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Other techniques and Stomas


On this page you can find the following procedures and stomas:

Pouch (IPAA) (faeces)
INRA (faeces)
Dynamic gracilis plastic (faeces)
Pacemaker in the buttocks (faeces / urine)
Stomach stimulators
Continent stoma (urine / faeces)
Indiana pouch (urine)
Hautmann procedure (neo-bladder) (urine)
Cystostomy (urine)
Mitrofanoff stoma (urine)
Nefrostomy (urine)
Ureterostomy (urine)
Coffey-stoma (urine)
Vesico stoma (urine)
Malone procedure / cecostomy (colonic irrigation)
Gastrostomy (PEG) (feeding stoma)
Jejunostomy (PEJ) (feeding stoma)
Total Parenteral Nutrition (TPN) (feeding)
Tracheostomy (opening in the wind pipe)

Liver stoma (Bile flow stoppage)


Ileo Pouch Anal Anastomosis (IPAA)

The pouch (IPAA) is used to replace an ileostomy. In this procedure both the large intestine and rectum are removed but the sphincter remains. The small intestine is then stitched to the anus. In order to be considered for this procedure you must have a sphincter that functions well. If the small intestine were to be connected directly to the anus you would have to go to the lavatory very frequently indeed. This is why a reservoir (the pouch) is made from the last part of the small intestine. This pouch is connected to the anus where the collecting function of the rectum is imitated. Faeces are collected in the pouch and thickened slightly so a bag outside the body is no longer necessary. Nowadays this procedure is carried out with a stapler which makes it safe and reliable. Most people receive a temporary ileostomy after the operation in order to relieve the pouch and prevent any possible leakage.


Shortly after the stoma has been removed you will probably have to go to the lavatory some 10 times a day. In approximately a year and a half the pouch will have expanded so much that it can contain circa 300ml of faeces. This means that you to have to go to the lavatory some 6 times a day. If this is not the case, you can take medicine which reduces the frequency of the bowel movements and thickens the faeces; this happens in about a third of the people who have a pouch. Since the faeces from the small intestine are more aggressive, then the skin around the anus can become dry and painful but a good cream can soon clear this up. 25%of patients find that the long recovery period and possible complications can be a significant disadvantage. Although it is a serious operation in which many complications can arise, 75-85% of patients have a properly functioning pouch after 1 year and 67% are happy with their pouch and say it has improved their quality of life. In the long run the pouch will fail to perform well in 5-8% of the cases and will then lead to a permanent stoma.


source picture: Mayo Clinic


There exist various pouch techniques, the so called “pouch alphabet”, such as the W, S, J and H. Beneath you can see that these are logical names. The J-pouch is currently the most used because it gives the best results. A pouch is often formed because of Colitis Ulcerosa and Polyposis Coli (FAP). People with Crohn’s are not considered suitable for this technique because Crohn’s can develop in the pouch.


source picture: General surgery

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INRA (Ileo Neo Rectal Anastomosis)

The above-mentioned procedure, the pouch, has been around for 25 years and has proved itself to be completely effective. But there are reservations, particularly to do with the possibility of complications. Nowadays there is a new procedure, the INRA or intestinal mucous tissue transplant. This procedure has been carried out in a few Dutch hospitals since 1998. In the INRA procedure the large intestine is removed but the rectum is left untouched. The diseased layer of mucous membrane is completely removed from the rectum (mucosectomy) but the layer of muscle remains. Healthy mucous membrane from the small intestine is then ‘transplanted’ onto the rectal muscle layer and grows there just like in any other skin graft. In an INRA procedure your rectum really gets a new inner lining..


In order to allow the mucous membrane to grow ‘quietly’ a temporary stoma is often created in this procedure and is usually removed after 3 months. In order to be considered for an INRA procedure, the small intestine must be healthy and there must be no signs of Crohn`s Disease. The advantage of this procedure is that there are fewer complications (infection, abscesses) than in the procedure described above, the IPAA. Since the rectum remains and there is no need of surgery in the pelvis then the risk of sexual problems is avoided. The disadvantage is that the recovery year after the operation is very difficult and trying; mainly because you have to train your sphincter again and in the beginning you have to take into account that you will need to go to the lavatory frequently, although later on not so often. Little is yet known of the long-term results.

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Dynamic Graciloplasty

In this procedure a new sphincter is made using a muscle from the inside of the thigh (gracilis muscle). This procedure is used if the sphincter is damaged or after removal of the rectum, which leaves you faecally incontinent. Continence can be regained with this procedure. The muscle is removed from the thigh and wrapped around the anus/old sphincter. The placing of the muscle has no effect on walking or moving around. This muscle is ‘switched on and off’ by means of a neurostimulator (a sort of pacemaker). This stimulator is implanted via a tiny cut in the skin.


A conducting wire is connected to the stimulator with 2 electrodes attached under the skin to the muscle which is wrapped around the anus. As the stimulator gives off weak electronic impulses, the muscle contracts, imitating the working of the sphincter. The stimulator consists of 2 parts, one part implanted in the skin as you have read above. The other part is used externally in order to switch the stimulator on and off by means of a remote control or a magnet. If you switch the muscle off, it relaxes, the sphincter opens and the faeces can be released.

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Pacemaker in the buttocks

A new development that can help people to control their faeces is the pacemaker in the buttocks. Using a modern operation technique, the sacral nerve stimulation, you receive a pacemaker (nerve stimulator) in the buttocks. From there an electrode by means of a hole in the sacrum to the sphincter muscle around the anus. Because the sphincter muscle is stimulated with electrical signals, it continues to function. Often you can also control the urine better as well, as the relevant areas lie close to each other. The pacemaker takes a half hour to install. It is not immediately inserted in you, first there are extensive investigations, and then you have to try it out to see if it works. You use an external neuron stimulator for a couple of weeks, and only if this works, is it implanted in your buttocks. This technique is still only scarcely used, because it is a very expensive procedure.

Source of image: NRC Handelsblad 

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Stomach stimulators

A stomach stimulator can help whenever the stomach cannot or can only insufficiently digest food, and is primarily inserted to prevent nausea and vomiting. In this technique two electrodes are implanted in the wall of the stomach. These two electrodes are attached to a food source and a regulator (the neurostimulator) which is the size of a pocket watch, which is inserted under the skin (usually somewhat lower in the abdomen). The apparatus gives light electrical pulses in order to stimulate the stomach to digest the food. Natural electrical signals are involved in the working of the stomach; the theory behind this treatment is that the stimulation of the electrodes helps to restore the normal working of the Vagus nerve. The electrical pulses stimulate the nerves and small muscles inside the stomach. You can see different results; with one person this stimulator works very well, whilst for another it makes little difference. It is inserted under general anaesthetic and then the stomach stimulator must be set up sing a hand held computer. In this manner it can also, without an operation, be removed. Exactly the same as the technique above, the neurostimulator has to be replaced when it is empty. It is guaranteed for 5 years, but in reality it has been for 8 – 10 years. Scanners can affect the working of the stimulator.


Source picture: Medtronic 

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Continent stoma

One procedure for replacing the ileostomy or urostomy is the continent pouch (Kock pouch) which means a “closed stoma”. Urine or faeces are no longer collected in a stoma bag but in a reservoir in the body. The reservoir is formed from the last 45-50 cm of the small intestine (also known as the ileum) and is situated in the abdominal cavity. The surgeon uses 30-35 cm of the small intestine to make the internal reservoir by cutting lengthwise 2 pieces of intestine, stitching them together and folding them over. The surgeon uses the remaining piece of intestine to create an outlet to the abdominal wall, where the reservoir outlet is in fact the stoma. It is a small round hole, on the right of the lower abdomen. In the first picture below you can see a continent ileostomy and in the second a continent urostomy.


In the lower right hand side of the stomach there is an opening where a catheter can be inserted to empty the reservoir at regular intervals. This occurs 3 to 6 times a day, depending on the size of the reservoir. It is important to be consistent when emptying the reservoir otherwise it can overfill and complications can arise. The opening is closed by means of a gauze dressing, a stoma plaster or cap. This procedure cannot be carried out in the case of a colostomy because unlike in a urostomy or ileostomy, the thickened faeces cannot be drained off through a catheter.


A continent stoma is not an option for all kinds of stomas. Most people with a stoma cannot be considered for this operation. For example, people with Crohn’s disease, as in this case the reservoir could become infected. The advantage of a continent stoma is that you no longer need to use a stoma bag. But there are also disadvantages: in the long term complications can arise, such as leakages because the valve does not work well or a narrowing of the opening can make using a catheter more difficult.

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The Indiana pouch

A relatively new variety of continent urostomy is the Indiana pouch. This surgical procedure was developed by Mr Rowland and was first used in 1987 in the American state of Indiana. Again, a reservoir is made which must also be emptied by using a catheter. The reservoir is made from the last 10cm of the small intestine and the first part of the large intestine. Between the small and the large intestine there is a valve (the Bauhin valve) which prevents the faeces running back into the small intestine. This natural valve is used to prevent any leaks from the reservoir.


Unlike a continent stoma the end of an Indiana pouch is often sewn into the navel, which is much less obtrusive than in the lower abdomen. Not everyone can have an Indiana pouch. This may be due to technical reasons or because the patient is not capable of using a catheter alone. And sometimes urine may escape from the stoma between catheterisations. If this is the case then you have to continue with stoma bags.

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The Hautmann procedure (neobladder)

A French urologist, Mr Camay, first developed the Hautmann procedure. In the Hautmann procedure a reservoir is made from a piece of the small intestine roughly 40cm in length, a sort of artificial bladder. This is why the procedure is also known as a neobladder (neo means ‘new’). The reservoir is connected to the urethra. The ureters are stitched to this reservoir so that in the end you have a bladder with a good capacity. As a result of this procedure you can, in theory, urinate once again in the ‘normal’ manner. However, you do have to learn how to do this all over again with the help of muscle exercises for the pelvic floor. A normal bladder is a muscle which contracts when you have to go to the lavatory, but the reservoir lacks this function and has to be emptied by stomach contractions.


In the case of a normal bladder the nerves send signals to the brain when the bladder is full and you feel like urinating. The reservoir does not have these nerves and so you do not know when the reservoir is full. You therefore have to keep an eye on the clock otherwise you can leak urine. Immediately after the operation you will have to go to the lavatory frequently, later the reservoir will get larger and trips to the lavatory will become fewer. It is important that the reservoir does not become too full as it can tear. The reservoir can produce a lot of mucous as it is made of intestinal tissue. You can improve the situation by using a mucous solvent. The advantage of this procedure is that you do not need to use a catheter or stoma bags.

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A cystostomy is an artificially created connection between the bladder and the abdominal wall. This is usually carried out when it is no longer possible to urinate naturally. A catheter in the opening ensures that it does not close up. This is called a suprapubic catheter and is generally replaced every 5 to 6 weeks.

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Mitrofanoff Stoma (appendicovesicostomy)

This technique is named after the man who conceived it in 1980: Paul Mitrofanoff, a French surgeon. Hereby an alternative urine way is made from a piece of appendix, small intestine or urethra. If the appendix is used the technique is called Mitrofanoff (appendicovesicostomy) , if the small intestine is used it is known as a monti stoma. This canal made from appendix, small intestine or urethra makes a joining between the bladder and the abdomen wall, so that the bladder can be emptied with a catheter. The canal is closed through the pressure in the bladder. A small opening is made in the abdomen wall; which seems like a small “navel”. You have to empty the bladder several times a day through the navel using a catheter.


Picture Source: AMC


This stoma is a continent stoma; you don’t have to wear a stoma bag with it. This technique is primarily used in children with spina bifida. For example if you are sitting in a wheelchair, catheterisation is a bit easier via the navel that via the urethras. After the construction a (temporary) silicon tube is inserted in the canal to prevent it healing up. However despite this a narrowing can sometimes occur.  

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In a nefrostomy a urine catheter is inserted into the renal pelvis via the back or the side. Thus, the urine comes directly out of the kidney. You are given a nefrostomy if the passage of urine between the kidney and the bladder is obstructed, in preparation for renal surgery or to reduce the pressure on the kidney if a tumour in the lower abdomen has squeezed the ureters together, for example. However, a nefrostomy can also be permanent. A bag to collect the urine is attached to a catheter which in turn can be strapped to the upper leg with a bandage system. The end of the catheter which goes into the body must be covered with a sterile gauze and fixed with plasters.


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A ureterostomy is an artificially created connection between one or both of the ureters and the abdominal wall; this procedure is used if your bladder no longer functions properly for one reason or another. There are a number of different kinds: a single ureterostomy, whereby one ureter is connected to the abdominal wall; a double ureterostomy whereby both ureters are connected to the abdominal wall, one on each side (see image below); a double ureterostomy whereby both ureters are connected to the same side and a trans ureterostomy (TUU) whereby both ureters are attached to the same side and the same stoma. The urine is collected in a stoma bag.


Source of image: UW medicine ostomy care

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The Coffey-stoma (ureterosigmoidostomie) is a kind of stoma procedure that is not carried out very often. It is, in fact, a very old form which existed even before the Bricker procedure. The ureters are attached to the rectum with the result that the urine ends up in the rectum. In practice this means that you urinate through your anus. And because the urine is mixed with faeces, then you actually have constant diarrhoea. One disadvantage is that the urine is reabsorbed into the body so that the kidneys have to work twice as hard. It is not a primitive form of stoma as is often supposed as it is little known in the Netherlands. In Moslem countries there is even a preference for this procedure because a stoma above the navel is considered to be unclean. Urinating via the anus is not a problem for Moslems, while this is exactly the reason while the Dutch do not want a Coffey-stoma. Urinating via the anus is something that we are not at all keen on!

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Vesico stoma

A vesico stoma (vesico means bladder) is an incontinent urine stoma, which means that you have no control over the urine. In this technique the bladder is bound to the stomach wall, the urine trickles continuously out of the stoma. This technique is often used with babies. It is necessary to use stoma bags with this stoma. If this stoma is placed in a good place, you can also use nappies.

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Malone procedure / Cecostomy

This is simply said, a hole in the beginning of the large intestine, through which you can clear your intestine using a catheter, thereby avoiding your anus. The man who first employed this technique was Mr. Malone, hence the name. this technique is also called MACE. Mace is an abbreviation for Malone, Antegrade (= with the flow), Colonic (= large intestine) and Enema (= rinsing). Using this technique, using a simple intervention, the large intestine is slightly extended to the stomach wall, and using a small cut in the stomach at bikini line height, a catheter is inserted, allowing access to the large intestine. This catheter remains in the patient for around four weeks. After this a small closable access point (port) is inserted, with a clasp, so that it can be opened and closed. A hose can be attached to this to rinse. There are various sorts of ports, usually used for feeding stomas, but they can also be useful for a Malone stoma. They all have one similarity: using a balloon on the inside to keep the port in place.


Source of right image: Applied Medical


The Malone technique is only suitable for people with constipation problems, caused by a too slow working rectum. If you have constipation problems for another reason, such as a tumor, then the Malone technique is not the solution. The stoma is also suitable for some people who are incontinent due to a malfunctioning rectum, in order to gain control and prevent accidents. Especially for children this can be a solution because it is a minor surgical intervention and not a large change to the body. You just have a port on your stomach, which is invisible under clothing. Unfortunately sometimes a Malone stoma is insufficient, and a intestinal stoma has to be formed.


Source of image: Cecostomy.com (Chait button)


There is also another variant, a precursor of the MACE : the appendix stoma. Herewith using the simple procedure of a cut in the stomach at the bikini line, the appendix is pulled out of the stomach wall and attached. The appendix stoma is rarely used nowadays because the opening closes far too quickly, no permanent catheter can be attached, and so every time you have to rinse you need to insert a catheter. 

For more information about irrigation click here.

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Gastrostomy (PEG)

A gastro Ostomy is a feeding stoma in the abdomen wall direct to the stomach, whereby liquid food is inserted via a catheter. PEG stands for percutaneous, which means it is brought through the skin. Endoscopic; meaning the technique the catheter is inserted by, and the G stand for Gastronomy. This technique has been used since 1980. The techniques have improved tremendously since then meaning the insertion is easier and the PEG can remain in place longer. Next to this there are various types meaning you have the choice in what is the most comfortable catheter for you. The insertion can be done through the push and pull technique, surgically, endoscopically or radio logically.


The liquid feeding via the PEG can often already be started 24 hours after insertion, this happens through a feeding pump which can be set on various settings.


Amongst other a PRG catheter or a Mic-Key can be inserted via this technique. A PRG catheter is a protruding tube outside the skin whereon the tube with the food can be directly connected. On the inner abdomen wall is a small balloon or plate, so that the catheter cannot become disconnected. The Mic-Key contains a small balloon. On the outside is a button with a closure cap whereby you can connect an extra tube for the liquid food.


Source of image: left  Nutricia and right Cobra medical Groningen


There are various variations of PEG. The PEG which has a catheter in the abdomen is the standard PEG. The catheter is pushed through from the stomach to the duodenum; this is called the PEG duodenum. Finally the catheter can be pushed into the small intestine; this is called a PEG jejunum (see the picture beneath.). With all three the insertion is in the stomach, just the catheter can be pushed further in. Apart from these you have the variations which are inserted by a radiologist rather than endoscopically. These are called: PRG (Percutane Radiological Gastronomy, directly into the stomach).The stomach is pierced from outside with a hollow needle using scans and x-rays, in order to lave behind a feeding catheter. Unlike the above mentioned technique with a balloon or plate but with a curl on the end. You also have the PTGJ 9percutane transgastromic jejunostomy) whereby a feeding catheter is inserted via the stomach into the small intestine.


Source of image: ACG

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Jejunostomy (PEJ)

A jejunostomy (PEJ) is a stoma in the middle section of the small intestine, the jejunum. As opposed to the PEG, this catheter does not sit in the stomach whereby it eventually gets shoved, but is inserted through the abdomen wall directly into the small intestine.

Source of image: ACG


This stoma can be used to introduce a feeding tube. This is a flexible tube through which thin, fluid food can be led directly into the intestine. There are 2 disc-shaped wafers attached to the catheter. One wafer sits on the inside of the small intestine wall so that the catheter does not slip out. The other wafer sits on the outside of the abdominal wall so that the catheter does not slip in. This also uses a small balloon in the inside. The end protruding from the abdomen can be closed with a special stopper.


This technique can also be performed by the radiologist rather than endoscopically. This is then called: PRJ (Percutane Radiological Jujunostomy). This is also created with a curl rather than a plate or balloon.




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Total Parenteral Nutrition (TPN)

Whenever through either a (chronic) illness or operation there is a disturbance in the absorption of food and the body cannot be taken in via the oral (by mouth) or enteral (via the stomach/intestines) route, then total parenteral nutrition may be necessary. This is the delivering of nutrition outside the digestion system, directly into the blood stream. Because the food stuffs come directly into the blood stream the gastro-intestinal tract is spared. In TPN are all the nutrients which the body needs, such as sugars, albumen, fats, vitamins, minerals and trace elements, just as in normal food. The food is modified so that for those without digestion in the gastro-intestinal tract, it can be taken up directly in the blood stream. The composition of the parenteral feeding is not the same for all people. Depending on the need for energy, fluids and such like, the concentration of the various foodstuffs varies; just as the number of times it is necessary for the parenteral nutrition to be administered does. TPN is often used in the hospital, but can also be done at home. It can also be temporary or permanent.

The food comes into the blood stream via a catheter with a therein an infusion system and an infusion pump. There are 3 possibilities: the Hickman- catheter, also known as the long-line or Central Venus Catheter (CVC). Hereby often a tube is placed under the shoulder bone or in the neck (sometimes in the groin for people in intensive care), through a vein to the heart. The other end of the tube is outside the body, and the food/infusion can be attached to it. The catheter may have one, two or three outputs. Medicines can also be administered. A subclavian is roughly the same as a Hickman.


Not a tunnelled line


But a tunnel.

Another method is the Port-A-Cath (PAC) and the Pass-Port. This is an administration system that is inserted under the skin, often in the chest. The principle is the same as with the Hickman-catheter, however now the other end of the tubing is connected under the skin to a small box, the front of which is made of plastic. The skin is then punctured.


Finally the shunt. This is subcutaneously, mostly in the arm, making a connection between a vein and an artery. For this connection a vein from the arm is used which is diverted for this purpose to the artery, however sometimes a piece of a vein from a leg for example is used. Due to this connection (the shunt) the blood flows with a high speed making it more visible and easier to puncture.

Temporary you can choose for the insertion of a PICC. A PICC (Peripherally Inserted Central venous Catheter) is a catheter which is inserted in a periphery vein around the elbow crease and the tip is laid centrally around the heart.


Source pictures: left thanks to P-tje! And right Wellsphere.com


Those people who have TPN at home usually connect the infusion in the evening and let it run over night. The average running time for a full quantity of food is approximately 12 hours, which should not be stopped in the middle. Because the bag with the nutrition and the pump can be carried in a rucksack it is also possible to administer it over the day without causing serious constrictions. It is vital to be very hygienic to prevent an infection in the blood stream.

Use made of the website: Vereniging voor patiënten met parenterale thuisvoeding.

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The term ‘tracheostomy’ derives from trachea (wind pipe) and stoma (artificial opening). A tracheostomy can be necessary when there is any disorder which hinders the free passage of air through the throat and other parts of the upper air passages. Tracheostomy is one of the oldest surgical procedures. In this procedure an opening is made in the neck in which a tube is placed (trachea canula). Breathing in and out through a tracheostomy is different from breathing through the nose or mouth and you need a few days to get used to it. In the beginning the voice will also be affected and it will be difficult to speak or even make any sounds. If the stoma is only temporary, then after the tube is removed, recovery is rapid.


Source of images: left Kreft and right Letzgus+lang


It is best to cover the opening with a scarf, for example, to prevent any dust entering the air passage and to camouflage the stoma. There are all sorts of neck bands for this. There are also special filters which can be fixed in front of the tracheostomy which can filter and moisten the air when it is breathed in. These filters are also known as ‘artificial noses’ as they partly take over the function of the nose.


Source of image: Buyemp

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Liver stoma

A liver stoma, sometimes called a gall stoma, is a stoma of the gall bladder in order to remove bile fluid. This stoma is formed by two rare liver sicknesses: BRIC (Benign Recurrent Intrahepatical Cholestase) and PFIC (Progressive Familiar Intrahepatical Cholestase). About 20 people in The Netherlands have the hereditary sickness BRIC, of whom a few have a stoma. This illness can stop the galle channels from functioning normally (cholestase) and the bile salt mirror rises, there is a bile salt metabolism. Because of this the bile enters the blood in stead of the intestines, causing such problems as unbearable itching, no absorption of fats, sugars and vitamins, jaundice and tiredness. Often it can take from months to over a year to occur. The illness is in your DNA, in your genes. The difference between the liver sicknesses BRIC and PFIC is that by PFIC there is a permanent blockage of the gall channels rather than an attack. Amongst other things this can lead to a serious attack on the liver function (inadequate liver function). PFIC appears principally by the Amish in America. By forming a liver stoma the bile is drained away and the people with this illness often lose their symptoms.


The stoma is made with a piece of the large intestine. The piece of intestine is placed under the opened gall bladder, laid in a loop and then brought out of the stomach wall. After the making of the stoma it can take a while (minimum of 24 hrs) before real bile comes out, because the loop must first be filled. The first operations were performed laparoscopically, however that often caused problems. The operations took far too long, sometimes 8-9 hours. Now a traditional operation is performed, the stomach is opened enabling the surgeon to have a good view of what he or she is doing. The operation time is also cut in halve.





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