A stoma is created by bringing a section of bowel through an opening in the abdominal wall so that waste can exit the body into an external pouch. The surgeon makes a small circular cut in the skin, separates the abdominal muscle fibers without severing them, pulls a loop or end of intestine through the gap, and stitches the bowel edge to the skin surface. The whole process sounds dramatic, but the stoma-creation portion of an operation often takes only a fraction of the total surgical time, and the principles behind it have been refined over more than a century of practice.
Why a Stoma Is Needed
Stoma surgery is not a single procedure done for a single disease. It is a component of many different operations spanning a wide range of gastrointestinal and urinary conditions.1PubMed Central. Ostomy-Related Complications In adults, the most common reasons include colorectal cancer requiring removal of part of the bowel, inflammatory bowel disease such as Crohn’s disease or ulcerative colitis, diverticular disease complicated by perforation or abscess, and traumatic injury to the abdomen. Some stomas are temporary, placed to protect a freshly joined section of bowel while it heals. Others are permanent when the lower rectum or anus has been removed entirely. A less familiar type, called an ileal conduit or urostomy, diverts urine through a short segment of small intestine when the bladder has been removed, most often for bladder cancer.
Pre-operative Site Marking
Before the operation, a nurse specialist or surgeon marks the spot on the abdomen where the stoma will sit. This is not a cosmetic decision. The site needs to be on a flat area of skin that the patient can see and reach, away from bony prominences, skin folds, scars, and the belt line. Ideally the patient stands, sits, and bends during the marking session so the team can confirm the chosen spot stays visible and accessible in every position.
This step has a measurable impact on outcomes. A systematic review and meta-analysis found that pre-operative site marking roughly halved overall stoma-related complications compared with no marking, and it was linked to lower rates of skin problems and fewer revision surgeries.2PubMed. The effectiveness of preoperative stoma site marking on patient outcomes: A systematic review and meta-analysis A separate meta-analysis found especially strong reductions in leakage and skin complications when sites were marked in advance.3PubMed. The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy Even in emergency surgery, where there is less time to plan, a single-center study found that patients whose stoma sites were marked beforehand had significantly fewer complications than those whose sites were chosen on the fly in the operating room.4PubMed. Preoperative stoma site marking reduces postoperative stoma-related complications in emergency surgery In that study, stoma-site bleeding dropped from about 10 percent in unmarked patients to 2 percent in marked patients, and peristomal skin irritation fell from 18 percent to 10 percent.
The Core Surgical Steps
Regardless of the approach used to address the underlying disease, the act of constructing the stoma itself follows a consistent sequence. Once the surgeon has completed whatever bowel resection or diversion is required, attention turns to the abdominal wall at the pre-marked site.
First, the surgeon cuts a small circle of skin, typically about two to three centimeters across. The incision continues through the fat layer beneath the skin until the tough fibrous sheet covering the abdominal muscle (the anterior rectus sheath) comes into view. That sheet is opened in a cross-shaped (cruciate) fashion. The muscle fibers underneath are then gently spread apart rather than cut, preserving muscle function and strength around the stoma.5PubMed. The lateral rectus abdominis positioned stoma (LRAPS) in the construction of end colostomies, loop ileostomies and ileal conduits Behind the muscle sits another fibrous layer (the posterior sheath) and then the peritoneum, the membrane lining the abdominal cavity. These are opened to create a tunnel from inside the abdomen to the skin surface.
The prepared bowel is then drawn through this tunnel. If the stoma is an end stoma, only one open end of intestine comes through. If it is a loop stoma, a loop of bowel is pulled up and a slit is made in one wall, so both the upstream and downstream limbs sit at the skin surface. In ileostomies, the bowel is typically everted, meaning the end is folded back on itself like a cuff, producing a small spout that sticks up slightly above the skin.6PubMed. Improved stabilization of conventional (Brooke) ileostomies with the stapler technique That spout directs liquid output cleanly into the pouch and protects the surrounding skin. Colostomies produce firmer output and are usually brought flush with the skin surface or with a very slight protrusion.
Finally, the bowel edge is stitched to the skin with absorbable sutures. The result is a round, pink, moist opening that looks somewhat like the inside of your cheek. It has no nerve endings that sense pain, so touching it later while changing a pouch is painless, though it may bleed a small amount if rubbed because the surface is richly supplied with blood vessels.
Checking Blood Supply During Surgery
A stoma that does not receive adequate blood flow can turn dark, shrink, or die back in the days after surgery, a complication called stomal necrosis. To reduce that risk, surgeons visually inspect the color and texture of the bowel as it is delivered through the abdominal wall. In recent years, some teams have added a technology called indocyanine green fluorescence angiography. A dye is injected intravenously and glows under near-infrared light, giving the surgeon a real-time map of blood flow in the bowel wall. This allows adjustments to be made on the spot, potentially lowering the chance of post-operative complications related to poor perfusion.7PubMed. Indocyanine green fluorescent dye during bowel surgery: are the blood supply “guessing days” over?
Open Versus Laparoscopic Approaches
The stoma itself always exits through a small abdominal opening, but the way the surgeon accesses the abdomen to perform the underlying procedure can differ. In open surgery, a larger incision gives direct visibility and access. In laparoscopic (keyhole) surgery, a camera and instruments are inserted through several small ports, and the stoma is delivered through its own small separate incision.
Comparative data suggest laparoscopic stoma creation tends to produce fewer complications and shorter hospital stays, though the differences are not always dramatic. A large database study of over 3,300 colostomy patients found that the open group had higher 30-day complication rates (about 25 percent versus 17 percent for laparoscopic) and higher 30-day mortality, though part of that difference reflects the fact that sicker patients and more emergencies ended up in the open group.8PubMed. Short-term Outcomes After Open and Laparoscopic Colostomy Creation Even after adjusting for patient differences using statistical matching among elective cases, the open group had longer hospital stays and more wound complications. A smaller retrospective study found that peristomal skin problems were significantly less common after laparoscopic stoma creation (about 19 percent versus 48 percent in the open group), with less blood loss as well, though operating times were similar.9PubMed Central. Laparoscopic versus Open stoma creation: A retrospective analysis In pediatric patients with anorectal malformations, a study comparing the two approaches found complication rates of 14 percent (laparoscopic) versus 23 percent (open), though the difference was not statistically significant given the small sample sizes.10PubMed Central. Laparoscopically assisted versus open colostomy for anorectal malformations: a comparison of postoperative outcomes
The choice between approaches depends on the urgency of the operation, the patient’s body type and medical history, the underlying disease, and the surgeon’s expertise. Emergency operations, for instance, are more often performed open because speed and direct access matter when a patient is critically ill.
Common Complications and How Surgeons Try to Prevent Them
Stomas are lifesaving, but they are not trouble-free. Complications divide roughly into early ones that show up in the first weeks and late ones that develop months or years afterward.
Early complications include ischemia or necrosis of the stoma (inadequate blood supply causing tissue death), retraction (the stoma pulling back below skin level), separation of the bowel edge from the skin, and infection around the site. Late complications include parastomal hernia (the abdominal wall weakening around the stoma, creating a bulge), prolapse (excess bowel telescoping outward), and chronic skin irritation from stool or urine contact.11PubMed Central. Stoma Complications
Parastomal hernia is the most common long-term problem. For patients with an end colostomy, the rate exceeds 50 percent over long-term follow-up.12Journal of Abdominal Wall Surgery. Prophylactic Mesh in Parastomal Hernia Prevention: Current Evidence The rate is lower for ileostomies and urinary conduits, but the problem is still widespread. One growing area of prevention is placing a lightweight mesh around the stoma at the time of its creation. A meta-analysis found that prophylactic mesh cut the hernia rate by more than half beyond six months of follow-up, with the retromuscular placement approach showing the lowest hernia rates.13PubMed. Use of prophylactic mesh to prevent parastomal hernia formation: a systematic review, meta-analysis and network meta-analysis Mesh use at the time of stoma creation is not yet universal, partly because some surgeons worry about infection risk from placing synthetic material near a stoma, but the evidence in its favor has been growing steadily.
Stoma prolapse, where a length of bowel pushes outward through the stoma opening, is less common but can be alarming when it happens. Risk factors include obesity, chronic coughing, constipation, and anything that raises pressure inside the abdomen.14PubMed Central. Stoma prolapse handmade repair under local anesthesia with variation of Altemeier method in severe patients: a case report and review of the literature At the time of initial surgery, techniques that help prevent prolapse include keeping the fascial opening no larger than necessary, fixing the bowel to the abdominal wall, choosing the stoma site to minimize redundant bowel, and routing the bowel through an extraperitoneal path rather than straight through the abdominal cavity.15PubMed Central. Prolapse of intestinal stoma
What Happens to Your Body After an Ileostomy
When the stoma is made from the small intestine (ileostomy), the colon is either removed or bypassed. The colon’s main job is absorbing water and salt, so without it the body loses considerably more fluid than normal. Ileostomy output is liquid and can total a liter or more per day, carrying with it sodium and potassium that would otherwise have been reclaimed by the colon.16PubMed Central. Ileostomy diarrhea: Pathophysiology and management
The body compensates over time. The remaining small intestine gradually becomes more efficient at absorbing fluid and electrolytes, a process that unfolds over weeks to months. The adrenal glands ramp up production of aldosterone, a hormone that tells the kidneys and the gut lining to hold on to sodium and water more aggressively. Studies of long-term ileostomy patients show signs of this adaptation: lower urinary sodium output, more concentrated urine, and elevated aldosterone levels, all pointing to the body working harder to conserve fluid.17Gut. Water and electrolyte balance in subjects with a permanent ileostomy Even so, those same studies found evidence of chronic mild dehydration, with higher blood protein concentrations suggesting the body never fully replaces all the fluid lost through the stoma. This is why ileostomy patients are generally advised to drink more fluids than average, monitor their hydration, and be alert for signs of depletion, especially in hot weather or during illness.
Stoma Reversal
Temporary stomas are created with the intention of closing them once the underlying problem has resolved. For a loop ileostomy protecting a colorectal anastomosis, the reversal involves freeing the bowel from the abdominal wall, restoring continuity by sewing or stapling the two ends together, and closing the wound. Before the reversal, the surgical team confirms the downstream connection has healed properly, usually through a combination of imaging with contrast dye, physical examination, and sometimes endoscopy.18PubMed Central. Considerations in Stoma Reversal
Timing varies. For end colostomies created for complicated diverticular disease (the Hartmann procedure), fewer than a third of patients undergo reversal within the first year. In selected patients with an uncomplicated course, reversal has been shown to be safe as early as 45 to 110 days after the initial procedure, with better outcomes associated with earlier reversal when the patient is otherwise doing well.19JAMA Surgery. Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis For ileostomies, the concept of early reversal (sometimes within a few weeks) has gained interest. A meta-analysis found that early ileostomy closure reduced stoma-related complications, though wound infection rates at the closure site were higher, so the net benefit requires careful patient selection.20PubMed. The feasibility and safety of early ileostomy reversal: a systematic review and meta-analysis
Reversal itself is not risk-free. Common complications include surgical site infection (the most frequent), bowel obstruction, slow return of gut function, and, less commonly, leakage at the new join. Still, most patients who are candidates for reversal tolerate the operation well, and the psychological relief of stoma closure can be significant.
Stomas in Infants and Children
Babies and children undergo stoma surgery for different reasons than adults. The most common indication in the pediatric population is Hirschsprung disease, a condition in which nerve cells are missing from a segment of the colon, preventing it from relaxing and passing stool normally. The second most common reason varies by setting but often includes intestinal perforation from infections like typhoid fever (in low-resource settings) or necrotizing enterocolitis in premature infants.21Journal of Clinical Medical Research. Pediatric Stomas: A Study in a Teaching Hospital, Our Experience Anorectal malformations, where the anus has not formed normally, are another major indication. In these cases a colostomy is typically placed in the newborn period and reversed after a corrective procedure months later.22Genetics and Molecular Research. Colostomy in Infants — Indications, Surgical Approaches, Complications, and Current Outcomes: A Narrative Review
The surgical principles are the same as in adults, scaled down for smaller anatomy. Peristomal skin excoriation is the most common complication in pediatric stomas, partly because infant skin is more delicate and the output tends to be more liquid. Parents and caregivers take on a significant role in stoma care, and pediatric enterostomal therapy nurses provide specialized training to help families manage at home.
Living with a Stoma and the Psychological Adjustment
The physical construction of a stoma takes less than an hour, but adjusting to life with one takes considerably longer. A qualitative meta-synthesis of studies on adults with permanent stomas found that people reported physical limitations related to mobility, sleep, self-care, and sexual life, all of which influenced their perceived quality of life. Participants described needing to reorganize daily routines, social activities, and work, developing new patterns of living within the constraints of managing a pouch.23PubMed Central. Psychosocial effects and quality of life after stoma surgery: systematic review and qualitative meta-synthesis
Body image is a particular challenge. A descriptive study found that people with temporary stomas and those experiencing stoma complications had higher levels of body image disturbance, and that depressive symptoms and low self-efficacy were strongly linked to worse body image scores.24PubMed Central. Psychological Adaptation to Alteration of Body Image among Stoma Patients: A Descriptive Study Interestingly, younger patients tended to report more body image disturbance than older ones, and being overweight was also associated with higher disturbance scores. These findings point to the importance of psychological support alongside surgical and nursing care, especially in the early weeks when many patients report thoughts of depression or self-harm.
Over time, most people develop competence and confidence with their stoma. Support groups, specialized stoma care nurses, and modern pouching systems that are flat, odor-proof, and discreet all play a role in that adaptation. Many ostomates return to swimming, traveling, working, and having intimate relationships, though the adjustment timeline is highly individual.
How the Surgery Has Evolved
Stoma surgery has a surprisingly long history. The earliest recorded intestinal stomas date back to antiquity, though meaningful surgical progress did not happen until the 19th century, when developments in anesthesia, antisepsis, and surgical technique made abdominal operations survivable.25PubMed. Surgical history. Evolution of the stoma The earliest stomas were created by pulling injured bowel to the surface after trauma. Over time, surgeons moved toward planned stoma formation and eventually combined it with bowel resection for cancer and other diseases. By the 20th century, commercial pouching appliances appeared, replacing the homemade rags and bags patients had been forced to improvise.26PubMed. History of enterostomy devices: Yesterday, today, and tomorrow?
Today, much of the surgical technique is based on consensus guidelines rather than high-quality randomized trials, which means there is still room for refinement. Newer developments include the use of prophylactic mesh, fluorescence-guided assessment of blood supply, laparoscopic and robotic approaches, and enhanced-recovery protocols that get patients eating and moving sooner after surgery. Enterostomal therapy, the specialty nursing discipline focused on stoma care education, has also become standard practice, and the range of pouching products available to patients today would be unrecognizable to someone living with a stoma even 40 years ago.