What are the considerations and management strategies for an umbilical stoma in children?

Literature Review: Umbilical Stoma in Children (Last Five Years)

Overview and Indications

Umbilical stomas represent a safe and cosmetically superior alternative to conventional abdominal stomas in pediatric patients, with recent evidence demonstrating low major complication rates and excellent aesthetic outcomes. 1

The umbilical site offers several advantages for temporary ostomy creation in children:

• Natural anatomical location that is routinely used as an access port during laparoscopic colorectal surgery, eliminating the need for an additional abdominal incision 1, 2
• Superior cosmetic results as the scar after closure resembles a normal umbilicus, which is particularly important for the psychological well-being of children and adolescents 3
• Convenient site for appliance placement that facilitates stoma care management 3

Surgical Technique Considerations

Creation of Umbilical Stoma

The technique for creating an umbilical stoma has evolved to optimize both function and cosmesis:

• Modified concealed technique uses the base of the umbilicus as a superiorly based skin flap that is incorporated into the spatulated stoma, preserving the native appearance of the umbilicus 4
• Vertical incision approach is preferred in pediatric patients to avoid creating stenotic segments, similar to principles used in pediatric tracheostomy 5
• The stoma can be constructed from various bowel segments including appendix, stomach, or tapered ileum depending on the clinical indication 4

Technical Pearls

• Maturation sutures should be used to accelerate stoma healing and establishment, particularly important in younger children 5
• Proper sizing and positioning are critical to minimize complications such as peristomal skin irritation and prolapse 1
• The umbilical site allows for easy catheterization when used for urinary diversion procedures 4

Clinical Outcomes and Safety Profile

Major Complications

Recent evidence demonstrates favorable safety outcomes:

• No major surgical complications were reported in the most recent 2022 case series of 11 patients 1
• No mortality was observed in contemporary series 2
• No wound infections occurred in the most recent cohort 1
• Small bowel injury occurred in only 1 patient out of 10 in a 2015 series, representing the most significant intraoperative complication 2

Minor Complications

While major complications are rare, minor issues occur with some frequency:

• Peristomal skin irritation is the most common postoperative complication, primarily related to difficulties with pouching system management rather than the umbilical location itself 1, 2
• Ostomy prolapse can occur but appears infrequent (1 case in recent series) 1
• Incisional hernia after stoma reversal occurred in 3 of 11 patients (27%) in the most recent series, representing the most significant long-term complication 1
• Historical data from 1989 noted that complications were frequent but not specifically related to the umbilical site itself 3

Patient Selection and Indications

Appropriate Clinical Scenarios

Umbilical stomas have been successfully used for:

• Temporary diversion following colorectal resection for rectal cancer, diverticulitis, or ulcerative colitis 1
• Covering ileostomy after laparoscopic colorectal surgery, particularly in patients receiving neoadjuvant treatment for rectal cancer 2
• Staged procedures for ulcerative colitis, including conversion from end stomas to loop stomas 2
• Urinary diversion with catheterizable stomas, achieving continence with clean intermittent catheterization 4

Duration of Stoma

• The median duration of umbilical stomas in recent series was 113 days 2
• Temporary stomas in children generally remain in situ longer than in adult practice 6

Stoma Reversal and Long-Term Outcomes

Closure Technique

• Most umbilical stomas close spontaneously within hours or days after reversal 6
• If the stoma persists, formal surgical closure is necessary 6
• Excellent cosmesis is achieved after reversal, with the scar resembling a normal umbilicus 1, 2

Post-Reversal Considerations

• Incisional hernia represents the most significant long-term complication, occurring in approximately 27% of patients in recent series 1
• No peristomal hernias or stomatitis were reported with the concealed umbilical technique 4
• Anatomic closure of the stoma occurs rapidly, which may complicate emergency recannulation if needed 6

Practical Management Strategies

Stoma Care Education

Comprehensive family education is essential given the unique challenges of umbilical stoma management:

• Children's stoma nurses should provide support and education to help families adjust to the changes required 7
• Pouching system management requires specific instruction to prevent peristomal skin irritation 1
• Families must understand signs of complications including prolapse, skin breakdown, and hernia formation 7

Emergency Preparedness

• Parents and caregivers should be trained to assess stoma patency and manage common complications 6
• Immediate availability of appropriately sized equipment is essential for emergency management 6

Psychosocial Considerations

Impact on Child and Family

• Having a stoma represents a difficult adjustment for both the child and family, requiring significant lifestyle changes 7
• The superior cosmetic outcome of umbilical stomas may reduce psychological impact compared to conventional abdominal stomas 1, 3
• Children's stoma nurses play a critical role in helping families come to terms with the changes required 7

Quality of Life

• The concealed nature of umbilical stomas preserves body image, which is particularly important during adolescence 4
• Elimination of an additional abdominal incision reduces visible scarring 1, 2

Common Pitfalls and How to Avoid Them

Technical Pitfalls

• Inadequate stoma maturation can lead to early complications; use of maturation sutures helps accelerate this process 5
• Improper sizing contributes to peristomal skin irritation and appliance management difficulties 1
• Failure to properly spatulate the stoma can compromise catheterization in urinary diversion cases 4

Management Pitfalls

• Delayed recognition of incisional hernia after reversal; maintain appropriate follow-up protocols 1
• Inadequate family education regarding pouching system management leads to preventable skin complications 1
• Failure to prepare families for the possibility of complications may result in delayed presentation 7

Comparative Advantages

Umbilical stomas offer specific advantages over conventional abdominal stomas:

• One fewer incision required when combined with laparoscopic surgery 1, 2
• Superior cosmetic results with scar resembling normal umbilicus after closure 3
• Convenient appliance placement facilitating daily management 3
• Safety profile comparable to conventional stomas with no increase in major complications 1, 3