Neobook — clinical reference

Pre operative siting of a stoma is an extremely important part of patient care.
A poorly sited stoma has a huge effect on a patients quality of life.
It is a simple but vital step in the care of a patient who is undergoing colonic surgery.
Consider the possibility of creating a stoma in every patient who is being prepared for intra-abdominal surgery. Discuss the implications of a stoma in depth with the patient and their family prior to surgery, and when taking informed consent.
If your hospital has dedicated stoma trained staff, consult with them preoperatively.

Who should be sited?

All patients who are undergoing surgery which may involve the colon
All patients undergoing surgery to the small bowel who may have a contra-indication to an anastomosis
If in doubt it is better to site a stoma pre operatively and not use it than deal with a poorly sited stoma

Prior to siting

Know the diagnosis
Planned incision
Proposed intestinal stoma

Requirements

Permanent marker / Waterproof transparent film dressing

General Principles

Site within the rectus muscle
Site should be clearly visible to the patient on sitting, standing and lying down

Avoid

Lower costal margins
Old scars
Waistline/belt line
Obvious creases
Umbilicus
Iliac crests
Prosthesis straps
Irradiated abdominal fields
Pendulous breasts
Underside of abdominal rolls

Technique

Identify the waistline of the patient on standing and sitting, preferably with clothing garments on
In the supine position, observe the abdomen for bony prominences, scars, creases, contours, skin integrity and palpate the rectus muscle of the patient
With one hand, place your thumb and on the apex of the iliac crest and your index finger, on the umbilicus
The midway mark between your thumb and index finger is to be sited on the rectus muscle, on the apex of a fat roll
Mark the site clearly with a cross or large dot, using an indelible marker, on both the left and right side. Stand the patient up and re-check the visibility of the sites and adjust the sites, if required
The sites may be numbered, as the most preferable site
Cover the sites with a waterproof film dressing, to avoid it being rubbed off
This should be visible to the patient on sitting, standing and lying
Discuss the siting complications with the surgeon
In theatre, the surgeon should score the sites through the film dressing, thereafter remove the dressing, and prep the abdomen accordingly, pre abdominal surgery

In emergency cases

Lift the patients’ head, if in the supine position to make the rectus muscle visible
With one hand, place your thumb and on the apex of the iliac crest and your index finger on the umbilicus. The midway mark between your thumb and index finger, is the site / X
Site at least 2 inches away from the midline incision. If in doubt, place a stoma face plate/ flange over the potential stoma site, to be sure it fits well on the abdomen