Classification and creation goals
Stoma placement surgery serves several purposes: ensuring patient nutrition (in case of obstruction of proximal parts), administering therapy, content diversion (in case of obstruction of distal parts), or temporary exclusion of distal segments for wound and ulcer healing.
Depending on the organ on which the stoma is placed, they are distinguished into:
- Gastrostomy (gastric fistula).
- Enterostomy (small intestine fistula): jejunostomy or ileostomy.
- Colostomy (large intestine fistula): cecostomy, stomas of the ascending, transverse, descending colon, and sigmoidostomy.
According to the channel structure and duration of use, all fistulas are divided into two large groups: tubular (temporary) and lip-like (permanent).
Tubular fistulas (temporary)
Formed by creating an artificial channel from the anterior wall of the organ along its axis. A rubber tube is placed inside the channel.
- Structure: The channel is lined with serosa (seromuscular type).
- Mechanism: The tube is positioned tangentially or vertically, and fixation to the anterior abdominal wall creates a reliable valve preventing backflow of contents.
- Feature: As soon as the tube is removed, the opening quickly adheres and closes spontaneously.
- Main methods: Witzel method, Stamm-Kader method.
Stamm-Senn-Kader method differs in that the tube is placed not longitudinally, but in a vertical serous channel. For this, three purse-string sutures are applied to the anterior wall one above the other, sequentially invaginating them.
Guernez and Ho-Dak-Di modification is an improved Witzel method. The purse-string suture is applied in the area of the air bubble, and the tube is placed vertically. This eliminates contact of the stoma with liquid contents and prevents leakage.
Lip-like fistulas (permanent)
Created for long-term use. The stomach or intestinal wall is pulled into the surgical wound as a cone, the apex is opened and sutured to the integumentary tissues.
- Structure: The channel along its entire length is lined with mucosa, which is fixed directly to the skin.
- Feature: Such stomas do not close spontaneously. To remove a lip-like fistula, additional surgical intervention is required.
- Main methods: Toprover method (the most common option for the stomach).
In colon surgery, a lip-like fistula is called a fecal fistula (fistula stercoralis). With it, intestinal contents are discharged both through the stoma and naturally. If it is necessary to completely exclude the distal part of the intestine and divert all contents only through the artificial opening, an artificial anus (anus praeternaturalis) is created.
Features of gastrostomy technique
Stomach operations are usually performed via a left-sided transrectal approach (an incision about 10 cm long downward from the costal margin).
Witzel gastrostomy is used for inoperable cancer of the cardia and esophagus, burns, and strictures. A rubber tube is placed along the anterior wall of the stomach, invaginating it into a tunnel of 6–8 seromuscular sutures. The end is inserted into the lumen through an incision inside a half-purse-string suture. Then the stomach is obligatorily fixed to the parietal peritoneum (gastropexy), and the tube itself is brought out through a separate skin puncture (counter-opening).
Toprover gastrostomy involves pulling out the anterior wall in the form of a cone. Three concentric purse-string sutures are applied to it. After inserting the tube, the sutures are sequentially tightened, plicating the wall to create a valve. Fixation is strictly layer-by-layer: the lower (third) suture to the parietal peritoneum, the middle (second) to the aponeurotic sheath of the rectus muscle, and the upper (first) to the skin, forming a lip-like fistula.
How to remember the lining: Tubular fistula — "Tube in serosa" (heals on its own). Lip-like fistula — "Lips outward" (mucosa sutured to the skin, will not close on its own).
Class and exam questions
What is the difference between a fecal fistula and an artificial anus?
In a fecal fistula (fistula stercoralis), the contents exit both through the stoma and naturally through the anus. An artificial anus (anus praeternaturalis) completely bypasses the distal section, with all contents passing solely through the artificial opening.
Why does a tubular fistula close spontaneously?
Its channel is lined with serosa. After removing the rubber tube, the serous surfaces quickly adhere and fuse together.
What is the advantage of the Guernez and Ho-Dak-Di modification?
This is an improved Witzel method in which the opening is made in the area of the gastric air bubble, and the tube is placed vertically. This eliminates stoma contact with liquid contents and reliably prevents leakage.
What else to study on this topic
- Stages of forming the seromuscular tunnel according to Witzel
- Technique of placing concentric purse-string sutures according to Toprover
- Stamm-Senn-Kader method: creation of a vertical channel
- Layer-by-layer fixation of the stomach wall during lip-like fistula formation
- Gastropexy: rules for suturing the stomach to the parietal peritoneum
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