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Gastrointestinal Stomas in Children 431

length of bowel and mesentery so that maturation of the stoma can be
accomplished without tension. Additional mobilisation of bowel often
requires a laparotomy, and limited bowel resection is performed to remove
an ischaemic or stenotic segment. If the retracted stoma is sufficiently
mobile to allow the bowel to be everted, the bowel walls can be fixed
together by inserting several interrupted absorbable sutures with full
thickness bites. The new stoma should be matured at the same site, except
when retraction has resulted in significant skin excoriation or abdominal
wall sepsis; in these cases, a new ostomy site should be established. 4
If available, several firings of a noncutting linear stapler (e.g., the
GIA stapler without the blade) will simplify the procedure (Figure
72.1). Adhesion between the serosal surfaces of the everted stoma will
usually have occurred before the sutures are absorbed. The stapling
technique involves the following steps:
1. The stoma is retracted to its full extent by placing three pairs of
Babcock’s forceps (not shown in Figure 72.1).
2. A noncutting linear stapler (without the blade) is placed with Source: Nwomeh BC. Reoperation for stoma complications. In: Teich S, Caniano DA,
the jaws toward the mucocutaneous junction between the Babcock eds. Reoperative Pediatric Surgery. Humana Press, 2008. Reproduced with permission.
forceps. Care is taken to avoid the mesentery before firing the stapler. Figure 72.1: The stapling technique for fixation of a retracted stoma. See text
for procedure.
3. Three parallel rows of staples fix the two walls of the ileum together.
Prolapse
Stoma prolapse is a common and often frightening and distressing
complication to the child and family. Loop stomas are more likely than
end stomas to prolapse, and the distal segment of the loop stoma is most
frequently affected. It often begins as a prolapse of the mucosa through
the stoma, subsequently extending to the entire circumference of the
bowel. Prolapse usually occurs when a skin opening is made to accom-
modate dilated bowel, which, upon shrinking, leaves a loose stoma. It
may also be caused by inadequate fixation of the mesentery to the pari-
etal peritoneum. A prolapsed stoma may be traumatised by desiccation (A) (A) (B) (B)
or by an ill-fitting appliance, which may lead to mucosal ulceration and
bleeding. In the early stage, spontaneous or manual reduction is usually
possible, but in cases of persistent prolapse, intestinal obstruction, or
strangulated bowel, surgical intervention is required.
For temporary relief, a nonabsorbable monofilament material
(polypropylene or nylon) is used to place a simple purse-string suture,
similar to the Thiersch technique for rectal prolapse (Figure 72.2). If
this procedure is used in permanent stomas, however, the fixed ring
may produce stenosis as the child grows. The procedure for the purse-
string suture technique follows: (C) (C) (D) (D)
1. A 1-cm skin incision is made at the medial angle of the stoma down Source: Nwomeh BC. Reoperation for stoma complications. In: Teich S, Caniano DA, eds.
to the subcutaneous tissue (Figure 72.2(A)). Reoperative Pediatric Surgery. Humana Press, 2008. Reproduced with permission.
Figure 72.2: Purse-string suture technique for correcting prolapsed stoma. See
2. A finger is inserted into the stoma as a guide, and a 1-0 monofilament text for procedure.
nonabsorbable suture with a round cutting needle is passed around the
colostomy, staying within the subcutaneous layer (Figure 72.2(B)). The
needle is placed as far as it can comfortably go, usually about a quarter 1. The prolapse is reduced with a gentle inward pressure (Figure 72.3(A)).
of the circumference, then brought out through the skin. 2. A double-armed 3-0 nonabsorbable monofilament suture is used.
3. The needle is passed again through the same skin exit site toward One needle is placed through a latex bolster (or pledget) and a second
the lateral corner (Figure 72.2(C)). needle is passed 2–3 cm into the reduced limb of the stoma, then
through the bowel wall and out the abdominal wall an equal distance
4. One or two more passes of the needle are made as it marches from the stoma. The needle is then placed through a separate bolster
circumferentially around the stoma until it is brought out through the (Figure 72.3(B)).
medial incision. With a finger remaining in the lumen, the suture is
tied, causing puckering of the stoma without completely occluding the 3. The suture is tied without undue tension, sandwiching the bowel
lumen (Figure 72.2(D)). and abdominal wall between the bolsters (Figure 72.3(C)). The inset in
Another technique for temporary control of prolapsed stoma, the figure shows the bowel adherent to the abdominal wall following
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described by Gauderer, involves the placement of a “U” stitch from the removal of the bolsters 2 weeks later.
lumen of the reduced bowel through the abdominal wall with a double- Definitive relief may require resection of the prolapsed bowel and
armed needle (Figure 72.3). Before tying the suture ends, each needle is fixation of the mesentery. This procedure usually requires reopening the
passed through a pledget, thus creating an internal and external bolster main abdominal incision. A prolapsed loop ostomy may be divided with
that attaches the bowel to the body wall and prevents the suture from the closed distal end returned into the abdomen, thereby converting the
cutting through. The pledget made from a rubber catheter may be used. loop to an end ostomy that is less likely to prolapse. When appropriate,
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This technique has the following steps: closure of the ostomy is the best option.