Ileostomy Repair

Low colorectal, coloanal, or ileorectal anastomoses are usually protected with a temporary diverting, or defunctionalizing, ileostomy. While they cannot avoid anastomotic leaks, they can help to reduce related morbidity including sepsis, peritonitis, poor new rectal function, and cancer recurrence. Loop ileostomies are preferred over loop colostomies because they are less voluminous, odorous, and susceptible to prolapse, as well as having fewer repair issues. The closure of a loop ileostomy is related to a 17% morbidity rate and a 0.5 percent mortality rate. The majority of patients have their ileostomies closed with a peristomal cut, but 3.8 percent need a laparotomy. Wound infection and small intestinal blockage, which account for 5 and 7 percent respectively, are the most common problems associated with ileostomy closure.  Cigarette smoking more than doubles the chance of postoperative wound infection.

In the case of ruptured diverticulitis or other left colon rupture, a temporary colostomy, such as a Hartmann's operation, is often used. With a morbidity rate of more than 51%, reversing Hartmann's surgery can be challenging, and as a consequence, many patients never get their stoma reversed. Sepsis, wound infection, and ileus are the most common consequences following Hartmann's reversal procedure. Hartmann's repair is frequently being done laparoscopically, which results in less morbidity, shortened hospital stay, and a faster recovery of bowel function.

What is an ileostomy?

An ileostomy is an operatively created opening in the abdomen. It's frequently required because the ileum isn't working correctly or because a disease has invaded that area of the colon and it needs to be removed. The ileum (lower section of the small intestine) is passed through this opening to produce a stoma, which is normally located on the lower right side of the abdomen. Because that region of the colon requires time to relax and heal from a condition or disorder, an ileostomy may only be necessary for a short time (temporary), perhaps 3 to 6 months. However, if a problem is more significant, such as malignancy, an ileostomy may be required for the remainder of a person's life (permanent).

A Wound Ostomy Continence (WOC) nurse is an adequately trained registered nurse that looks after and educates ostomy patients. This type of nurse is also known as an ostomy nurse.  will most likely collaborate with the surgeon to determine the optimal location and method of stoma management.

When you look at the stoma, you're looking at the mucosa of the small intestine, which resembles the inside lining of the cheek. The stoma will change color from pink to scarlet. It's hot and wet, with a minor amount of mucus secreted. Soon following the surgery, it will shrink. It will have a circular to oval form. Some stomas protrude from the skin, while others are flush with it.

The stoma, unlike the anus, lacks a valve or sealing muscle. This implies you won't be able to control how much stool comes out of the stoma. Because the stoma contains no nerve fibers, it is not a cause of pain or discomfort.

The colon (the main part of the large intestine) and rectum (the lower part of the large intestine where produced feces is stored until it is released out of the body through the anus) are frequently removed as part of this procedure. This signifies that the colon and rectum are no longer functioning properly. Only a portion of the colon and rectum are sometimes resected.

What is an Ileostomy Repair?

Ileostomy repair, also known as ileostomy closure or ileostomy reversal, is When an ileostomy that was constructed to redirect the passage of bowel contents or stool from the bowel downstream is linked to the bowel downstream. The ileostomy is a hole cut into and through the lower abdomen through which the small bowel is inserted and bowel content or stool is collected in a plastic bag or device that is cleaned at periodic times as needed.

One or both ends of the bowel may be brought out at the stoma site in an ileostomy. An end ileostomy is defined as an ileostomy with only one end. Depending on how they're made, an ileostomy with two ends is called a loop or an end-loop ileostomy.

The most frequent ileostomy may be a loop ileostomy, which is employed to redirect stool or feces far away from the downstream bowel while we wait for the downstream bowel wound to heal after rectal surgery. A tiny cut is typically made around the ileostomy and the two ends of the small bowel are brought together with sutures or stapling instruments in the case of a loop ileostomy. One further incision to the ileostomy is typically needed to enter the downstream bowel and link the two ends together in the case of an end ileostomy.

Wound infection, hernia, bowel leakage, bleeding, and the patient's cardiac arrhythmia, lungs infection, kidney and urinary tract infections, and venous system (deep vein thrombosis, pulmonary emboli) are all risks linked with an ileostomy closure.

Ileostomy Repair Approach

One Day Before Surgery

The day before the procedure, you will have to stick to a pure liquid diet. Only clear liquids are included in a pure liquid diet. Examples can be found in the Pure liquid diet in any source.

While you are on a pure liquid diet, you have to do the following:

• Don't consume anything solid.
• While awake, try drinking at least one glass of clear liquid hourly.
• Various clear liquids should be consumed. Don't restrict yourself to water, coffee, or tea.
• If you have diabetes mellitus and a person of the care team advises you to, don't consume sugar-free liquids.

For diabetes mellitus patients, follow these instructions:

• If you are diabetic, talk to the diabetes care physician about what to do while you're on a pure liquid diet.
• If you take insulin or another diabetes treatment, find out if you need to adjust the dosage.
• Check with your doctor to see if you should consume sugar-free clear liquids.
• While on a pure liquid diet, remember to check the blood glucose levels frequently. Consult the healthcare practitioner if you have any concerns.

Special Instructions by the Doctor

• Finish the preoperative drink 2 hours before the planned arrival time if the healthcare physician prescribed it. Nothing else, including water, should be consumed after midnight the night before the procedure.
• If your healthcare professional has not provided you with a preoperative drink, you can drink 10 ounces of water between midnight and two hours before the planned arrival time. Nothing else should be consumed.
• Take only those pills with a glass of water if the healthcare practitioner advised you to do so the morning of the procedure. This could be all, part, or none of the morning pills, based on the prescriptions you use.

Important Things to keep in mind

• Wear something that is loose-fitting and comfortable.
• Wear the glasses rather than the contact lenses if you use them. Contact lenses might harm the eyes if you use them during the procedure.
• Wearing metal things is not a good idea. The Jewelry, including body piercings, should be removed. If the equipment used during the procedure comes into contact with metal, it can lead to burns.
• Remove any lotion, makeup, powder, perfume, or fragrance from your body.
• Leave valuables at home, including credit cards, jewelry, and the checkbook.
• Use a sanitary napkin instead of a tampon if you are having a period. You will get disposable underwear and, if necessary, a pad.

Things you Have to Bring

• Sneakers with a lace-up front. It's possible that the feet are swollen. Over this swelling, lace-up sneakers can be worn.
• If you have it, the sleep apnea breathing device.
• If you have finished them, the Health Care Authority form and other advance directives.
• The phone, as well as its charger.
• Only the cash you will need for minor purchases.
• If you have one, a bag for your personal belongings (such as eyeglasses, hearing aids, and dentures).

Intraoperative Details

If you have hearing aids, dentures, or prosthetic devices, you must remove them before the procedure. You will either enter the surgery theater on your own or be carried in on a stretcher. An operating theater team member will assist you onto the operating table and insert compressive boots on the lower legs. These inflate and deflate slowly to promote blood flow in the legs.

Your anesthesiologist will give you an anesthetic through the Intravenous (IV) line after you are relaxed, and you will fall asleep. During and after the surgery, you will get hydration through the Intravenous infusion.

The bowel is reconnected after an incision is created around the ileostomy. This is then reinserted into the abdomen. If the doctor needs to re-join the bowel, he may have to open the midline scar you already have.

To assist you in breathing, a breathing tube will be put through the mouth and into the larynx once you've fallen asleep completely. Following surgery, the breathing tube is normally removed while you are still in the operating theater. Gauze and a dressing will be applied to the wound.

Postoperative Period

You won't be able to eat anything till the bowels have shown that they are functional following the procedure. Patients usually begin producing stool through the rectum in up to 48 hours, but it might take up to 72 hours in some cases. Patients are frequently discharged from the hospital on the third or fourth day following the procedure.

A suture (stitch) is used to close the wound in the abdomen, which you may not be able to see. The stitches are hidden behind the skin and will dissolve when the wound heals.

When you first start passing stool, it is likely that it will be watery. Until the colon becomes adjusted to taking in more water, they may have a lot of watery stools. Following surgery, you may experience loose, frequent stools for one to four weeks.

The skin in this area is extremely sensitive since it hasn't been in touch with stool in a long time.

Ileostomy Repair Complications

The procedure to repair the stoma, like any procedure, carries some dangers that you should be aware of. The surgical team will take all precautions possible to avoid them.

The following are a few common post-surgery complications:

1. Deep vein thrombosis. It is a blood clot in the leg that can travel through the bloodstream and into the lungs, resulting in a pulmonary embolism. To prevent this from happening while you're in the hospital, you will get an anticlotting injection every day and wear support socks.
2. Infection of the lung.
3. Infection of the urinary tract.
4. Infection of the wound.
5. The surgery site is leaking blood.
6. Postoperative Hernias. When the bowel bursts through the muscles of the abdomen, generating a protrusion beneath the skin, it is called a hernia. When lying, sitting, or standing, the hernia might shrink or expand. Hernias develop in areas where there is a risk of weakness. A hernia is a rare complication, but it is more probable in weak, elderly, and overweight people. It's also more common among those who have stressed their muscles or overexerted themselves during the first few weeks after surgery. Supporting your hernia using a belt or binder is part of hernia treatment. This aids in the reduction of protrusion and the maintenance of healthy posture. The majority of hernias occur within a few months after surgery, generally within the first two years. However, surgical correction may be required in a small percentage of patients.

Early mobilization and deep breathing help to avoid these consequences. These issues can be avoided by rapidly getting up, moving around, and leaving the hospital.

These are the most common problems, albeit they are not life-threatening. Antibiotics would be used to treat the condition, and the fluid would either be reabsorbed by the body or drained via the wound. Wound infection is more likely to happen after you've returned home, so if the wound becomes warm, red, or painful, visit the Doctor or practice nurse for help.

Less Common Complications

1. Anastomotic leak. A leak from the sutures where the bowel is stitched back together is known as an anastomotic leak. This occurs in 1 out of every 300-ileostomy repair. This is a more dangerous consequence that almost always necessitates subsequent surgery. The stoma may need to be reconstructed if this occurs. This does not indicate that it will be permanent; depending on the overall health, another trial at repair may be attempted in the future. If there is a leak, you will most likely feel a dull ache. You have a fever and feel tired after repairing the ileostomy. This problem usually appears a few days after the surgery and can make you feel poorly in general.
2. Abdominal collection. This is a collection of contaminated fluid within the abdomen that causes pain and bloating to get worse. You could also have a fever and have recurrent loose stools or have the bowels stop performing. Antibiotics and draining of the collection with ultrasonography or Computed tomography are used to treat this condition.
3. Fistula formation. A fistula is an unnatural connection between two sections of the body, most commonly the bowel and the skin's barrier. Once the stoma is repaired and the bowel integrity is restored, issues from the join established during the first procedure can emerge in rare circumstances. An infection around the rectal anastomosis, which might manifest as a fistula, is the most frequent problem. Some fistulas heal on their own, but if the fistula does not heal within a year, surgery may be recommended.
4. Ileus and intestinal obstruction: There is a chance that the bowel will stop operating adequately following surgery. This is due to peristaltic movement, which is a delay in bowel movement or contractions. The handling of the colon during operation, as well as the bruising that causes edema, are the most common causes of this ailment. It may take a few days for regular bowel movements to return to normal and you to begin passing both gas and stool via your passage. If the bowels become temporarily blocked due to an ileus or bowel obstruction, you may have increased flatulence, abdominal discomfort, nausea, and vomiting. Stopping nutritional intake and allowing the colon to rest will help with this. To alleviate the discomfort, a tiny tube may be inserted through the nose and into the stomach. Ileus can be avoided by being active and chewing gums.

Hand-sewn Versus Stapled Anastomoses

The anastomosis in loop ileostomy repair can be done with either a stapled or hand-sewn approach. Because the defunctionalized limb is generally thin after a period of disuse, the stapled approach allows for a larger anastomosis. Patients with stapled anastomosis have a lower rate of early postoperative small intestinal blockage due to the larger anastomosis. Though the stapled approach has a higher cost, the benefits of shorter operation periods and hospital stays outweigh the disadvantages. There was no difference in the probability of anastomotic leak in a meta-analysis of 4,508 patients who had loop ileostomy repair, 1,370 of whom had a stapled anastomosis, and 3,131 of whom had a hand-sewn anastomosis. When compared to the hand-sewn cohort, patients who underwent stapled anastomoses had reduced operative durations, shorter lengths of stay, and reduced incidence of conservatively managed small intestinal obstructions at 30 days.

Other trials have found similar findings with stapled anastomosis, including lower rates of intestinal blockage, shorter lengths of stay, and shorter operational periods, as well as roughly the same rate of anastomotic leak. A current retrospective study of 361 side-to-side functional end-to-end stoma repairs indicated that when a 100-mm linear stapler was utilized, ileus resolution was much faster than when shorter stapler lengths were employed.

Conclusion

Ileostomy and colostomy both play a critical function in preserving anastomoses and preventing peritoneal infections. Temporary stoma repair is associated with significant consequences, which can be reduced by maximizing stoma repair timing and assessing anastomotic continuity before stoma repair. The morbidity of ileostomy and colostomy repair has been reduced using a variety of approaches. Minimally invasive techniques are recommended because they reduce postoperative morbidity and speed up recovery.