Stoma Reversal

In most people, a stoma can be reversed after a period of time. How long this is depends on a number of factors. Six weeks is the minimum, but we usually find it better to wait longer until any adhesions (band-like structures, essentially scar tissue) that formed during the previous surgery have settled. If the stoma was created as part of cancer surgery and chemotherapy is needed, it is best to wait until chemotherapy is completed, which may take up to one year. In general, we like to wait until you are as healthy as you can possibly be before reversing your colostomy or ileostomy.

Reversal of a loop colostomy or ileostomy is performed as an open procedure. A small rim of skin is cut around the stoma and the cut is continued down until the abdominal cavity is reached. At this point, the bowel and abdominal cavity are checked to make sure that all is in order. The hole in the bowel that was brought to the outside when the stoma was created is then closed with sutures or surgical staples. If the procedure is straightforward, reversal of a loop procedure takes about 30-45 minutes. However, if extensive adhesions arising from previous surgery are found, more extensive surgery may be needed to free up the bowel ends, which may take up to 2 hours.

Reversal of an end colostomy (usually Hartmann’s procedure) is planned as a laparoscopic procedure because one end of the bowel that is to be rejoined is still inside the abdomen. The first step is to free up the colostomy wound. This is then closed over the anvil portion of a laparoscopic stapling device and dropped into the abdominal cavity. The hole left by the freed up colostomy then serves as access to the abdomen for keyhole surgery. Three further incisions allow keyhole instruments to free up the large bowel further down. This freed up bowel is then stapled to the previously freed up colostomy by using a laparoscopic stapling device. The skin can be closed with dissolvable stitches or partially closed and medicated gauze left in the unstitched portion. Reversal of Hartmann’s procedure takes about 1–3 hours, depending on how extensive the surgery needs to be.

Stoma reversal is done under general anaesthesia, so you will be asleep and feel no pain. You will need to fast from midnight on the night before if your surgery is scheduled for the morning, or from 7 am if it is scheduled for the afternoon.

No bowel preparation is necessary if you are having reversal of a loop colostomy or ileostomy.However, if you are having a reversal of Hartmann’s procedure, full bowel preparation will be needed beforehand. This can be done at home, and entails you taking a special laxative to clear your bowel completely on the day before your operation. The preparation may also include a low-fibre diet. The following website explains in detail what you can eat and drink on a low-fibre diet (www1.ghc.org/html/public/specialties/gastroenterology/colon-diet). You will be given detailed instructions on what you need to do and the medication needed in advance of your admission. For a reversal of Hartmann’s procedure, you will also need an enema an hour before surgery.

You will be given a long-acting antibiotic in the anaesthetic room and an injection of local anaesthetic before you leave the operating theatre.

After your operation

After your surgery, you will be taken to the recovery area and then to the ward. When you wake up, you will have several tubes attached to your body, including an intravenous infusion tube in your arm to give you fluids and any necessary drugs, and a catheter in your bladder to drain urine. For a reversal of Hartmann’s, you may also need a drain placed in the abdomen near where your bowel has been rejoined. These tubes are removed after 24-48 hours. Supplementary oxygen is given by nasal prongs.

Some discomfort is to be expected after this type of surgery when your local anaesthetic wears off. The anaesthetist will decide on the method of postoperative pain relief that is best for you. Oral painkillers are all that is needed in most patients. However, some patients require intravenous analgesia. This can be provided by a patient-controlled analgesia device, where a drip in your arm is connected to a syringe of pain-killing medication within a box. When the patient presses a button, a small dose of medication is pushed into the drip. There is a lockout that make it impossible to overdose.

You can eat and drink as you wish after the operation, and if there is no problem with drinking, the drip providing fluid will be stopped. Some patients feel a little nauseous after eating and drinking soon after their surgery. In these patients, we wait a little longer before introducing food and fluid and keep the fluid drip going. You will be mobilised on the day following your surgery. The stay in hospital after stoma reversal surgery is around 1–5 days, depending on what type of reversal has been performed. Hospital stays can be longer for reversal of Hartmann’s procedure.

Many people find that their bowel function returns to normal in about 1–3 days after surgery, and they can resume their normal diet at that time. Eating a balanced diet after your operation will aid your recovery. When you are discharged, you will be given pain medication to take home. It is best to keep taking this medication until the discomfort is manageable.

You will not be able to drive when you are discharged from hospital, so it is important to arrange a friend or relative to take you home. When patients can resume driving after this type of surgery is determined on a case-by-case basis. This is usually 2 weeks, but will be discussed with you after your surgery. Most people need longer before they can safely, forcefully, and quickly press the emergency footbrake to avoid a potential incident whilst driving. Please let your insurance company know when you have been given the all-clear to resume driving.

When you get home

Many people feel tired and weak after surgery of this type. Full recovery may take a month for reversal of a loop colostomy or ileostomy and up to 2 months for reversal of Hartmann’s procedure. When you get home, you will need someone to help with meals, housework, and shopping. For the first week or two you may tire easily, so try to alternate short periods of light activity and rest in bed, taking care not to spend too much time lying down because of the risk of developing a blood clot in your legs (deep venous thrombosis). If the stoma site is left partially open, then a district nurse may visit you at home to dress the wound, or you can have this done at your GP practice.

Do not lift anything heavy, such as children, groceries or washing, or do strenuous work like digging the garden or lawn mowing for the first 6 weeks. You may resume intercourse when you wish.

You may get some pain off and on around your wound for 4 weeks. This is to be expected. Taking a mild painkiller regularly will help with this. If the pain does not seem to improve or you are worried, contact your GP or our colorectal nurses.

How soon you can return to work following stoma reversal surgery depends on what type of work you do, and this will be discussed with you after your operation.

A follow-up appointment in the clinic will be arranged for 1–2 weeks after your surgery to check your surgical wound and discuss further management if necessary.