Complications of Median Versus Lateral Colostomy* RITA ZANOLLA,M.D., FEDERICO BOZZETTI, M.D., MARCELLADEL VECCHIO, PH.D., VITTORIO VENTAFRIDDA, M.D.
DESPITE THE WIDE USE OF surgical resection in the treatment of cancer of the rectum and low sigmoid colon, the importance of the selection of the stoma site for successful inanagement of the colostomy patient still receives little consideration by many surgeons. Ideally, the stoma should be situated on a flat area of the abdominal wall, well removed from scars, deformities, and bony prominences; the exact site for the colostomy should be chosen preoperatively by the enterostomal therapist and the surgeon after study of the patient in various positions. However, the lack of enterostomal therapists and training schools for enterostomal therapy in many countries often prevents this cooperative preoperative evaluation. In addition, emergency surgery and a preoperative acutely distended abdomen often compel the surgeon to select the stoma site during the operative procedure. This study, performed at the Istituto Nazionale Tumori of Milan, analyzes the local complications we have observed in lateral and median colostomies in which the site was selected during the operation according to the personal preference of the surgeon.
From the Istituto Nazionale Tumori,
Milan, Italy
Early complications include skin irritation, bleeding, ischemia, infection, and retraction; late complications include stenosis, prolapse, and hernia. Massive peristomal evisceration of the small intestine or omentum, or left colic gutter herniation and obstruction of the small intestine were never observed. Rare complications, such as peristomal or extrastomal fistulas and fissuring of the stoma, were not observed in this case series. We evaluated end colostomies and double-barreled colostomies separately. Analysis of rate and kind of complications was performed by both the physiatrist and the surgeon. The percentage of colostomy revisions was regarded as an index of severity of the complications. In addition, late complications were evaluated after different periods of observation: after one year, two years, and three years. Statistical assessments were achieved when possible, by the chi square test.
Patients and M e t h o d s Results
For periods ranging from three months to three years, 211 patients with colostomy were followed by the medical staff of the Pain Treatment and Rehabilitation Service of the Istituto Nazionale Tumori of Milan. Local complications were evaluated in two groups of patients: group one included 143 patients with lateral colostomy, and group two included 68 patients with median colostomy. Colostomies were always performed on the descending or sigmoid colon, except median doublebarreled colostomies, which were performed with a loop of transverse colon pulled through the explorative wound. The surgical procedures had been performed in patients with cancer of the large intestine and most of them during an elective operation without previous obstruction. When colostomy was terminal, the exteriorized toop was closed by a purse-string suture, which was removed after 48 to 72 hours. No attempt was made to accomplish an immediate maturation by means of a p r i m a r y m u c o c u t a n e o u s sutnre. * Received for publication March 27, 1979. Address reprint requests to Dr. Zanolla: Instituto Nazionale Tumori, Via G. Venezian, I, 20133, Milan, Italy.
The incidence of early complications in lateral colostomy versus median colostomy is shown in Table 1. Bleeding and retraction occurred more frequently in median end colostomies, although the difference between the two groups was not statistically significant (P > 0.05). In double-barreled colostomy, the overall complication rate was also higher in median stoma, but, due to the small n u m b e r of cases, statistical evaluation was not possible. The incidence of late complications in terminal colostomy is shown in Table 2. The incidence of hernia was quite similar in median and lateral colostomies; however, it should be pointed out that the group of lateral colostomies included not only peristomal hernias but also median herniation in laparotomic incisions. The incidence of stenosis was always higher in patients with median stoma after each observation period, while prolapse occurred more frequently after lateral colostomy; statistical evaluation was not possible due to the small number of patients. The only late complication we observed in doublebarreled colostomy was prolapse, which occurred d u r i n g the first year of observation in one of eight patients with lateral stoma and in one of two patients
00t2-3706/79/0900/0387/$00.65 9 American Society of Colon and Rectal Surgeons
387
388
Dis. Col. & Rect.
ZANOLLA, ET AL.
September 1979
TAULE 1. Incidence of Early Complications Lateral Stoma Complications Number
Per Cent
(123 patients) 5 12 9 12 4 (20 patients) 1 3 0 0 0
Terminal Colostomy Skin irritation Bleeding Ischemia Infection Retraction Doubled-barreled colostomy Skin irritation Bleeding Ischemia Infection Retraction
Median Stoma Complications
5 15 0 0 0
Discussion
Our results show that double-barreled colostomies h a v e a h i g h e r c o m p l i c a t i o n r a t e t h a n d o t e r m i n a l colostomies, and that after double-barreled colostomy, e a r l y a n d late c o m p l i c a t i o n s o c c u r m o r e f r e q u e n t l y if t h e site o f t h e s t o m a is m i d l i n e .
Per Cent
(61 patients) 3 14 5 8 5 (7 patients) 1 2 1 2 0
4.0 9.7 7.0 9.7 3.2
with m e d i a n s t o m a . T h e p r o x i m a l s e g m e n t a p p e a r e d to be t h e u s u a l site o f p r o l a p s e , in p a r t p r o b a b l y bec a u s e o f t h e l a r g e i n t e s t i n e peristalsis. T h e r e was n o statistical d i f f e r e n c e in t h e o v e r a l l i n c i d e n c e o f p a t i e n t s with a n y c o m p l i c a t i o n s in t h e two g r o u p s b e t w e e n l a t e r a l a n d m e d i a n e n d colost o m i e s ( T a b l e 3), while n o statistical e v a l u a t i o n was possible on double-barreled colostomies. P e r c e n t a g e o f s u r g i c a l r e v i s i o n s p e r f o r m e d in late r a l a n d m e d i a n s t o m a was, r e s p e c t i v e l y , 33 p e r c e n t a n d 24 p e r c e n t (P > 0.05).
Number
5.0 23.0 8.2 13.0 8.2 14.0 28.5 14.0 28.5 0
E v e n i f t h e o v e r a l l c o m p l i c a t i o n r a t e is s i m i l a r a f t e r b o t h p r o c e d u r e s , we p r e f e r , i f it is possible, to p l a c e t h e s t o m a in t h e left l o w e r q u a d r a n t o f t h e a b d o m e n f o r s e v e r a l r e a s o n s . T h e i n c i d e n c e o f p r o l a p s e in late r a l s t o m a c a n p r o b a b l y be r e d u c e d if m o r e a t t e n t i o n is p a i d to a v o i d i n g t o o w i d e a n o p e n i n g in t h e ~ inal wall with e x c e s s i v e e x t e r i o r i z a t i o n o f t h e c o l o n a n d to c a r e f u l l y s u t u r i n g t h e i n t e s t i n a l wall to t h e p e r i t o n e u m a n d fascia t r a n s v e r s a l i s . W i t h r e f e r e n c e to t h e t e r m i n a l c o l o s t o m i e s , t h e incidence of complications varies; bleeding, retraction, a n d stenosis w e r e m o r e f r e q u e n t in m e d i a n s t o m a s , while p r o l a p s e o c c u r r e d m o r e f r e q u e n t l y in t h e lateral ones. B l e e d i n g was m o r e f r e q u e n t in m e d i a n c o l o s t o m i e s , p r o b a b l y as a c o n s e q u e n c e o f t h e l o c a t i o r i o f t h e s t o m a at t h e b e l t line. R e t r a c t i o n c a n b e d u e to a misj u d g m e n t d u r i n g s u r g e r y , b u t m o r e f r e q u e n t l y it d e -
TABLE 2. Incidence of Late Complications in Terminal Colostomy Lateral Stoma
Median Stoma
Complications Follow-up Period Hernia I year 2 years 3 years Stenosis I year 2 years 3 years Prolapse 1 year 2 years 3 years
Patients Followed (number)
Number
69 35 26
Complications
Per Cent
Patients Followed (number)
Number
Per Cent
4 5 6
5.7 14.2 23.1
50 32 19
4 3 4
8.0 9.4 21.0
69 35 26
2 0 1
2.8 0 3.8
5O 32 19
2 2 2
4.0 6.2 10.5
69 35 26
2 2 2
2.8 5.7 7.7
50 32 19
0
0 3.1
I I
5.2
Volulne 22
Number 6
389
MEDIAN VS. LATERAL COLOSTOMY TABLE 3. Incidence of Initial Complications Median Stoma
Lateral Stoma Complications Follow-up Period Terminal Colostomy 1 year 2 years 3 years Double-barreled colostomy 1 year 2 years 3 years
Patients followed (number)
Number
69 35 26 8 2 1
Complications
Per Cent
Patients Followed (number)
Number
Per Cent
21 16 13
30.0 45.7 50.0
50 32 19
21 18 12
42 56 63
3 1 0
37.5 50.0 0
2 1 0
2 1 0
100 100 0
velops later d u e to a b d o m i n a l fat gained d u r i n g convalescence. Since lateral stomas include d e s c e n d i n g or sigmoid colostomies, recession will always be m o r e f r e q u e n t in m e d i a n colostomy, because the distance f r o m the foot o f the loop to the a b d o m i n a l wall is longer than it is in lateral colostomy. Stenosis is caused by contraction o f a fibrous ring s u r r o u n d i n g the stoma; it m a y be total or confined to the skin, fascial or peritoneal level. It is s o m e t i m e s due to the r e g a i n i n g o f n o r m a l weight or to obesity, but m a y also result f r o m p o o r technique in m a k i n g the s t o m a or s e c o n d a r y to infection or fistulas. In fact, stenosis is m o r e c o m m o n w h e n e v e r p r i m a r y healing between the m u c o s a and the skin does not occur. An additional cause for stenosis in m e d i a n colostomy is, in o u r opinion, the particular site o f the s t o m a surr o u n d e d by the scar tissue o f the laparotomic wound. In o u r e x p e r i e n c e r e g u l a r finger dilatation was not successful in m a i n t a i n i n g the s t o m a patent. O n the contrary, it is possible that the r e p e a t e d m i n o r peristomal insults o f daily stoma dilatation may p r o d u c e progressive stricture as scar tissue accumulates. I m m e d i a t e m a t u r a t i o n o f the stoma by suturing the m u cosa directly to the skin has been advocated 2 as an e f f i c i e n t device to p r e v e n t serosity a n d e v e n t u a l stenosis. P r i m a r y m u c o c u t a n e o u s suture in m e d i a n colost o m y carries a considerable risk o f c o n t a m i n a t i n g the l a p a r o t o m i c w o u n d , with serious a n d p o t e n t i a l l y d a n g e r o u s c o n s e q u e n c e s , w h e r e a s it r e p r e s e n t s a m u c h safer p r o c e d u r e in lateral colostomies. I n addition, intestinal obstruction d u e to herniation a n d volvulus o f the small intestine can be m o r e easily prevented by closing the left colic gutter between the sigmoid or descending colon and parietal p e r i t o n e u m , whereas this p r o c e d u r e cannot be perf o r m e d a f t e r m e d i a n colostomy. Finally, it is generally accepted I that, w h e n e v e r possible, the loop or the functional s e g m e n t should be b r o u g h t out t h r o u g h a separate a b d o m i n a l wound.
Since we e x p l o r e all cases with cancer of the r e c t u m or sigmoid colon with a m e d i a n l a p a r o t o m y , we reco m m e n d the lateral colostomy. We think that m e d i a n or even umbilical a colostomy should be r e g a r d e d as a s e c o n d - c h o i c e p r o c e d u r e , in very o b e s e patients, w h e n l a p a r o t o m y is left p a r a m e d i a n , or w h e n transfer o f the s t o m a is necessary.
Summary T h e p u r p o s e o f this study is the evaluation of early a n d late complications in two g r o u p s o f patients: 143 patients with lateral colostomy and 68 patients with m e d i a n colostomy. Patients were followed f o r periods r a n g i n g f r o m t h r e e m o n t h s to t h r e e years. Early complications included skin irritation, bleeding, ischemia, infection, a n d retraction. Late complications included hernia, prolapse, a n d stenosis. F r o m the analysis of the case series, the a u t h o r s conclude that (1) d o u b l e - b a r r e l e d colostomies have a h i g h e r complication rate t h a n do simple colostomies; (2) after d o u b l e - b a r r e l e d colostomy, late a n d early complications occur m o r e f r e q u e n t l y if the site o f the stoma is midline; (3) with r e g a r d to terminal colostomies, the incidence of complication varies-bleeding, stenosis and retraction a p p e a r to be m o r e f r e q u e n t in m e d i a n s t o m a , while p r o l a p s e occurs m o r e f r e q u e n t l y in lateral stoma. No d i f f e r e n c e was f o u n d in the p e r c e n t a g e o f surgical revisions. T h e a u t h o r s p r e f e r to place the s t o m a in the left lower q u a d r a n t o f the a b d o m e n , since, a f t e r m e d i a n l a p a r o t o m y , a lateral colostomy has less risk o f stenosis.
References 1. Green EW: Colostomies and their complications. Surg Gynecol Obstet 122: 1230, 1966 2. Patey DH: Primary epithelial apposition colostomy. Proc R Soc Med 44: 423, 1951 3. Raza SD, Portin BA, Bernhoft WH: Umbilical colostomy: A better intestinal stoma. Dis Colon Rectum 20: 223, 1977
DESPITE THE WIDE USE OF surgical resection in the treatment of cancer of the rectum and low sigmoid colon, the importance of the selection of the stoma site for successful inanagement of the colostomy patient still receives little consideration by many surgeons. Ideally, the stoma should be situated on a flat area of the abdominal wall, well removed from scars, deformities, and bony prominences; the exact site for the colostomy should be chosen preoperatively by the enterostomal therapist and the surgeon after study of the patient in various positions. However, the lack of enterostomal therapists and training schools for enterostomal therapy in many countries often prevents this cooperative preoperative evaluation. In addition, emergency surgery and a preoperative acutely distended abdomen often compel the surgeon to select the stoma site during the operative procedure. This study, performed at the Istituto Nazionale Tumori of Milan, analyzes the local complications we have observed in lateral and median colostomies in which the site was selected during the operation according to the personal preference of the surgeon.
From the Istituto Nazionale Tumori,
Milan, Italy
Early complications include skin irritation, bleeding, ischemia, infection, and retraction; late complications include stenosis, prolapse, and hernia. Massive peristomal evisceration of the small intestine or omentum, or left colic gutter herniation and obstruction of the small intestine were never observed. Rare complications, such as peristomal or extrastomal fistulas and fissuring of the stoma, were not observed in this case series. We evaluated end colostomies and double-barreled colostomies separately. Analysis of rate and kind of complications was performed by both the physiatrist and the surgeon. The percentage of colostomy revisions was regarded as an index of severity of the complications. In addition, late complications were evaluated after different periods of observation: after one year, two years, and three years. Statistical assessments were achieved when possible, by the chi square test.
Patients and M e t h o d s Results
For periods ranging from three months to three years, 211 patients with colostomy were followed by the medical staff of the Pain Treatment and Rehabilitation Service of the Istituto Nazionale Tumori of Milan. Local complications were evaluated in two groups of patients: group one included 143 patients with lateral colostomy, and group two included 68 patients with median colostomy. Colostomies were always performed on the descending or sigmoid colon, except median doublebarreled colostomies, which were performed with a loop of transverse colon pulled through the explorative wound. The surgical procedures had been performed in patients with cancer of the large intestine and most of them during an elective operation without previous obstruction. When colostomy was terminal, the exteriorized toop was closed by a purse-string suture, which was removed after 48 to 72 hours. No attempt was made to accomplish an immediate maturation by means of a p r i m a r y m u c o c u t a n e o u s sutnre. * Received for publication March 27, 1979. Address reprint requests to Dr. Zanolla: Instituto Nazionale Tumori, Via G. Venezian, I, 20133, Milan, Italy.
The incidence of early complications in lateral colostomy versus median colostomy is shown in Table 1. Bleeding and retraction occurred more frequently in median end colostomies, although the difference between the two groups was not statistically significant (P > 0.05). In double-barreled colostomy, the overall complication rate was also higher in median stoma, but, due to the small n u m b e r of cases, statistical evaluation was not possible. The incidence of late complications in terminal colostomy is shown in Table 2. The incidence of hernia was quite similar in median and lateral colostomies; however, it should be pointed out that the group of lateral colostomies included not only peristomal hernias but also median herniation in laparotomic incisions. The incidence of stenosis was always higher in patients with median stoma after each observation period, while prolapse occurred more frequently after lateral colostomy; statistical evaluation was not possible due to the small number of patients. The only late complication we observed in doublebarreled colostomy was prolapse, which occurred d u r i n g the first year of observation in one of eight patients with lateral stoma and in one of two patients
00t2-3706/79/0900/0387/$00.65 9 American Society of Colon and Rectal Surgeons
387
388
Dis. Col. & Rect.
ZANOLLA, ET AL.
September 1979
TAULE 1. Incidence of Early Complications Lateral Stoma Complications Number
Per Cent
(123 patients) 5 12 9 12 4 (20 patients) 1 3 0 0 0
Terminal Colostomy Skin irritation Bleeding Ischemia Infection Retraction Doubled-barreled colostomy Skin irritation Bleeding Ischemia Infection Retraction
Median Stoma Complications
5 15 0 0 0
Discussion
Our results show that double-barreled colostomies h a v e a h i g h e r c o m p l i c a t i o n r a t e t h a n d o t e r m i n a l colostomies, and that after double-barreled colostomy, e a r l y a n d late c o m p l i c a t i o n s o c c u r m o r e f r e q u e n t l y if t h e site o f t h e s t o m a is m i d l i n e .
Per Cent
(61 patients) 3 14 5 8 5 (7 patients) 1 2 1 2 0
4.0 9.7 7.0 9.7 3.2
with m e d i a n s t o m a . T h e p r o x i m a l s e g m e n t a p p e a r e d to be t h e u s u a l site o f p r o l a p s e , in p a r t p r o b a b l y bec a u s e o f t h e l a r g e i n t e s t i n e peristalsis. T h e r e was n o statistical d i f f e r e n c e in t h e o v e r a l l i n c i d e n c e o f p a t i e n t s with a n y c o m p l i c a t i o n s in t h e two g r o u p s b e t w e e n l a t e r a l a n d m e d i a n e n d colost o m i e s ( T a b l e 3), while n o statistical e v a l u a t i o n was possible on double-barreled colostomies. P e r c e n t a g e o f s u r g i c a l r e v i s i o n s p e r f o r m e d in late r a l a n d m e d i a n s t o m a was, r e s p e c t i v e l y , 33 p e r c e n t a n d 24 p e r c e n t (P > 0.05).
Number
5.0 23.0 8.2 13.0 8.2 14.0 28.5 14.0 28.5 0
E v e n i f t h e o v e r a l l c o m p l i c a t i o n r a t e is s i m i l a r a f t e r b o t h p r o c e d u r e s , we p r e f e r , i f it is possible, to p l a c e t h e s t o m a in t h e left l o w e r q u a d r a n t o f t h e a b d o m e n f o r s e v e r a l r e a s o n s . T h e i n c i d e n c e o f p r o l a p s e in late r a l s t o m a c a n p r o b a b l y be r e d u c e d if m o r e a t t e n t i o n is p a i d to a v o i d i n g t o o w i d e a n o p e n i n g in t h e ~ inal wall with e x c e s s i v e e x t e r i o r i z a t i o n o f t h e c o l o n a n d to c a r e f u l l y s u t u r i n g t h e i n t e s t i n a l wall to t h e p e r i t o n e u m a n d fascia t r a n s v e r s a l i s . W i t h r e f e r e n c e to t h e t e r m i n a l c o l o s t o m i e s , t h e incidence of complications varies; bleeding, retraction, a n d stenosis w e r e m o r e f r e q u e n t in m e d i a n s t o m a s , while p r o l a p s e o c c u r r e d m o r e f r e q u e n t l y in t h e lateral ones. B l e e d i n g was m o r e f r e q u e n t in m e d i a n c o l o s t o m i e s , p r o b a b l y as a c o n s e q u e n c e o f t h e l o c a t i o r i o f t h e s t o m a at t h e b e l t line. R e t r a c t i o n c a n b e d u e to a misj u d g m e n t d u r i n g s u r g e r y , b u t m o r e f r e q u e n t l y it d e -
TABLE 2. Incidence of Late Complications in Terminal Colostomy Lateral Stoma
Median Stoma
Complications Follow-up Period Hernia I year 2 years 3 years Stenosis I year 2 years 3 years Prolapse 1 year 2 years 3 years
Patients Followed (number)
Number
69 35 26
Complications
Per Cent
Patients Followed (number)
Number
Per Cent
4 5 6
5.7 14.2 23.1
50 32 19
4 3 4
8.0 9.4 21.0
69 35 26
2 0 1
2.8 0 3.8
5O 32 19
2 2 2
4.0 6.2 10.5
69 35 26
2 2 2
2.8 5.7 7.7
50 32 19
0
0 3.1
I I
5.2
Volulne 22
Number 6
389
MEDIAN VS. LATERAL COLOSTOMY TABLE 3. Incidence of Initial Complications Median Stoma
Lateral Stoma Complications Follow-up Period Terminal Colostomy 1 year 2 years 3 years Double-barreled colostomy 1 year 2 years 3 years
Patients followed (number)
Number
69 35 26 8 2 1
Complications
Per Cent
Patients Followed (number)
Number
Per Cent
21 16 13
30.0 45.7 50.0
50 32 19
21 18 12
42 56 63
3 1 0
37.5 50.0 0
2 1 0
2 1 0
100 100 0
velops later d u e to a b d o m i n a l fat gained d u r i n g convalescence. Since lateral stomas include d e s c e n d i n g or sigmoid colostomies, recession will always be m o r e f r e q u e n t in m e d i a n colostomy, because the distance f r o m the foot o f the loop to the a b d o m i n a l wall is longer than it is in lateral colostomy. Stenosis is caused by contraction o f a fibrous ring s u r r o u n d i n g the stoma; it m a y be total or confined to the skin, fascial or peritoneal level. It is s o m e t i m e s due to the r e g a i n i n g o f n o r m a l weight or to obesity, but m a y also result f r o m p o o r technique in m a k i n g the s t o m a or s e c o n d a r y to infection or fistulas. In fact, stenosis is m o r e c o m m o n w h e n e v e r p r i m a r y healing between the m u c o s a and the skin does not occur. An additional cause for stenosis in m e d i a n colostomy is, in o u r opinion, the particular site o f the s t o m a surr o u n d e d by the scar tissue o f the laparotomic wound. In o u r e x p e r i e n c e r e g u l a r finger dilatation was not successful in m a i n t a i n i n g the s t o m a patent. O n the contrary, it is possible that the r e p e a t e d m i n o r peristomal insults o f daily stoma dilatation may p r o d u c e progressive stricture as scar tissue accumulates. I m m e d i a t e m a t u r a t i o n o f the stoma by suturing the m u cosa directly to the skin has been advocated 2 as an e f f i c i e n t device to p r e v e n t serosity a n d e v e n t u a l stenosis. P r i m a r y m u c o c u t a n e o u s suture in m e d i a n colost o m y carries a considerable risk o f c o n t a m i n a t i n g the l a p a r o t o m i c w o u n d , with serious a n d p o t e n t i a l l y d a n g e r o u s c o n s e q u e n c e s , w h e r e a s it r e p r e s e n t s a m u c h safer p r o c e d u r e in lateral colostomies. I n addition, intestinal obstruction d u e to herniation a n d volvulus o f the small intestine can be m o r e easily prevented by closing the left colic gutter between the sigmoid or descending colon and parietal p e r i t o n e u m , whereas this p r o c e d u r e cannot be perf o r m e d a f t e r m e d i a n colostomy. Finally, it is generally accepted I that, w h e n e v e r possible, the loop or the functional s e g m e n t should be b r o u g h t out t h r o u g h a separate a b d o m i n a l wound.
Since we e x p l o r e all cases with cancer of the r e c t u m or sigmoid colon with a m e d i a n l a p a r o t o m y , we reco m m e n d the lateral colostomy. We think that m e d i a n or even umbilical a colostomy should be r e g a r d e d as a s e c o n d - c h o i c e p r o c e d u r e , in very o b e s e patients, w h e n l a p a r o t o m y is left p a r a m e d i a n , or w h e n transfer o f the s t o m a is necessary.
Summary T h e p u r p o s e o f this study is the evaluation of early a n d late complications in two g r o u p s o f patients: 143 patients with lateral colostomy and 68 patients with m e d i a n colostomy. Patients were followed f o r periods r a n g i n g f r o m t h r e e m o n t h s to t h r e e years. Early complications included skin irritation, bleeding, ischemia, infection, a n d retraction. Late complications included hernia, prolapse, a n d stenosis. F r o m the analysis of the case series, the a u t h o r s conclude that (1) d o u b l e - b a r r e l e d colostomies have a h i g h e r complication rate t h a n do simple colostomies; (2) after d o u b l e - b a r r e l e d colostomy, late a n d early complications occur m o r e f r e q u e n t l y if the site o f the stoma is midline; (3) with r e g a r d to terminal colostomies, the incidence of complication varies-bleeding, stenosis and retraction a p p e a r to be m o r e f r e q u e n t in m e d i a n s t o m a , while p r o l a p s e occurs m o r e f r e q u e n t l y in lateral stoma. No d i f f e r e n c e was f o u n d in the p e r c e n t a g e o f surgical revisions. T h e a u t h o r s p r e f e r to place the s t o m a in the left lower q u a d r a n t o f the a b d o m e n , since, a f t e r m e d i a n l a p a r o t o m y , a lateral colostomy has less risk o f stenosis.
References 1. Green EW: Colostomies and their complications. Surg Gynecol Obstet 122: 1230, 1966 2. Patey DH: Primary epithelial apposition colostomy. Proc R Soc Med 44: 423, 1951 3. Raza SD, Portin BA, Bernhoft WH: Umbilical colostomy: A better intestinal stoma. Dis Colon Rectum 20: 223, 1977
