool through the ileum instead of the anus.

• To protect against colon anastomosis. It is a surgical connection of two structures, such as two parts or open ends of the colon. The stool diverts from its causal route for excretion, the colon. It is required to prevent the leakage of stool from healing or partially healed anastomosis.

• To divert the stool route when the colon is entirely removed due to cancer.

• To avoid bowel obstruction that blocks the movement of the stool during excretion.

What Are the Types of Ileostomy?

Based on the time duration, it can be of different types:

1. Temporary Ileostomy: It is done for a short time, such as a few weeks to months, to reroute the stool or waste excretion and allow complete healing of the colonic anastomosis. After full recovery, the ileostomy is reversed, and stool excretion occurs from its natural passage.

2. Permanent Ileostomy: It is done when a part of the intestine is removed or diseased. This type of ileostomy remains for a lifetime.

3. Ileo-Anal Ileostomy: In this type, a permanent pouch is created internally between the ileum and the anus, bypassing the colon. This pouch is called J-pouch. The excretion of stool occurs in its natural way.

What Is the Location of an Ileostomy?

An ileostomy is done on the lower right side of the abdomen.

When Is Ileostomy Contraindicated?

There is no specific condition in which an ileostomy cannot be performed. However, a few common contraindications are:

• Mesentery: Obese or overweight patients who have small mesentery of their small intestines. The mesentery is a set of tissues or folded muscles that attach the small intestine to the abdomen wall.

• Carcinomatosis - Cancer that starts from one part and spreads to other body parts.

How Is Ileostomy Done?

• Before Surgery:

  • Patients must quit smoking one month before surgery. Smoking interferes with the healing process.

  • If possible, the patient must consider losing weight before surgery because an ileostomy is contraindicated in obese patients with short mesentery.

• During the Surgery:

  • General anesthesia is given to the patient.

  • The surgery site is marked with ink.

  • Skin is prepared with an antiseptic solution.

  • The skin is cut in a circular shape of two to three centimeters in diameter.

  • The tissues are cut, and the rectus abdominis muscle is retracted. It is important to take care of the blood vessels in this muscle. The doctor must avoid damaging those vessels.

  • Another incision, called the cruciate incision, is marked, and the peritoneum (internal lining of the abdomen) is lifted with the help of clips.

  • A cut is made between the peritoneum to access the peritoneal cavity.

  • The open space or defect is stretched to make appropriate space to create an ileostomy.

  • A part of the ileum is then passed through the open space.

Mentioned above are the basic steps to performing an ileostomy. After this, there can be two types of ileostomy to perform:

Loop Ileostomy:

• While passing the part of the ileum, as mentioned above, if loop ileostomy is performed, then a loop of the ileum is passed through.

• The loop placement must be above the skin level to prevent the going back of the ileum.

• The space is then closed with sutures. These sutures are placed in different directions, such as 3, 9, and 12 o’clock.

• The opening creates a stoma, usually at the right lower part of the abdomen.

End Ileostomy:

• The ileum's last part, or stapled end, is passed through the space.

• The space is then closed with sutures. These sutures are placed in different directions, such as 3, 9, and 12 o’clock.

What Is Stoma?

A stoma is an opening created surgically by the doctor while performing an ileostomy. This opening is visible to the patient. Sometimes, a pouch is attached to this stoma to collect the stool.

What Is the Pouching System?

The pouching system has a pouch or a bag placed over the stoma after ileostomy. This pouch collects all the fluids, such as urine, and waste materials, such as stool, from the patient’s body. It is important to clean the pouch seven to eight times every day. This pouching system has the following:

1. A pouch or a bag.

2. Adhesive to attach the pouch to the skin. It also acts as a barrier to the surrounding healthy skin to prevent inflammation and infection.

3. The end part of the pouch has an opening to drain out the waste collected in the pouch.

What Are the Different Types of Pouching Systems?

The different types of pouching systems are:

1. One-Piece System: It has one pouch and adhesive.

2. Two-Piece System: It has one pouch and a separate adhesive, which is detachable. The pouch can be detached from the adhesive when not needed.

How Much Waste is Excreted Through Stoma per Day?

After an ileostomy, up to 600 to 700 mL is the excretion of fluids and waste every day.

What Are the Complications of Ileostomy?

The common complications are:

• Stenosis - Narrowing of the spinal cord.

• Hemorrhage - Excessive internal bleeding.

• Necrosis - The death of tissues of an organ due to interrupted blood supply.

• Hernia - Protrusion of part of an organ, such as the intestine, on the skin surface.

• Retraction - Slipping off the part of the intestine that was surgically taken out and sutured during ileostomy.

• Imbalance of Electrolytes - Losing large amounts of sodium and potassium.

• Dehydration - Losing more water than consuming. This condition stops the body from doing its normal functions.

• Fistula - Abnormal connection between two body structures: the intestine and abdomen wall.

• Hematoma - The pooling of blood outside the blood vessels.

Conclusion

An ileostomy is a life-saving surgical procedure that may be performed as elective surgery or emergency surgery. After undergoing an ileostomy, the patient can perform daily functions. However, ileostomy can be done for any health-related condition and does not have any specific contraindications. It is generally not performed in obese patients and those with cancerous conditions. Providing complete patient education about stoma and hygiene maintenance is essential.