Background Information:

What are the other Names for the Procedure?

• Enterostomy

What is Ileostomy surgical procedure?

• Ileum is the lowest part of the small intestine that joins the large intestine (colon)
• Ileostomy is a surgical procedure in which the ileum is brought outside, through an opening in the abdominal wall and connected to the skin
• An opening is made on the ileum that is on the skin surface and this opening (stoma) is connected to a bag (pouch), onto which the intestinal waste passes out of the body

What part of the Body does the Procedure involve?

An Ileostomy procedure involves the abdominal wall and the lowest part of the small intestine

Why is the Ileostomy surgical procedure Performed?

An Ileostomy can be a temporary or a permanent procedure:

Temporary Ileostomy: (Loop Ileostomy)

• A loop of ileum is brought out to the exterior
• It is mainly performed to divert the feces from the large intestine

Reasons for diverting Ileostomy:

• In conditions, such as complicated diverticulitis, inflammatory bowel diseases, like ulcerative colitis and Crohn’s colitis, colon cancer, trauma to the colon - a part of the colon may be removed and reconnected. In order to protect the new connection from the feces (which is formed), a diversion is performed to give some time to heal
• After ensuring that the new connection is well-healed, with no evidence of leak on a barium enema study, the Ileostomy is reversed
• An Ileostomy closure or reversal is performed, either by closing the opening on the ileum, or by resecting that portion of the ileum that was outside and reconnecting the two ends of the ileum, and then placing it back inside the abdomen
• After an Ileostomy reversal, the abdominal wall is closed in layers

Permanent Ileostomy: It is mainly performed when the entire colon is removed

What are some Alternative Choices for the Procedure?

To divert the feces, Ileostomy procedure remains the gold standard approach.

What are the Recent Advances in the Procedure?

Minimally invasive (laparoscopic) surgery is a recent advancement with respect to the creation of Ileostomy.

What is the Cost of performing the Ileostomy surgical procedure?

The cost of Ileostomy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Ileostomy procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5^th Edition, New York, 2006

http://www.nlm.nih.gov/medlineplus/ency/article/007378.htm

http://www.ostomy.org/ostomy_info/factsheets/facts_ileostomy_en.shtml

Prior to Ileostomy surgical procedure:

How is the  Ileostomy surgical procedure Performed?

• The surgeon makes an incision in the abdomen. The incision is carried down through different layers of the abdominal wall, until the abdominal cavity is entered
• After performing surgery on the colon, the ileum is brought outside through another opening, most commonly on the right side
• After performing an Ileostomy, the abdominal wall is closed in layers

Loop Ileostomy:

• A loop of ileum is brought outside and an opening is made on the intestine
• The periphery of the opening is then sutured to the skin

End Ileostomy:

• The ileum is divided and the divided upper end is brought outside and an opening made on the intestine
• The periphery of the opening is then sutured to the skin

Where is the Procedure Performed?

An Ileostomy surgical procedure is performed at a hospital.

Who Performs the Procedure?

A surgeon trained in general surgery performs the Ileostomy procedure.

How long will the Procedure take?

• In most cases, Ileostomy is performed as a secondary procedure in conjunction with the removal and reconstruction of the colon
• For the ileostomy part alone, it may take anywhere between 30 to 45 minutes

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient, including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for an Ileostomy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Ileostomy surgical procedure?

Before an Ileostomy procedure, the patient has to undergo certain tests (based on the condition suspected), such as:

• Routine blood and urine analysis
• X-rays
• Electrocardiography (ECG)
• CT scan of the abdomen and pelvis
• Colonoscopy

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is an Ileostomy surgical procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Ileostomy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia by injection and inhalation is used for this procedure.

How much Blood will you lose, during the Procedure?

The blood loss is generally minimal with Ileostomy, unless any complications arise.

What are the possible Risks and Complications during the Ileostomy surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the surgery are:

• Excessive bleeding
• Infection surrounding the surgical wound
• Bowel leakage inside the abdomen
• Formation of blood clots
• Anesthetic complications
• Accidental injury to the neighboring tissues

What Post-Operative Care is needed at the Healthcare Facility after the Ileostomy surgical procedure?

• After the surgical procedure, patients will be sent to an area of the hospital, called postoperative recovery area (PACU), and then admitted to the floor
• The patient’s blood pressure, heart rate, and respiration cycle, will be closely monitored
• Any additional pain associated with the procedure will also be treated
• Patients may be kept NPO (nil per os, or nothing through the mouth), till bowel functions return (Ileostomy bag will have gas and the output will be greenish to brownish)
• Patients are initially started on clear liquid diet, which is gradually advanced to regular diet, as tolerated
• They are usually discharged from the hospital, 3-7 days after the surgery is performed

After the Ileostomy surgical procedure:

What are the possible Risks and Complications after the Ileostomy surgical procedure?

Post Ileostomy procedure, the following complications may arise:

• Excessive bleeding
• Signs of infection around the surgical wound
• Abnormal accumulation of pus within a tissue (abscess)
• Abnormal scarring
• Irritation of skin surrounding the stoma
• High output from the Ileostomy, leading to dehydration and electrolyte imbalances
• Incisional hernia
• Hernia around the Ileostomy (parastomal hernia)

What is the Prognosis after the Surgery?

The prognosis is usually excellent and a complete recovery expected, without any serious complications.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Worsening pain and swelling around the surgical wound
• Abnormal swelling
• Inflammatory and painful sensation of skin surrounding the stoma
• Signs of an infection
• Fever
• Dizziness
• Feeling sick
• Muscle aches
• Headaches
• Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Ileostomy surgical procedure?

At home, the following post-operative care is recommended, after an Ileostomy procedure:

• Resume regular/daily activities, as early as possible (under advice by the physician). This aids in a faster recovery
• Avoid all activities that are physically strenuous for about 6 weeks after surgery
• Resume showering; however, keep the wound clean and dry. Gently wash the surgical wound with unscented soap and water
• Elevate legs while resting, to prevent the formation of blood clots and reduce the possibility of swelling
• Complete the course of prescribed medication, as advised by your physician
• Avoid taking nonprescription medications, such as aspirin. However, individuals may take acetaminophen to relieve pain, as necessary
• Take antibiotic medication to help combat or prevent infection, as directed by your physician
• Resume driving only after 3-4 weeks of the surgical procedure, or follow your physician’s advise
• Avoid sex till complete healing has taken place (under advise by your physician)
• The Ileostomy pouch may have to be emptied several times a day as and when it gets filled-up. The pouch should be changed periodically depending on the type used.

How long does it normally take to fully recover, from the Procedure?

It usually takes approximately 6 weeks, to fully recover from this procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The Ileostomy procedure per se, does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the creation of Ileostomy, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Ileostomy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility, a physician’s office, or the hospital
• An anesthesiologist
• The surgeon performing the procedure

The patient is advised to inquire and confirm the type of billing, before the Ileostomy procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA