When is surgery indicated for stomal prolapse?

• A. When the prolapse reduces spontaneously
• B. When there is no pain or edema
• C. When the patient requests cosmetic repair only
• D. When prolapse cannot be manually reduced and there are signs of ischemia or necrosis

Answer: (D)

The important idea here is tissue viability and reducibility. A stomal prolapse that can be easily and completely reduced, with healthy-appearing skin and no signs of compromised blood flow, is typically managed nonoperatively with observation and gentle reduction. Surgery becomes necessary when the prolapsed segment cannot be manually reduced and there are signs that the bowel is not getting enough blood or is dying—ischemia or necrosis. In this situation, ongoing strangulation risks rapid progression to full-thickness necrosis, perforation, infection, and sepsis, so urgent surgical intervention is required to resect nonviable tissue and/or revise the stoma. Signs of ischemia or necrosis include discoloration of the prolapsed bowel (dusky, purple, or black), increasing edema, tenderness or severe pain, and potential systemic concerns. Cosmetic concerns or a reducible prolapse don’t justify surgery; surgery is reserved for irreducible prolapse with compromised tissue viability.