PK Q6\_rels/PK Q6\ docProps/PK Q6\ppt/PK Q6\ ppt/_rels/PK Q6\ ppt/charts/PK Q6\ppt/charts/_rels/PK Q6\ppt/embeddings/PK Q6\ ppt/media/PK Q6\ppt/slideLayouts/PK Q6\ppt/slideLayouts/_rels/PK Q6\ppt/slideMasters/PK Q6\ppt/slideMasters/_rels/PK Q6\ ppt/slides/PK Q6\ppt/slides/_rels/PK Q6\ ppt/theme/PK Q6\ppt/notesMasters/PK Q6\ppt/notesMasters/_rels/PK Q6\ppt/notesSlides/PK Q6\ppt/notesSlides/_rels/PK Q6\` [Content_Types].xml PK Q6\]] _rels/.rels PK Q6\ 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 15 15 0 0 false Fonts Used 2 Theme 1 Slide Titles 15 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15 PptxGenJS false false false 16.0000 PK Q6\   docProps/core.xml Stoma Surgery - Comprehensive Surgical Overview PptxGenJS Presentation PptxGenJS PptxGenJS 1 2026-04-02T06:50:34Z 2026-04-02T06:50:34Z PK Q6\ ppt/_rels/presentation.xml.rels PK Q6\Oݨ ppt/theme/theme1.xmlPK Q6\;G#yyppt/presentation.xml PK Q6\Xppt/presProps.xml PK Q6\ppt/tableStyles.xml PK Q6\D >00ppt/viewProps.xml PK Q6\H7t!ppt/slideLayouts/slideLayout1.xml PK Q6\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK Q6\kPppt/slides/slide1.xml SURGICAL EDUCATIONStoma SurgeryA Comprehensive Surgical OverviewTypes · Indications · Techniques · Complications · ReversalGeneral Surgery | Colorectal DivisionPK Q6\3 ppt/slides/_rels/slide1.xml.rels PK Q6\.ppt/notesSlides/notesSlide1.xml 1PK Q6\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK Q6\.-Q-Qppt/slides/slide2.xml LEARNING OBJECTIVES 1Define a stoma and classify the various types by anatomical site and function 2Identify the indications for stoma formation (emergency and elective) 3Describe pre-operative assessment including stoma siting principles 4Explain the surgical technique for colostomy, ileostomy, and urostomy formation 5Recognise and manage early and late post-operative stoma complications 6Outline the principles of parastomal hernia prevention and management 7Describe the indications and technique for stoma reversal (closure) 8Discuss the psychological impact and patient education requirementsPK Q6\2- ppt/slides/_rels/slide2.xml.rels PK Q6\ppt/notesSlides/notesSlide2.xml 2PK Q6\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK Q6\}zzzppt/slides/slide3.xml DEFINITION & CLASSIFICATION OF STOMAS STOMA (Greek: στόμα = mouth/opening) | A surgically created opening between a hollow organ and the external surface of the body, fashioned to divert the flow of intestinal contents or urine. COLOSTOMYLarge Bowel (Colon)Opening of the colon onto the abdominal wall. Stool consistency depends on location — solid (sigmoid), semi-solid (transverse).End (Hartmann's)Single barrel; distal end oversewn. Most common permanent stoma.Loop ColostomyBoth limbs over a rod. Defunctioning — typically temporary.Double-barrelBoth cut ends brought to surface. Allows easy reversal.📍 LLQ (sigmoid) / LUQ (transverse) ILEOSTOMYTerminal IleumOpening of the ileum onto abdominal wall. Output is liquid; high in enzymes — caustic to skin. Requires a spout.End IleostomyBrooke's spout (everted 2–3 cm) — directs output into appliance.Loop IleostomyTemporary defunctioning; most common before low anterior resection.Kock PouchContinent ileostomy with internal reservoir; largely historical.📍 RLQ (right iliac fossa) UROSTOMYUrinary DiversionDiversion of urine to the abdominal wall. Ileal conduit is the gold standard. Output is continuous urine.Ileal Conduit15 cm ileal segment; ureters anastomosed; gold standard.UreterostomyDirect ureter(s) to skin. High stenosis rate. Salvage procedure.Indiana PouchContinent reservoir with catheterisable stoma. Elective only.📍 RLQ (right iliac fossa)PK Q6\W/ ppt/slides/_rels/slide3.xml.rels PK Q6\K |Őppt/notesSlides/notesSlide3.xml 3PK Q6\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK Q6\'$@@ppt/slides/slide4.xml INDICATIONS FOR STOMA FORMATION⚡ EMERGENCY INDICATIONS Obstructing Colorectal CancerAcute large bowel obstruction — Hartmann's procedure or defunctioning loop colostomy Perforated DiverticulitisGeneralised faecal/purulent peritonitis — Hartmann's + washout (Hinchey III–IV) Ischaemic Colitis / VolvulusTransmural ischaemia / failed volvulus reduction → resection ± end colostomy Trauma / Rectal InjuryPenetrating abdominal trauma, destructive rectal injury — protective loop stoma Anastomotic LeakPost-operative leak requiring defunctioning loop ileostomy or colostomy Severe IBD / Toxic MegacolonSubtotal colectomy with end ileostomy — life-saving procedure🗓 ELECTIVE INDICATIONS Colorectal Cancer→ Low rectal cancer (abdominoperineal resection)→ Protection of low anterior resection anastomosis Inflammatory Bowel Disease→ Total colectomy + end ileostomy (severe UC)→ Crohn's disease — fistula/stricture/perianal disease Benign Conditions→ Familial adenomatous polyposis (FAP/IPAA)→ Refractory faecal incontinence (end-stage) Urological / Gynaecological→ Bladder cancer — ileal conduit (radical cystectomy)→ Recto-vaginal fistula (radiation/obstetric)💡 ~130,000 people in the UK live with a stoma. Approximately 21,000 new stomas are formed annually across all indications.PK Q6\` ppt/slides/_rels/slide4.xml.rels PK Q6\vsppt/notesSlides/notesSlide4.xml 4PK Q6\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK Q6\pRqbqbppt/slides/slide5.xml PRE-OPERATIVE ASSESSMENT & STOMA SITING 📋 Pre-operative AssessmentHistory: Indication, previous abdominal surgery, BMI, comorbidities, medications (steroids, anticoagulants)Nutritional Status: Serum albumin, BMI, MUST score. Optimise pre-operatively if elective.Stoma CNS Referral: Specialist stoma nurse — pre-operative counselling essential for all planned stomasPatient Education: Explain stoma type, pouching systems, lifestyle changes, reversal possibilityPsychological Assessment: Body image concerns, depression screening, social support networkPhysical Examination: Assess abdomen: scars, skin folds, belt line; examine in standing/sitting/lying positionsInformed Consent: Permanent vs temporary, complications, reversal probability, impact on QoL/intimacy 📍 Stoma Siting PrinciplesWithin Rectus AbdominisPasses through the muscle — significantly reduces parastomal hernia riskVisible to PatientMust see the stoma to manage independently — assess in standing, sitting, lying positionsAway from Bony ProminencesAvoid ASIS, costal margin — prevents appliance leakageAway from Skin Folds & ScarsFolds and scars prevent appliance adherence → chronic leakageBelow Belt Line (Usually)Allows normal clothing; site above if obese or short trunk≥5 cm from All WoundsAway from wound/drain sites for independent appliance managementColostomy → LLQ | Ileostomy → RLQ | Urostomy → RLQPK Q6\5 ppt/slides/_rels/slide5.xml.rels PK Q6\W8ppt/notesSlides/notesSlide5.xml 5PK Q6\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK Q6\Pb}b}ppt/slides/slide6.xml COLOSTOMY — TYPES & SURGICAL TECHNIQUE End Colostomy — Operative Steps1Stoma site incisionCruciate skin incision at pre-marked LLQ site; core of subcutaneous fat excised2Fascial entryCruciate incision anterior rectus sheath; split rectus fibres; incise posterior sheath and peritoneum3Aperture sizeAccommodate two fingerbreadths — must pass bowel without tension or constriction4Bowel mobilisationMobilise sigmoid colon with adequate mesentery; preserve marginal artery5ExteriorisationDeliver bowel end 2–3 cm above skin without tension; confirm orientation (no twist)6MaturationFull-thickness seromuscular sutures to dermis (2/0 Vicryl) — flush, not everted (unlike ileostomy) Loop Colostomy (Defunctioning)◆ Transverse / sigmoid loop delivered through aperture over a support rod◆ Enterotomy on antimesenteric border — proximal (functional) limb faces patient's head◆ Rod removed after 5–7 days once fixation established◆ Reversal: simple closure or formal resection at 8–12 weeks◆ Higher prolapse risk than sigmoid — use sigmoid in preference Key Technical ConsiderationsTension-free: Mobilise splenic flexure if needed; mesentery must not be tautBlood supply: Preserve marginal artery; check viability — pink bowel, pulsatile mesenteryOrientation: Avoid 180° twisting; mark proximal limb with suture before deliveryAperture size: Too tight = ischaemia; too large = prolapse/hernia. Two fingerbreadths optimalLaparoscopic: Stoma often created first laparoscopically; camera port aids site selectionPK Q6\ج+ ppt/slides/_rels/slide6.xml.rels PK Q6\zppt/notesSlides/notesSlide6.xml 6PK Q6\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK Q6\Ǥ 4{4{ppt/slides/slide7.xml ILEOSTOMY — TYPES & SURGICAL TECHNIQUE Brooke's Ileostomy — Spout Maturation1. Aperture: Right iliac fossa pre-marked site; trephine through rectus abdominis muscle2. Exteriorise bowel: Terminal 8–10 cm ileum delivered; close mesenteric gap to prevent internal hernia3. Spout creation: Evert (fold back) distal 2–3 cm of ileum to create a 2.5–3 cm spout above skin level4. Why a spout?: Proteolytic enzymes are caustic — spout directs liquid output into appliance, away from peristomal skin5. Maturation sutures: 3-point sutures: full-thickness bowel tip → seromuscular at skin level → dermis (Brooke technique) Ileostomy vs ColostomyFeatureIleostomyColostomyOutputLiquidSemi-solidVolume/day500–1500 mL100–300 gSkin riskHigh (enzymes)LowSpoutYes (2–3 cm)No (flush)ApplianceDrainableClosed bagSiteRLQLLQ/LUQ Loop Ileostomy — Critical PointsIndication: Protect low colorectal/IPAA anastomosis; most common temporary stoma in colorectal surgeryOutput risk: HIGH output (>1500 mL/day) → dehydration, AKI, electrolyte imbalance — monitor and replace dailyReversal: Typically 8–12 weeks; confirm distal anastomosis intact (water-soluble contrast enema before closure)Dysfunction: Early: high output; Late: adhesive obstruction, herniation — both require prompt investigationPK Q6\F ppt/slides/_rels/slide7.xml.rels PK Q6\)lppt/notesSlides/notesSlide7.xml 7PK Q6\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK Q6\li r rppt/slides/slide8.xml UROSTOMY — URINARY DIVERSION Ileal Conduit — Gold Standard Technique1Bowel segment selectionIsolate 15–20 cm of terminal ileum (10–15 cm from ileocaecal valve); restore bowel continuity with ileo-ileal anastomosis2Ureteric anastomosisLeft ureter tunnelled under sigmoid mesentery; both ureters spatulated and anastomosed end-to-side (Wallace or Bricker technique)3Stoma formationDistal end of conduit brought to pre-marked RLQ site through rectus muscle aperture4Maturation & stentingEverted spout (1–2 cm); ureteric stents placed and removed at 10–14 days; appliance fitted post-operatively5Wallace vs BrickerWallace: conjoined ureteric plate (fewer anastomoses); Bricker: independent ureteric anastomoses (separate leak control) Types of Urinary Diversion▶ Ileal Conduit: Incontinent; gold standard; excellent long-term outcomes▶ Indiana Pouch: Continent, catheterisable reservoir — complex, selected patients▶ Neobladder: Orthotopic reconstruction — continent voiding per urethra▶ Ureterostomy: Emergency/salvage — high ureteric stenosis rate Specific Complications• Ureteroileal anastomotic stricture (10–15%)• Pyelonephritis / recurrent UTIs• Hyperchloraemic metabolic acidosis• Renal deterioration (monitor GFR annually)• Stomal stenosis / retraction• Mucus production in conduit (normal — reassure)PK Q6\6 ppt/slides/_rels/slide8.xml.rels PK Q6\iސppt/notesSlides/notesSlide8.xml 8PK Q6\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK Q6\14__ppt/slides/slide9.xml STOMA APPLIANCES & PERISTOMAL SKIN CARE One-Piece SystemFlange + bag as single unit✅ Simple to use — ideal for new patients ✅ Less bulky under clothing ✅ Quick to apply and remove⚠ Skin exposed each change ⚠ Less flexible for changing stoma sizeBest used for:Colostomy / Simple ileostomy Two-Piece SystemBaseplate + separate bag✅ Bag changed without disturbing skin ✅ Multiple bag options (open/closed/drainable) ✅ Preferred by most active patients⚠ Slightly more complex initially ⚠ Flange-bag junction can occasionally leakBest used for:Ileostomy / Urostomy / Active patients Closed BagSealed, non-drainable pouch✅ Discreet with minimal odour ✅ Simple — change 1–3× per day⚠ Not suitable for liquid output ⚠ More product wasteBest used for:Colostomy (formed stool output) Drainable BagOpen-ended with clip/velcro seal✅ Less frequent full changes ✅ Suitable for liquid/semi-liquid output ✅ Emptied 4–6× daily⚠ Less discreet than closed bag ⚠ Requires emptying techniqueBest used for:Ileostomy / UrostomyAccessories: Barrier rings/paste · Flange extenders · Stoma powder (weeping skin) · Barrier wipes · Convex baseplates (retracted stoma) · Support beltsPK Q6\>$ ppt/slides/_rels/slide9.xml.rels PK Q6\qppt/notesSlides/notesSlide9.xml 9PK Q6\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK Q6\ووppt/slides/slide10.xml EARLY POST-OPERATIVE COMPLICATIONS (<30 DAYS)Early complications occur in 20–70% of patients — vigilant post-operative stoma assessment by nursing staff is essential. Stomal Ischaemia / NecrosisURGENT⚙ Cause: Inadequate blood supply; tension on mesentery; tight aperture constricting vessels👁 Signs: Dark/black discolouration; no bleeding on pin-prick; foul odour — assess depth urgently💊 Mx: Monitor hourly; assess with test tube + torch; superficial → observe; full thickness → re-operation High Output StomaCRITICAL⚙ Cause: Ileostomy >1500 mL/day; short gut; proximal stoma; high GI secretions👁 Signs: Thirst, polyuria, dehydration; ↓Na⁺, K⁺, Mg²⁺; rising creatinine (AKI)💊 Mx: Oral rehydration salts; loperamide + codeine; restrict hypotonic fluids; IV replacement if severe Mucocutaneous SeparationCOMMON⚙ Cause: Ischaemia of sutures; infection; tension; malnutrition; steroids👁 Signs: Suture line dehiscence; gap between stoma edge and skin; stoma recessed💊 Mx: Alginate/hydrocolloid wound products; specialist pouching; heals by secondary intention Stomal RetractionMODERATE⚙ Cause: Tension, obesity, ischaemia; inadequate bowel mobilisation at primary operation👁 Signs: Stoma below skin level; poor appliance seal; chronic leakage and skin breakdown💊 Mx: Convex baseplate ± support belt; surgical revision if persistent or severe Stomal OedemaEXPECTED⚙ Cause: Normal post-operative response to surgical trauma; improves over 4–6 weeks👁 Signs: Swollen, firm, shiny stoma; difficulty fitting appliance — cut aperture larger💊 Mx: Temporarily cut larger aperture; topical sugar (osmotic) for severe oedema; reassurance Peristomal Skin IrritationCOMMON⚙ Cause: Chemical dermatitis from effluent; mechanical trauma; adhesive allergy👁 Signs: Erythema, maceration, excoriation around stoma; leakage perpetuating cycle💊 Mx: Barrier creams; correct appliance sizing; stoma powder on weeping skin; CNS specialist reviewPK Q6\Ѳ!ppt/slides/_rels/slide10.xml.rels PK Q6\O ppt/notesSlides/notesSlide10.xml 10PK Q6\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK Q6\yppt/slides/slide11.xml LATE COMPLICATIONS (>30 DAYS) Parastomal Hernia30–50%Bowel herniates through abdominal wall defect adjacent to stoma. Most common late complication of colostomy.Mx: Support belt; Sugarbaker mesh repair; prophylactic mesh at primary formation reduces incidence by 50% Stomal Prolapse2–10%Telescoping of bowel through the stoma opening. Loop stomas and transverse colostomies most at risk.Mx: Manual reduction if viable bowel; elective surgical revision; resection if irreducible or ischaemic Stomal Stenosis5–15%Narrowing of stomal outlet due to ischaemia, fibrosis, or Crohn's disease at the mucocutaneous junction.Mx: Digital dilatation; Hegar dilators; formal surgical refashioning if severe or recurrent Fistula / Sinus3–8%Track from stomal bowel to skin — Crohn's disease, suture abscess, foreign body reaction to mesh.Mx: Wound care; treat underlying cause; surgical excision ± stoma relocation if persistent Peristomal VaricesRarePortal hypertension → caput medusae around stoma. Risk of massive haemorrhage — life-threatening.Mx: TIPSS procedure; local injection sclerotherapy; suture ligation; rarely stoma relocation Pyoderma GangrenosumRareNeutrophilic dermatosis causing painful ulceration; strongly associated with IBD. NOT a wound infection.Mx: High-dose systemic corticosteroids; ciclosporin; biological therapy. DO NOT debride — pathergy Allergic Contact Dermatitis5–42%Reaction to adhesive, appliance materials, or barrier products — causes eczematous peristomal rash.Mx: Patch testing; change appliance system; topical hydrocortisone; CNS specialist review Psychosocial MorbidityUp to 40%Depression, body image disturbance, sexual dysfunction, social isolation — profoundly underdiagnosed.Mx: Psychological screening tools (PHQ-9); CBT; stoma support groups; sexual health referralPK Q6\;!ppt/slides/_rels/slide11.xml.rels PK Q6\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK Q6\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK Q6\${ s sppt/slides/slide12.xml PARASTOMAL HERNIA 30–50%Overall incidence >80%After end colostomy (5yr) ~30%Require surgical repair 30–50%Post-repair recurrence ⚠ Risk Factors⚙ Obesity (BMI >30) (modifiable)⚙ Site outside rectus abdominis (modifiable)• Emergency stoma formation• Post-operative wound infection⚙ Steroid / immunosuppressant use (modifiable)• COPD / chronic cough / straining⚙ Large trephine aperture (>3 cm) (modifiable)⚙ Malnutrition / hypoalbuminaemia (modifiable) 🔧 Prevention & Surgical RepairProphylactic Mesh (Prevention):→ Lightweight large-pore mesh at primary formation→ Reduces hernia rate by 50% (NNT = 3–4)→ Keyhole / Sugarbaker configuration→ No significant increase in infection rateConservative:→ Support hernia belt — first-line if asymptomatic→ Patient education: avoid constipation, liftingSurgical Options:→ Sugarbaker: mesh placed around stoma→ Keyhole: mesh with central aperture for stoma→ Stoma relocation: opposite side — complex but definitivePK Q6\c!ppt/slides/_rels/slide12.xml.rels PK Q6\*)@ ppt/notesSlides/notesSlide12.xml 12PK Q6\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK Q6\ {l\l\ppt/slides/slide13.xml STOMA REVERSAL (CLOSURE) Pre-Reversal AssessmentTiming: Loop ileostomy: 8–12 weeks; End colostomy (Hartmann's): 3–6 months after primary surgeryContrast Study: Water-soluble enema or CT contrast enema — confirms intact anastomosis. MANDATORY before reversalEndoscopy: Sigmoidoscopy to exclude anastomotic stricture, recurrent disease or local recurrencePatient Fitness: Nutritional optimisation (albumin >3.0); no active sepsis; fully recovered from primary illnessOncological: Complete all adjuvant chemotherapy before reversal if indicated; restage disease first Reversal TechniqueLoop Ileostomy Closure1. Circumferential incision around stoma base2. Mobilise loop from abdominal wall (avoid laparotomy)3. Close enterotomy transversely or resect and anastomose4. Skin: purse-string closure — halves SSI risk vs primary closureHartmann's Reversal (End Colostomy)1. Laparotomy or laparoscopically-assisted approach2. Adhesiolysis; identify and mobilise rectal stump3. Colorectal anastomosis with EEA stapler or hand-sewn Outcomes & Complications of ReversalReversal rate: Only 60–80% of intended temporary stomas are eventually reversed — patient/disease factors prevent manyMortality: ~0.4% loop ileostomy reversal; ~1.5% Hartmann's reversal — significantly more complex procedureSSI at stoma site: 15–25% wound infection rate; purse-string closure or delayed primary closure significantly reduces thisAnastomotic leak: 1–5% after Hartmann's reversal; ensure defunctioned segment is decompressed and contrast study done pre-opBowel dysfunction: LAR syndrome; urgency; faecal incontinence after ileostomy reversal — pelvic floor physiotherapy helpsIncisional hernia: Up to 20% at reversal wound site; consider prophylactic mesh or laparoscopic approach to reduce riskPK Q6\x!ppt/slides/_rels/slide13.xml.rels PK Q6\Ї ppt/notesSlides/notesSlide13.xml 13PK Q6\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK Q6\ٚccppt/slides/slide14.xml PSYCHOLOGICAL IMPACT & PATIENT EDUCATION Psychological Challenges◆ Body image disturbance — stoma seen as mutilating◆ Depression & anxiety (up to 40% of patients)◆ Fear of leakage, odour, and noise in public◆ Sexual dysfunction & altered intimacy/relationships◆ Social isolation and withdrawal from activities◆ Loss of control over bodily functions◆ Identity adjustment challenges ('ostomate' identity) Stoma CNS (Nurse) Role◆ Pre-operative counselling & stoma siting◆ Post-operative appliance training and education◆ Troubleshooting complications: leakage, skin care◆ Ongoing community support and follow-up visits◆ Liaison with surgical team, GP, and dietitian◆ Introduction to support groups and resources◆ Medication review affecting stoma output Patient Education Topics◆ Appliance application and bag changing technique◆ Diet: avoid gas-producing foods initially (beans, cabbage)◆ Fluid intake: 2–3L/day; rehydration salts for ileostomy◆ Activity: gradual return; avoid heavy lifting (6 weeks)◆ Swimming, sport, travel — all achievable with stoma◆ Clothing adaptations; support belts; specialist swimwear◆ When to seek help: leakage, skin issues, no output >6h💙 Most ostomates report acceptable quality of life within 12 months — early psychological support and specialist stoma nursing are the key determinants of long-term adjustment.PK Q6\O!ppt/slides/_rels/slide14.xml.rels PK Q6\0 ppt/notesSlides/notesSlide14.xml 14PK Q6\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK Q6\Q`Z`Zppt/slides/slide15.xml SUMMARY & KEY TAKEAWAYS3 TypesColostomy · Ileostomy · Urostomy30–50%Parastomal hernia incidence60–80%Temporary stomas reversed40%Psychological morbidity1Stomas are classified by origin (colon/ileum/urinary) and type (end/loop). Each has distinct indications, output characteristics and appliance requirements.2Pre-operative stoma siting by a specialist nurse is essential — within rectus abdominis, visible to the patient, away from bony prominences and skin folds.3Ileostomies require a Brooke's spout (2–3 cm); colostomies are fashioned flush. High-output ileostomy (>1500 mL/day) is the most dangerous early complication.4Parastomal hernia (30–50%) is the most common late complication. Prophylactic mesh at primary formation reduces incidence by ~50%.5Water-soluble contrast study is mandatory before any stoma reversal to confirm intact distal anastomosis.6Psychological morbidity affects up to 40% of ostomates. Early CNS involvement, patient education, and peer support are as important as technical stoma care.Stoma Surgery — Comprehensive Surgical Overview · General Surgery & Colorectal Division · For Academic Use OnlyPK Q6\*R!ppt/slides/_rels/slide15.xml.rels PK Q6\Qz ppt/notesSlides/notesSlide15.xml 15PK Q6\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK Q6\K !ppt/slideMasters/slideMaster1.xml PK Q6\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK Q6\6TT!ppt/notesMasters/notesMaster1.xml 7/23/19Click to edit Master text stylesSecond levelThird levelFourth levelFifth level‹#›PK Q6\s **,ppt/notesMasters/_rels/notesMaster1.xml.rels PK Q6\_rels/PK Q6\ $docProps/PK Q6\Kppt/PK Q6\ mppt/_rels/PK Q6\ ppt/charts/PK Q6\ppt/charts/_rels/PK Q6\ppt/embeddings/PK Q6\ ppt/media/PK Q6\Bppt/slideLayouts/PK Q6\qppt/slideLayouts/_rels/PK Q6\ppt/slideMasters/PK Q6\ppt/slideMasters/_rels/PK Q6\  ppt/slides/PK Q6\3ppt/slides/_rels/PK Q6\ bppt/theme/PK Q6\ppt/notesMasters/PK Q6\ppt/notesMasters/_rels/PK Q6\ppt/notesSlides/PK Q6\ppt/notesSlides/_rels/PK Q6\` P[Content_Types].xmlPK Q6\]] T$_rels/.relsPK Q6\00nppt/viewProps.xmlPK Q6\H7t!]rppt/slideLayouts/slideLayout1.xmlPK Q6\ђ77,Kuppt/slideLayouts/_rels/slideLayout1.xml.relsPK Q6\kPvppt/slides/slide1.xmlPK Q6\3 ppt/slides/_rels/slide1.xml.relsPK Q6\.ppt/notesSlides/notesSlide1.xmlPK Q6\:A*ippt/notesSlides/_rels/notesSlide1.xml.relsPK Q6\.-Q-Q|ppt/slides/slide2.xmlPK Q6\2- ppt/slides/_rels/slide2.xml.relsPK Q6\ppt/notesSlides/notesSlide2.xmlPK Q6\xշ*ppt/notesSlides/_rels/notesSlide2.xml.relsPK Q6\}zzzppt/slides/slide3.xmlPK Q6\W/ tppt/slides/_rels/slide3.xml.relsPK Q6\K |Ővppt/notesSlides/notesSlide3.xmlPK Q6\9 Y*}ppt/notesSlides/_rels/notesSlide3.xml.relsPK Q6\'$@@ppt/slides/slide4.xmlPK Q6\` Nppt/slides/_rels/slide4.xml.relsPK Q6\vsZppt/notesSlides/notesSlide4.xmlPK Q6\J *' ppt/notesSlides/_rels/notesSlide4.xml.relsPK Q6\pRqbqb: ppt/slides/slide5.xmlPK Q6\5 mppt/slides/_rels/slide5.xml.relsPK Q6\W8oppt/notesSlides/notesSlide5.xmlPK Q6\Qe*vppt/notesSlides/_rels/notesSlide5.xml.relsPK Q6\Pb}b}xppt/slides/slide6.xmlPK Q6\ج+ _ppt/slides/_rels/slide6.xml.relsPK Q6\zkppt/notesSlides/notesSlide6.xmlPK Q6\=|*8ppt/notesSlides/_rels/notesSlide6.xml.relsPK Q6\Ǥ 4{4{Kppt/slides/slide7.xmlPK Q6\F |ppt/slides/_rels/slide7.xml.relsPK Q6\)l~ppt/notesSlides/notesSlide7.xmlPK Q6\|g*ppt/notesSlides/_rels/notesSlide7.xml.relsPK Q6\li r rppt/slides/slide8.xmlPK Q6\6 ppt/slides/_rels/slide8.xml.relsPK Q6\iސppt/notesSlides/notesSlide8.xmlPK Q6\pO*ppt/notesSlides/_rels/notesSlide8.xml.relsPK Q6\14__ppt/slides/slide9.xmlPK Q6\>$ dppt/slides/_rels/slide9.xml.relsPK Q6\qfppt/notesSlides/notesSlide9.xmlPK Q6\1*mppt/notesSlides/_rels/notesSlide9.xml.relsPK Q6\ووoppt/slides/slide10.xmlPK Q6\Ѳ!ppt/slides/_rels/slide10.xml.relsPK Q6\O ppt/notesSlides/notesSlide10.xmlPK Q6\T+ppt/notesSlides/_rels/notesSlide10.xml.relsPK Q6\yppt/slides/slide11.xmlPK Q6\;!ppt/slides/_rels/slide11.xml.relsPK Q6\s6ӑ ppt/notesSlides/notesSlide11.xmlPK Q6\O+ppt/notesSlides/_rels/notesSlide11.xml.relsPK Q6\${ s sӜppt/slides/slide12.xmlPK Q6\c!ppt/slides/_rels/slide12.xml.relsPK Q6\*)@ ppt/notesSlides/notesSlide12.xmlPK Q6\Fb+ppt/notesSlides/_rels/notesSlide12.xml.relsPK Q6\ {l\l\ppt/slides/slide13.xmlPK Q6\x!wppt/slides/_rels/slide13.xml.relsPK Q6\Ї yppt/notesSlides/notesSlide13.xmlPK Q6\yv+ppt/notesSlides/_rels/notesSlide13.xml.relsPK Q6\ٚccppt/slides/slide14.xmlPK Q6\O!fppt/slides/_rels/slide14.xml.relsPK Q6\0 tppt/notesSlides/notesSlide14.xmlPK Q6\?ݤ+Cppt/notesSlides/_rels/notesSlide14.xml.relsPK Q6\Q`Z`ZXppt/slides/slide15.xmlPK Q6\*R!Kppt/slides/_rels/slide15.xml.relsPK Q6\Qz Mppt/notesSlides/notesSlide15.xmlPK Q6\$Q+Tppt/notesSlides/_rels/notesSlide15.xml.relsPK Q6\K !Vppt/slideMasters/slideMaster1.xmlPK Q6\N),uppt/slideMasters/_rels/slideMaster1.xml.relsPK Q6\6TT!wppt/notesMasters/notesMaster1.xmlPK Q6\s **,Oppt/notesMasters/_rels/notesMaster1.xml.relsPK__DÖ