 improved outcomes in colon and rectal surgery other anastomotic configurations after resection in Crohn’s disease. Dis Col Rectum 2007; 50(10): 1674–87. 132. Landsend E, Johnson E, Johannessen H, Carlsen E. Long- term outcome after intestinal resection for Crohn’s disease. Scand J Gastroenterol 2006; 41(10): 1204–8. 133. Steele SR. Operative management of Crohn’s disease of the colon including anorectal disease. Surg Clin North Am 2007; 87(3): 611–3. 134. Penner RM, Madsen KL, Fedorak RN. Postoperative Crohn’s disease. Inflamm Bowel Dis 2005; 11(8): 765–77. 135. Yamamoto T. Factors affecting recurrence after surgery for Crohn’s Disease. World J Gastroenterol 2006; 11(26): 3971–9. 136. Thaler K, Dinnewitzer A, Oberwalder M et al. Assessment of long-term quality of life after laparoscopic and open surgery for Crohn’s disease. Colorectal Dis 2005; 7: 375–81. 137. Casellas F, Vivancos JL, Badia X, Vilaseca J, Malagelada JR. Impact of surgery for Crohn’s disease on health-related quality of life. Am J Gastroenterol 2000; 95(1): 177–82.   Ostomies Vance Y Sohn and Scott R Steele CHALLENGING CASE A 55-year-old morbidly obese male undergoes a low ante- rior resection with concomitant defunctioning loop ileostomy for a T2 rectal cancer. Six weeks postoperatively, he presents to the clinic with an obvious parastomal hernia that is easily reduc- ible. He complains of worsening pain, difficulty with application of his ostomy appliances, and symptoms of intermittent obstruction. CASE MANAGEMENT In this patient, the optimal management includes reversal of the ostomy after ensuring that the distal anastomosis has healed. This is usually confirmed by a contrast study, often a gastrograf- fin enema or CT scan with rectal contrast. An ostomy reversal ameliorates and addresses all of the symptoms including the her- nia, obstruction, and pain. After reversal, the skin of the ostomy can be primarily closed, however extreme vigilance of the wound is necessary secondary to an increased rate of local wound infec- tion. Depending on the size of the fascial defect and correspond- ing hernia, additional mesh may be needed for hernia repair. Due to increased risk of infection of most prosthetics, biologic materials should be considered as a first option. For patients who are not candidates for ostomy reversal, various options are avail- able and include both open and laparoscopic approaches. These options include primary fascial repair, repair with biologic or prosthetic mesh, and stoma relocation. The approach and the method of repair is dependant on the surgeon’s preference and experience. Certainly, observation for minimally symptomatic parastomal hernias is the preferred option until stomal take- down is possible. INTRODUCTION Intestinal stomas, either temporary or permanent, are the surgi- cal exteriorization of either small or large bowel to the anterior abdominal wall. An ostomy may be placed temporarily, often when its primary purpose is to divert the fecal stream away from an area of concern such as a high-risk anastomosis in a field of prior radiation treatment, following a coloanal repair, or concern for leak after a stapled end-to-end anastomosis. Once the distal anastomosis has adequately healed, gastrointestinal continuity can be reestablished when the ostomy is reversed. A permanent stoma is created following an oncologic resection for rectal cancer that includes removal of the anorectum and associated sphinc- ter complex. In this instance, a descending colostomy would be required to avoid perineal soiling with a coloanal anastomosis in the absence of the sphincters. While there are various types of ostomies described for a broad spectrum of disease processes such as the neo-bladder construction with an ileal conduit, this chapter will focus solely on outcomes for ostomies created with the small or large bowel for colon and rectal diseases. PSYCHOLOGICAL IMPACT OF LIVING WITH A STOMA Regardless of the type of ostomy, living with a stoma exacts a tremendous psychological burden on patients and requires adjustments to activities of daily living. In addition to the physical adjustment of caring for an ostomy, the possibility of participating in simple activities, such as dining out, often becomes disrupted in the patient’s mind. Unfortunately, this is one of the major fears of patients whether or not it is founded in reality. Yet, it is also one that is often not discussed in detail before the operation, nor able to be appropriately counseled and educated when stomas are required in the emergent setting. In 1952, Sutherland et al., (1) published the first report on the important psychological needs of patients living with stomas. Since then, multiple studies have reported the negative impact ostomies have on overall quality of life.(2–6) It is not surprising that the presence of a stoma is asso- ciated with decreased quality of life measurements in the imme- diate and early postoperative setting.(7) Unfortunately, it often appears that while overall quality of life, return to prior activity levels, pain and fatigue all improve with time following surgery, self-impression views such as body image and sexual function do not seem to change with time.(8) Thus, despite evidence to the contrary that a “return to normalcy” is achievable, many patients can never get past the idea of having to live with a stoma. More recently, Krouse and colleagues (9) evaluated the quality of life of 239 male patients from multiple Veterans Affairs (VA) hospitals living with stomas. Their report, which was a case-control sur- vey study, used various previously-validated quality of life indices to compare patients with ostomies versus 272 patients who had undergone similar operations, but not requiring stoma forma- tion. Their study highlighted multiple important psychosocial facts about patients living with ostomies. There was increased self-reported postoperative depression and suicidal ideations among respondents living with ostomies. Such feelings may have been compounded by issues of coping and social acceptance, as their fears related mostly to both others’ perceptions of patients with stomas and their own personal fears of having stoma-related accidents. As these fears became more frequent, they clinically translated into decreased social interactions and eventual isola- tion. The authors’ recommendation of encouraging social net- working among ostomates to clarify issues and limit the trial and error approach that many patients with ostomies undergo, is a valid conclusion which should be supported by all physicians. This is not to say that all patients do poorly or are mentally burdened by living with a permanent stoma. In a large meta- analysis of 1,443 rectal cancer patients from 11 studies, there was no difference in general quality of life scores at 2 years following surgery between those patients undergoing an abdominoperineal resection from those undergoing a low anterior resection with in- continuity reconstruction.(10) These contradictory findings may  improved outcomes in colon and rectal surgery in part depend on the questionnaire given, the disease process for which the stoma was created, and the preoperative functional level of the patient. For example, factors such as patient age, (11) decreased preoperative continence, (12) and severe active peria- nal Crohn’s fistulizing disease (13) have all been shown to have an improved quality of life following stoma formation. Thus, while it would be inaccurate to state that placement of stoma will end up with a lowered quality of life and significant psycho- logical problems, it also is naïve to think that stoma creation will not have a significant impact on a patient’s subsequent immedi- ate and long-term recovery. It is well-established, that in addi- tion to networking, a close relationship with a readily available and experienced enterostomal therapist is an invaluable aspect of the multidisciplinary approach. These expert therapists can significantly alleviate initial fears and anxieties that often plague patients living with a stoma. Furthermore, in our experience, preoperative counseling about expectations, education regard- ing the indication for the ostomy, and even “practicing” the wearing of an appliance before surgery all aid in lessening the psychological impact on the patient and promotes adaptation to their ostomy. STOMA SITE MARKING In 2007, the American Society of Colon and Rectal Surgeons (ASCRS), in collaboration with the Wound, Ostomy, and Continence Nurses (WOCN) Society developed a position state- ment on the value of preoperative stoma marking for patients undergoing ostomy surgery.(14) Their ultimate goal was to decrease stomal complications and improve quality of life for patients. In addition to precise step-by-step instructions on the proper siting of stomas, the statement recommended that all patients scheduled for ostomy surgery undergo preoperative stoma marking by an experienced, trained clinician. This evaluation includes examining the patient in the lying, sitting, and stand- ing positions, and accounting for patient factors such as previous incisions, waist and belt lines, abdominal habitus, and hernias, to determine the optimal stoma position that is crucial to decreasing the incidence of stomal complications. One of the more impor- tant aspects of this preoperative marking evaluation is the iden- tification of the rectus abdominus muscle, as placement of the stoma through the rectus muscle may prevent peristomal her- niation or prolapse (Figure 33.1).(15) Furthermore, preoperative siting allows for patient participation and education regarding stoma care and the use of ostomy appliances. While this posi- tion statement has yet to be clinically validated, previous reports have demonstrated the importance of preoperative stomal siting. In a retrospective analysis, Bass and associates (16) reviewed a single institution’s stoma complication rate in 593 patients over an 18-year period. The study compared 292 patients who under- went preoperative marking by an enterostomal therapist to the remaining 301 remaining patients who did not undergo pre- operative marking. The endpoints of their study, early and late complications, were favorable for the patients who underwent preoperative marking with a 23% versus 43% early complication rate (p < 0.03) and 9% versus 31% late complication rate (p = NS). This study, and the joint statement by ASCRS and WOCN, highlights the importance of proper preoperative stoma marking for decreasing complication rates. STOMAL TYPES End Ostomies End ostomies, either permanent or temporary, are most often placed in the left lower quadrant of the abdominal wall using the left colon or in the right lower quadrant when utilizing the ileum. The indication for stoma creation is important, as this Figure 33.1 Stomal placement. The site is selected to bring the stoma through the rectus abdominis muscle.  ostomies often dictates whether gastrointestinal continuity can be reestab- lished. For instance, in patients undergoing an abdominoperineal resection (APR) for rectal cancer, a permanent end colostomy is the only option as the anorectum and surrounding musculature are removed. Similarly, patients who undergo a proctocolec- tomy, usually for inflammatory bowel disease (IBD) or Familial Adenomatous Polyposis (FAP), are candidates for an end ileos- tomy. For patients wanting more fecal control, a continent ileos- tomy may be offered. Ostomies remain permanent when the altered anatomy pro- hibits reestablishment of gastrointestinal continuity, the risks of undergoing another surgery are prohibitive due to comorbidi- ties, or the functional results of a reanastomosis would adversely impact quality of life. This latter point is common with reanasto- mosis of the ileum with the mid- or distal rectum or anus (since the large absorptive capacity of the colon or the storage ability of the compliant rectum is lost), or when the patient has poor sphincter function. Barring the aforementioned contraindica- tions, most ostomies can be reversed and thus, are temporary. A common temporary end ostomy performed routinely by sur- geons is the Hartmann’s procedure. Initially described by Henri Hartmann in 1921 for rectal cancer, this versatile procedure is indicated for a variety of benign and malignant scenarios where primary resection of colon and reanastomosis is unsafe or not possible. As discussed later, reversal is associated with complica- tions and the benefits of stoma reversal must be balanced with the potential risks to the surgery. Ideal candidates for reversal are young, healthy patients with preserved sphincter mechanisms. The optimal time for this colostomy reversal has been controver- sial. Some have found that reversals after 4 months were associ- ated with a higher complication rate; after this time, the rectal stump was less readily accessible and therefore, led to increased complications.(17) Others have found no outcome differences between early or late reversals and considered the timing an insig- nificant factor.(18) The benefits of an end ileostomy with immediate maturation, initially described by Brooke in 1952, have decreased the incidence of stenosis, dysfunction, retraction, and serositis associated with an ileostomy.(19, 20) Since that time, this has become the standard technique for ileostomy and most colostomy formations. Despite increasing experience with restorative continuity procedures such as the ileal pouch-anal anastomosis (IPAA), an end ileos- tomy remains an important part of the surgical armamentarium. For instance, in patients with toxic megacolon undergoing total abdominal colectomy, when the principles of “damage control” surgery are paramount, an end ileostomy following abdominal colectomy remains the procedure of choice. Additionally, an end ileostomy would be preferred over an IPAA or an ileal-rectal anastomosis (IRA) for patients with poor anal sphincter mecha- nisms where continence is questionable. Alternatively, in young healthy patients with inflammatory bowel disease or FAP requir- ing proctocolectomy, IPAA should be considered, or IRA when the rectum is spared. Purported benefits of an IPAA compared to the end ileostomy revolve around the maintenance of conti- nuity and thus, a more psychologically favorable outcome for the patient. Pemberton et al. (21) evaluated this relationship by comparing quality of life for 298 patients with IPAAs and 406 patients with end-ileostomies. Greater than 93% of patients in both groups were satisfied with their surgeries, although 39% in the end ileostomy group would have preferred an IPAA. After anal- ysis, the authors concluded that patients who underwent an IPAA experienced significant advantages in performing daily activities with resultant improved quality of life. While the benefits of IPAA are beyond the scope of this chapter, this procedure should be considered as a viable alternative for patients considered for end ileostomy. It should be noted, however, that a significant portion of IPAA patients require a temporary stoma, with an additional ~10% developing pouch failure that requires either pouch exci- sion with permanent stoma or permanent pouch diversion.(22) Thus even in this select cohort, education regarding stoma care and outcome is of utmost importance. Continent ileostomy Continent ileostomy, first reported by Nils Kock in 1969, is a less frequently performed procedure due to the technical expertise required, the significant complication rate associated with its nipple-valve mechanism, and the preference for creation of ileoa- nal pouches.(20) Occasionally, the continent ileostomy remains a useful option for patients undergoing proctocolectomy for FAP or IBD, or in those patients who develop IPAA failure. In 2006, Nessar et al. (23) reported the long-term outcomes of patients undergo- ing continent ileostomy at the Cleveland Clinic Foundation. Their study population included 181 patients with continent ileostomies, 69 of whom previously had an end ileostomy, and 35 patients who had an end ileostomy after excision of a continent ileostomy. With a median follow-up of 11 years, 17% of patients had their conti- nent ileostomy excised; there was only a 7 month complication- free interval, and a 14 month revision-free interval. Long-term complications were common, with 30% experiencing valve slip- page, 26% developing pouchitis, 25% with fistula formation, and 15% with parastomal herniation. Other complications included valve prolapse, difficult intubation, stoma stricture, and pouch bleeding. Importantly, even in centers with significant experience, the complication profile remains considerable. Similarly, in a study by Kohler et al. (24) comparing outcomes in patients between end ileostomy, continent ileostomy, and ileal pouch-anal anastomosis (IPAA), those patients with IPAA had fewer restrictions in sport and sexual activities when compared to patients with continent ileostomy. Patients with end ileostomy fared the best with regards to the travel capabilities when compared to the other two. In our practice, continent ileostomies are seldom performed. Due to the aforementioned complication profile, patients are counseled for either an IPAA, IRA, or an end ileostomy. Yet, despite our reluc- tance to perform this procedure, select institutions well-versed in this procedure report excellent outcomes and overall high patient satisfaction.(25–27) Loop End Stomas A loop end stoma is a variation in which a section of the bowel several inches proximal to the divided end of the bowel is brought through the abdominal opening (Figure 33.2). The loop can be supported with a rod and the bowel is opened and matured in a fashion similar to a loop stoma. This type of stoma is helpful in challenging situations such as thick shortened  improved outcomes in colon and rectal surgery mesentery, tenuous blood supply, or friable bowel. Its advantage is that no blood vessels are divided and with a rod, the tension is on the back wall of the bowel rather than the mucocutane- ous anastomosis. This type of stoma is slightly more difficult to pouch as it is slightly oval and may not have the protrusion of a well-formed end stoma. Diverting or Loop Ostomies The ultimate purpose when creating a diverting stoma is to pre- vent the fecal stream from reaching a distal segment of distal small bowel or large intestine for the purpose of either treat- ing or preventing a leak. To that end, either a loop colostomy or ileostomy will suffice. However, an ileostomy is often pre- ferred due to its perceived ease of closure. Proponents of a loop colostomy cite the lower risk of high stomal output leading to fluid and electrolyte abnormalities occasionally seen with a loop ileostomy. The common indications for concomitant proximal fecal diversion include protection of distal at-risk anastomo- sis, especially low-lying colo-anal anastomosis and ileal pouch anal-anastomosis (IPAA), complicated diverticulitis, treatment of anastomotic leaks and pelvic sepsis, large bowel obstruction, trauma, extensive perianal Crohn’s disease, and less commonly, fecal incontinence. The indication for a concomitant proximal fecal diversion for low lying anastomosis, most commonly performed for rectal cancer, has been intensely studied. Wong and Eu (28) reported the results from a prospective, comparative study of 1,078 patients undergo- ing elective low or ultra-low (defined as colonic anastomosis to the anal canal) anterior resections from 1994 to 2004. In the diverted group, 28% developed a clinically significant leak while of the non- diverted group, 13% had a clinically significant leak (p = 0.86). 95% of these leaks required a salvage operation, and analysis revealed no statistical difference between anastomotic leak complications between patients undergoing and not undergoing fecal diversion. These authors concluded that a defunctioning ileostomy did not influence the complication rate of a rectal anastomosis, rather it minimized the clinical sequela of leaks in high risk patients. They recommended that proximal diversion should be used on a selected basis. In another prospective study from Sweden, the Rectal Cancer Trial On Defunctioning Stoma (RECTODES) randomized 234 patients undergoing low rectal (<15 cm from the anal verge) anas- tomosis to fecal diversion versus no diversion.(29) Their primary endpoint was to assess whether there was a difference in the rate of symptomatic anastomotic leakage in patients between the two arms of the study. While there was a disproportionate number of patients (72%) not undergoing randomization due to various factors including intraoperative concerns requiring diversion, the total number of patients with and without diversion were simi- lar (116 pts vs 118 pts). Patient characteristics were similar with increased operative times for those undergoing stoma placement as the only statistically significant difference between the two patient cohorts. In their analysis, patients without a defunctioning stoma had significantly more symptomatic leakages (28%) when com- pared to those without proximal diversion (10%). The group not undergoing diversion consequently constituted 75% of all urgent reoperations. Of the 28 out of 33 patients without initial fecal diversion who developed a leak, urgent reoperation was accom- panied with either a loop ileostomy or permanent end colostomy. Consequently, these investigators recommended routine defunc- tioning loop stoma in low anterior resections for rectal cancer. Based on these and other studies, it is now generally acknowledged that a proximal defunctioning stoma does not abolish the risk of leakage, but certainly mitigates the consequences. In our practice, defunctioning stomas are almost always placed for any anastomo- sis within 5 cm of the anal verge, although exceptions such as the one stage IPAA occurs occasionally. Furthermore, patient factors such as previous irradiation, intraoperative hemodynamic insta- bility, poor nutrition, and chronic steroid use lead us to liberally “protect” the distal anastomosis. When deciding to perform a proximal fecal diversion or a defunctioning stoma, the two traditional options include a trans- verse loop colostomy or a loop ileostomy. These two options were compared in a prospective randomized study by Williams et al. for elective protection of distal anastomoses.(30) In their analysis, nearly all complications were twice as common with transverse colostomies than ileostomies and included infection at the time of creation and at takedown, odor, leakage, and skin problems. Additionally, multiple visits to the stoma therapist were needed Figure 33.2 Z-Plasty repair for stenosis. A, incisions in skin and bowel. B, completed repair.  ostomies in 58% of colostomy patients versus 18% of ileostomy patients. In another prospective randomized study by Edwards et al., there was no difference in operating time required to construct either stoma, and in fact, reversing the colostomy was easier due to the larger fascial opening.(31) This larger defect however, resulted in worse complications manifested as parastomal hernias, pro- lapse, fecal fistula, and in the follow-up period, incisional hernias. These increased rates of complications with loop colostomy and increased rate of hernia formation at the ostomy closure site, and has led to an almost universal preference of loop ileostomy for diverting stoma.(31, 32) Should one choose to perform a loop transverse colostomy, choosing a point in the colon adjacent to the flexures may decrease the risk of prolapse to a small extent. COMPLICATIONS WITH OSTOMIES The incidence of stoma complications varies in surgical literature from 10–70%, and can range from minor skin irritation to parasto- mal herniation requiring operation.(33–35) The wide variance in complication rates is due to the definition of complication and the length of follow-up in the studies. Furthermore, there are a multi- tude of factors that influence complication rates, including the type and location of the ostomy, patient factors such as gender, BMI, diagnosis, and urgency in which the procedure is performed. In a study from Cook County Hospital, the incidence of stoma com- plications was 34% in a review of 1,616 patients, with 28% hav- ing an early complication (<30 days from time of surgery) and 7% late complication (>30 days).(36) In a national audit, Cottam and associates identified 1,329 (34%) patients out of a cohort of 3,970 stomal patients that developed early complications (<3 weeks from times of surgery) defined as stoma retraction, necrosis, ischemia, muco-cutaneous separation, and dehiscence.(37) Statistically sig- nificant factors increasing postoperative complications were stoma height (<20 mm for ileostomy and <7 mm for colostomy), female gender, loop ileostomy, advanced BMI, younger age, malignant diagnosis, and emergent procedures. Similarly, in a prospective study of 97 patients, Arumugam et al. found elevated BMI, diabetes, and emergency surgery as significant risk factors for the develop- ment of stoma complications.(38) In yet another study evaluating risk factors for stoma complications, Saghir and colleagues identi- fied advanced age, advanced American Society of Anesthesiologists (ASA) grade, and noncolorectal specialty-trained surgeons per- forming the ostomy as risk factors for stoma complications.(39) As evident in these studies, various patient and surgeon factors can increase the risk of developing complications. Thus, it is impera- tive for the surgeon caring for these patients to be well aware of not only the things they can do to prevent these complications, but also how do deal with any complications should they arise. In the following section, the presentation and management of common complications will be addressed. Skin Complications Skin conditions are common among patients living with stomas and are more prevalent in patients with ileostomies than colostomies. (5) Common causes include fungal or bacterial infections, irrita- tion from the ostomy effluent, folliculitis, contact dermatitis from the appliance, a manifestation of IBD such as pyoderma gangreno- sum, or simple skin excoriation from frequent appliance changing. To a certain degree, minor skin irritation is unavoidable. However, preoperative stoma marking, precise ostomy creation, involvement of an enterostomal therapist, and diligent postoperative care may prevent some of the more severe complications. Proper location of an ostomy diminishes leaking from the appliance and entails avoid- ing previous incisions, scars, natural skin folds, and belt lines that prevent circumferential adhesion of the appliance. Leaking around the appliance and can lead to social embarrassment and dramatic skin irritation. These problems can occasionally be mitigated by careful appliance fitting which entails minimizing unprotected skin and sealing leaks from the caustic effluent. Various commer- cially produced barriers, powders, ointments, and creams are avail- able especially for this purpose and should be applied with the help of an enterostomal therapist. If skin excoriation, maceration, and irritation persist despite these conservative measures, consider- ation should be given for ostomy reversal, revision or repositioning the ostomy, or if possible, converting a high output ileostomy to a lower output colostomy. Retraction Stoma retraction occurs in up to 15% of patients and is most often the result of a technical error from improper construction and/or tension.(40–42) Postoperatively, complete retraction of the stoma into the abdomen mandates immediate re-exploration and re-creation of the ostomy. Fortunately, this potentially cata- strophic complication is extremely rare. Partial stoma retraction occurs more frequently and is more problematic for an ileostomy than a colostomy. In ileostomies, retraction leads to difficulties with appliance placement and subsequent skin irritation. In the thicker viscous colostomy effluent, skin irritation is less of an issue and can often be conservatively managed. In severe cases, opera- tive stoma revision may be required. The principles of revision include tension free ostomy and adequate eversion emphasizing the Brooke method. Ischemia and Stenosis Ostomy necrosis, due to either arterial insufficiency or venous engorgement, presents in the early postoperative period and is first recognized by mucosal ischemia. Arterial insufficiency is a complication of overaggressive mesenteric mobilization with resultant lack of small vessel collateralization to the mucosa. It can also be seen in patients with foreshortened or thickened mesenteries, in obese patients with thick abdominal walls, or after an inadequate fascial opening. Likewise, stoma necrosis from venous engorgement as the etiology ultimately leads to the same end result. Clinically, differentiating the etiology of necro- sis is not important as management is the same regardless of the cause. When both considering and managing stoma necrosis, it is imperative to identify the proximal extent of ischemia. This can be done by a simple bedside “test-tube test” in which a clear test tube is inserted into the stoma and then trans-illuminated or direct visualization is obtained via a pediatric anoscope or proctoscope. Necrosis seen below the fascia mandates re-exploration and revi- sion while necrosis isolated above the fascia can be conservatively managed. Surgically, principles of revision include excision back to healthy, viable bowel, and recreation of the stoma. This may entail a more thorough intraabdominal mobilization to reduce  improved outcomes in colon and rectal surgery tension through the abdominal wall, revision of the fascial open- ing, or ensuring no kinking of the blood supply. In very difficult cases, consideration for a loop-end ostomy is advised since less mesenteric mobilization is required. Conservative management of stoma necrosis is possible when the necrosis is isolated above the level of the fascia. Simple mea- sures, such as maintaining an adequate blood pressure for stoma perfusion and awaiting edema resolution after bowel manipula- tion can avoid the morbidity of a re-exploration. Even with frank necrosis, conservative measures with local wound care should be attempted. However, conservative management of stoma isch- emia is a risk factor for ostomy stenosis which occurs in 2–9% of patients.(34, 40, 41) Stoma stenosis is described as narrowing of the lumen of the ostomy at the skin or fascia level and is due to luminal contraction from scar tissue formation. In addition to ischemia, stenosis can occur due to insufficient skin excision at the stoma site, peristomal abscess, or mucocutaneous separa- tion. Stenosis, easily diagnosed by visual inspection and digital exam of the stoma, is rarely clinically significant and can be man- aged with a low residue diet and stool softeners. In refractory and symptomatic cases, dilation, excision of scar tissue, or stoma revi- sion can be performed. A local type of revision involves a Z-plasty repair (Figure 33.3).(43, 44) Parastomal Hernias By definition, a stoma is a hernia in the anterior abdominal wall, thus leading Goligher to state that the true rate of parastomal hernias is 100%. As such, parastomal hernias are a well-known complication of stomal surgery, and can be a major source of morbidity (Figure 33.4).(45) The incidence of hernias ranges from 5–10% of stomal patients with colostomies more prone to herniate than ileostomies.(34, 46) Fortunately, most are well tolerated and manageable nonoperatively. However, approxi- mately 30% of hernias require operative repair for symptoms that include bleeding, obstruction, abdominal masses, poor fitting appliances, and leakage.(47, 48) Surgical therapy has cen- tered on stomal relocation, primary fascial repair, and prosthetic mesh—alone, or in combination. Each of these has been widely touted; however, significant morbidity and complication rates up to 88% have left surgeons searching for a better answer to this difficult problem.(49–52) Equally frustrating is the high rate of recurrence following initial repair. Rubin et al. found an initial recurrence rate of 60%, with approximately 70% having subse- quent failures following additional surgery for both primary fas- cial repair alone and stomal relocation.(51) Although prosthetic mesh has shown improved results over stomal relocation and primary fascial repair, these reports are hindered by low patient numbers and lack of long-term follow-up to draw meaningful conclusions regarding complications and recurrences.(49–51, 53–56) A variety of surgical mesh repair techniques exist, includ- ing a circumferential onlay mesh, two separate intraperitoneal pieces placed lateral to the stoma, one large piece placed via a midline approach, and an incomplete mesh ring.(49, 53, 57, 58) Additionally, both open and laparoscopic approaches have been used.(59, 60) Yet, fear of mesh infection and erosion has led to concerns regarding mesh use, and the perceived need to avoid any contact between the bowel and mesh.(57) At our institution, one operative approach to symptomatic parastomal hernias commonly used is primary fascial repair with nonabsorbable suture and placement of mesh via a “stove-pipe” hat repair (Figure 33.5). In this technique, one piece of mesh is placed overlying the fascial repair, the stoma is then pulled through Figure 33.3 Loop end colostomy. A, loop of bowel brought through abdominal wall opening. B, stoma rod is placed through the mesenteric opening to support the loop on the skin and the bowel is opened. C, Completed loop colostomy. (A) (B) (C)  ostomies the center of the mesh, thus creating a 360-degree repair. An addi- tional piece of mesh is then tacked to both the bowel circumfer- entially and to the onlay mesh. Once constructed, this creates the “stove-pipe hat” appearance. In selected cases, an additional piece of mesh is placed beneath the fascia to provide additional sup- port. Drains are routinely placed at the time of surgery. In a recent review of our experience, we analyzed 58 patients that underwent parastomal hernia repair with polypropylene mesh.(64) With a mean follow-up of 50.6 + 40.1 months, the overall complication rate related to the polypropylene mesh was 36.2%, and occurred at a mean of 27.2 months. Complications encountered included recurrence (25.8%), surgical bowel obstruction (8.6%), prolapse (3.4%), wound infection (3.4%), fistula (3.4%), and mesh erosion (1.7%). No patients required extirpation of the mesh. Data analysis demonstrated that stomas placed for underlying colorectal cancer were associated with a decreased rate of complications while increased complications were significantly associated with younger age (59.6 vs. 67 years, p < 0.05). With the increased availability and use of the biologic mesh products, fear of contact between mesh and bowel with subsequent erosion and infection have allowed for increased use of these products using a similar technique. In addition, while not extensively studied, we have periodically placed mesh dur- ing the primary creation of a stoma in select cases, such as for those patients with diminished fascia, prolonged steroid use, and re-siting of stoma from prior failures. Future data on this practice awaits further recommendations. Prolapse Ostomy prolapse is the telescoping of the intestine through the stoma and can be a source of discomfort and anxiety for the patient. Causes include a large fascial opening in the abdominal muscula- ture, redundancy of the intestine through the abdomen, failure to place the stoma through the rectus muscle, insufficient suturing to the abdominal wall, distended abdomen, and increased abdominal pressure. Prolapses are most commonly seen in loop stomas with the distal loop more prone to prolapse. The diagnosis is easily con- firmed by inspection and the treatment depends on the severity of the prolapse. In severe prolapse, stoma obstruction and ischemia may result from excessive tension on the underlying mesentery. Ischemic changes manifested as ulceration or dusky appearance of the bowel mandates expeditious surgical intervention and resto- ration of blood flow. In the more chronic setting, prolapse can be managed conservatively with manual reduction and symptomatic relief of discomfort or pain. The application of the ostomy appli- ance is important for patients who suffer from prolapse. The skin barrier opening should be cut to accommodate the stoma at its larg- est size and two piece pouching systems with plastic rings should be avoided to prevent strangulation. Surgery may ultimately be neces- sary to resect the prolapse and revise the stoma if symptoms persist. Again, especially in the setting of loop colostomies, using a portion of bowel near the flexures where it tends to be more tethered, may aid in decreasing the incidence of prolapse. Special Consideration Morbidly Obese Patients Morbid obesity, defined as a body mass index >35 kg/m 2 , is a pub- lic health epidemic in the United States with the prevalence in the adult population ranging from 2.8–5.1%.(62, 63) The impact of obesity on the complication profile of patients undergoing col- orectal surgeries have been well documented and include a higher incidence of wound infection, dehiscence, wound herniation, anastomotic, pulmonary, cardiovascular, thromboembolic com- plications, increased operative time and length of hospital stay, and overall increased morbidity and mortality.(61) Additionally, morbid obesity has been found to increase the complication rates associated with stomas. A prospective risk factor analysis of 97 patients for stoma complications found that elevated BMI was independently associated with an increased rate of ostomy retrac- tion, early skin excoriation, and overflow.(36) Furthermore, in a retrospective review of 156 patients undergoing stoma formation, Duchesne et al. found obesity, defined as a BMI > 30 kg/m 2 , was significantly associated with stoma complications, most com- monly, stoma necrosis, prolapse, and skin irritation.(65) Similarly, Leenan and Kuypers found that obese patients had a significantly higher percentage of overall stoma complication (47 vs 36%) Figure 33.5 “Stove-pipe” hat repair: Parastomal hernia repair with mesh demonstrating the onlay piece of mesh in as well as circumferential component overlying the fascial repair. An additional piece (not shown) may be placed in the sub-fascial location as well. (Courtesy of Patrick Y. Lee, M.D.) Figure 33.4 Computed tomography image of a patient with a parastomal hernia. The arrowhead represents a herniated portion of small bowel adjacent to the ileostomy (arrow). Also note the large midline incisional hernia.  improved outcomes in colon and rectal surgery including a higher incidence of stoma necrosis.(40) Cottam’s group, in a nationwide audit of stoma complications, found that increasing BMI, even that not meeting criteria for “morbid obe- sity”, was associated with more stoma problems.(37) Various reasons for a higher complication rate in the obese include a relatively shortened and fatty mesentery, thicker abdomi- nal wall through which the stoma must traverse, poor small ves- sel circulation associated with comorbidities of obesity, and the physical difficulties of stoma appliance application in the redun- dant pannus. Ultimately, these factors predispose obese patients to undergo increased mesenteric mobilization so that the bowel reaches the skin, with the end result being arterial insufficiency to the super-fascial stoma. Additionally, an inadequate fascial opening or physical compression of the abdominal wall on the stoma as it traverses the abdominal wall may lead to constriction of venous return with resultant stoma engorgement, stenosis, or necrosis. In morbidly obese patients undergoing stoma formation in an elective setting, preoperative weight loss should be encouraged. Realistically however, sufficient weight loss to favorably impact the complication profile is unlikely. There may be a unique subset of patients who can defer abdominal surgery requiring stoma forma- tion until after undergoing bariatric surgery. In these cases, stoma formation should be delayed until massive weight loss has stabilized as significant changes on the abdominal wall may require ostomy revision if the order of surgery is reversed. In addition to timing of surgery, the preoperative preparation of the morbidly obese patient is critical. This high risk patient population should undergo age appropriate and comorbidity appropriate risk stratification and work-up as they are at increased risk for perioperative complications. In regards to ostomy complications, preoperative stoma marking is important in all patients undergoing stoma formation, but is argu- ably even more important in this patient population already at increased risk for local skin complications. Large skin creases prone to superficial fungal infections in the obese should be avoided, as well as low lying ostomies which may be difficult for the patient to adequately visualize and properly maintain (Figure 33.6). Technically, a sufficient fascial opening should be made to easily accommodate the bowel through the abdominal wall. Conservative mesenteric mobilization is encouraged, with mini- mal length required for the bowel to reach the skin without ten- sion for proper maturation the ultimate goal. In patients with foreshortened mesenteries or those with significant abdominal wall thickness, a loop ostomy, or end-loop stoma in which a loop of bowel is brought through the fascia and the distal por- tion closed allowing a few additional centimeters of bowel length for construction, should be considered as these are less prone to complications associated with vascular insufficiency. Finally, removal of some local adipose tissue through which the stoma will traverse is reasonable, although over-aggressive “de-fatting” may lead to skin necrosis. Additional options include a modified abdominoplasty (abdom- inal wall countering), localized flaps with skin or fat removal, or liposuction. Although frequently successful, these techniques have potential for significant morbidity. Patients who may ben- efit from these techniques include those with stomal retraction (especially those who have bowel limitations [e.g., continent ileo- stomies, dense intraabdoninal adhesions or short gut], prolapse, large peristomal hernias, abdominal wall laxity (usually resulting from major weight loss), and peristomal skin problems such as pyodermia. In many of these patients stomal relocation may not be the best option. A modified abdominoplasty or abdominal wall contouring is similar to the technique employed by plastic surgeons.(66, 67) A low curvilinear transverse incision is made at the inferior abdominal fold or 2–3 cm above the pubis and anterior superior iliac spines and carried down to the fascia (Figure 33.7). A flap of skin and subcutaneous tissue is created by electrocautery dis- section in a cranial direction, just above the fascia. Perforating vessels are identified and ligated or cauterized. As the dissection continues the stoma will be encountered. With the flap on trac- tion, the intestine is separated from the skin and subcutaneous tissue. Care is taken to avoid injury to the bowel or its blood sup- ply. The dissection should err on leaving additional subcutane- ous fat attached to the intestine. This can be carefully resected later. A similar maneuver may be performed at the umbilicus if Figure 36.6 Loop ileostomy in an obese patient. It is important to consider stoma placement in the lying (A), seated (B), and standing (C) positions. Note the placement of the ostomy with relation to the pannus and mid-line incision. Improper cutting of the stoma appliance cause peristomal skin excoriations. This patient was preoperatively marked by an enterostomal therapist with good postoperative functional outcome. (A) (B) (C) Figure 33.7 Redundant abdominal wall folds of skin associated with ileostomy retraction. (A) Frontal view. (B) Sagittal section demonstrating skin and subcutaneous fat incisions. (B) (A)  ostomies the surgeon and patient prefer to preserve it in its normal loca- tion. Again care is taken to preserve the tissue’s blood supply. If the umbilicus is not to be maintained, it can be amputated at the fascial level. The flap dissection is continued cranially just above the fascia until enough laxity or length is obtained in the upper flap for the upper edge of the previous stomal opening to reach the inferior portion of the incision without excessive tension or to the costal margins. Any associated peristomal hernia can be repaired at this time with suture repair of the fascia and/or mesh (synthetic or biologic) reinforcement. As the flap is retracted inferiorly, new sites for the ostomy and, if desired, the umbilicus are selected and openings created in the flap. Excess subcutaneous fat can be carefully removed to thin the flap. Fortunately, there is usually less subcutaneous fat above the umbilicus compared to below it. The excess, distal portion of the flap is excised (Figure 33.8). The intestine and umbilicus are brought through the respective flap openings and matured with interrupted absorbable sutures (Figure 33.9). Excess bowel or umbilical tissue can be carefully excised. Closed suction drains are placed below the flap to avoid seromas and the inferior inci- sion is closed in layers. As intraabdominal dissections are avoided with this technique, patients usually recover quickly. Morbidity is usually associated with infection, flap ischemia, or seromas. These are managed with wound care. A more localized procedure involves the use of flaps to modify the abdominal wall around the stomas. Most involve peristomal dissections and removal of skin and subcutaneous fat. This can be performed via a medial or inferolateral approach (Figure 33.10). An incision is made down to the fascia and advanced toward the stoma. The ostomy is dissected free of the skin and subcutaneous tissue as described above. After the stoma is freed, lateral or cra- nial dissection will provide enough laxity to advance the previous stoma site to the incision (advancement flap). As above, a new ostomy opening, in fresh skin, is created. Excess fat may be excised around the stoma and redundant midline skin is resected. If the skin flap is not redundant enough to advance the origi- nal ostomy opening to the midline, the subcutaneous fat can be excised and the stoma returned to its original skin opening through the thinned flap. Either method is performed in such a manner to leave a smooth, flat, thinned flap that provides a flat surface to site the appliance. The stoma is matured and the inci- sion is closed. Subcutaneous closed suction drains are placed above and below the stoma. The circumstomal approach starts with an incision around the stoma at the mucocutaneous junction. With careful dissection, the bowel is separated from the subcutaneous tissue down to the fascia. The subcutaneous tissue is then separated from the fascia with electrocautery in a circumferential manner to a point 7–8 cm out from the stoma. A wedge of subcutaneous tissue is circumfer- entially created from the upper skin edge to meet the outer edge of the extrafascial dissection. Small closed suction drains may be placed and the ostomy is matured to the skin edges. If there was a preoperative stenosis, the skin opening may be enlarged or the bowel may be matured with a Z-plasty technique.(43, 68) If the preoperative stomal opening was too large or it becomes too large from the dissection, the diameter of the opening can be reduced with interrupted sutures (Figure 33.11). This type of closure has been referred to a “Mercedes technique”.(69) Rapid and significant weight gain in ostomy patients may pro- duce stomal retraction. If attempts at weight loss have not been successful and stomal revision is not desirable or feasible (e.g., con- tinent ileostomy or short gut patients), liposuction is an excellent option. This method is preferred if there is no associated stomal Figure 33.8 Excess skin and subcutaneous fat have been excised. (A) Frontal view, (B).Sagittal section. (A) (B) Figure 33.9 Ileostomy relocated through upper flap and skin incisions closed. Closed suction drains placed below flaps. (A) Frontal view, (B) Sagittal section. (A) (B) Figure 33.10 Medial approach. (A) Frontal view with skin incision marked, (B) Cross section demonstrating midline incision and areas of subcutaneous fat excision, (C) After removal of excess subcutaneous tissue, incision is closed, flaps attached to fascia, and stoma matured with adequate eversion. (A) (B) (C) . includes examining the patient in the lying, sitting, and stand- ing positions, and accounting for patient factors such as previous incisions, waist and belt lines, abdominal habitus, and hernias,. undergoing an abdominoperineal resection from those undergoing a low anterior resection with in- continuity reconstruction.(10) These contradictory findings may  improved outcomes in colon and. Also note the large midline incisional hernia.  improved outcomes in colon and rectal surgery including a higher incidence of stoma necrosis.(40) Cottam’s group, in a nationwide audit of