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58 Thorson
be very helpful. In addition, having a list of ostomy patients who are willing
to visit with new patients can go a long way in alleviating fear. In most
centers, the United Ostomy Association (www.uoa.org) has volunteers who
can fulfill this function. A visit from an ostomy patient of a like age and
gender can be particularly reassuring.
Many questions will frequently arise if the physician is interested
enough to listen. Does it hurt? What does an appliance look like? How
does an appliance stay on and how often will I have to change it? What
will I do about sexual relations? How will I be able to swim or shower or
take a bath? Will I still be able to participate in sports? Will I have to wear
special clothing? These and many other questions are commonplace. While
the physician may be able to address many of these questions, time con-
straints will likely limit his or her ability to do them justice in the eyes of
the patient. If at all possible, an enterostomal therapist (ET nurse) or a
wound, ostomy, and continence care nurse (WOC) should also play a role.
Such specialists will not only be able to answer the patient’s questions but
can also show him or her some of the many appliances available and even
allow the patient to try them on preoperatively.
The ET or WOC nurse will frequently provide important counseling
functions to the patient. He or she can reinforce the surgeon’s discussion
of the risks and potential benefits of ostomy surgery. Depending on the
indication for the surgery, this may include potentially curative treatment
for cancer, protection from infectious processes, or improved quality of life.
The nurse can also reinforce the surgeon’s discussion of the risks, so as to
ensure complete understanding and an informed consent. Potential compli-
cations—including bladder and sexual dysfunction, peristomal skin prob-
lems, parastomal herniation, and stomal prolapse—need to be thoroughly
understood if true informed consent is to be obtained. Such counseling rep-
resents an important step toward ensuring the achievement of quality-of-
life goals and decreasing complications following stoma surgery [1,2].
ANATOMICAL CONSIDERATIONS
Anatomy becomes important when it is time to select the site for a stoma.
The marking of a stoma site is best done in the preoperative period, when
the patient is able to change positions and demonstrate his or her ability to
visualize and work with the site. A site that cannot be visualized by the
patient is doomed to failure if the patient intends to remain independent in
stoma care. Careful consideration must be given to all of the usual land-
marks, including the costal margins, umbilicus, waistline, and groins. In
addition, scars from previous operations and skinfolds must be identified
and their potential impact on stoma function recognized.
There are several primary anatomical characteristics that should be
identified in selecting the placement of a stoma on the abdominal wall.
Preoperative Considerations 59
These include a 5- to 7-cm area of skin that remains relatively flat, regard-
less of patient position, through which the stoma can be placed. In addition,
the location of the rectus muscle, especially its lateral border, must be iden-
tified. Finally, a site that can be visualized by the patient and, if possible,
a site that rests below the belt line should be sought. Generally this site
sits within the “ostomy triangle,” which is bordered by the umbilicus, the
anterosuperior iliac spine, and the pubic symphysis (Fig. 1).
The process of marking a site should begin with the patient supine.
Having the patient raise his or her head and/or cough can help identify the
lateral borders of the rectus. When identified, these borders should be
marked. The patient should then be asked to sit on the edge of the table.
The infraumbilical fat pad should be identified, along with any creases,
deep wrinkles, or irregular contours. The patient should then lean over to
further accentuate any creases that might interfere with the integrity of the
Figure 1 When a stoma site is being chosen, scars, bony prominences, and the
umbilicus must be avoided. (Modified from Corman ML. Colon and Rectal Sur-
gery, 3rd ed. Philadelphia: Lippincott, 1993:939.)
60 Thorson
pouching system. A flat space matching the desired area of 5 to 7 cm across
should then be sought near the apex of the infraumbilical fat pad. Histori-
cally, it has been felt that a site within the marked borders of the rectus
muscle should then be selected to reduce the risk of parastomal herniation
[3]. However, recent evidence has questioned the value of this surgical
dogma, with at least one report suggesting that the rectus abdominis is not
protective [4]. Nevertheless, most surgeons will still place a stoma through
the rectus and site the stoma no closer than 5 cm to any bony prominence
or fold, crease, or scar.
Once such a space is identified, the ability of the patient to view it
must be confirmed. The patient should then stand and the examination be
repeated to confirm the absence of any creases that could interfere with the
appliance’s integrity. The patient should be asked to confirm that he or she
can touch and see the site while standing and lying down.
Selecting a site below the belt line allows greater flexibility in cloth-
ing selection. Tighter clothing may be worn with confidence and will help
to conceal the pouching system. In addition, underclothing can help to sup-
port the weight of the appliance. If the stoma ends up being above the belt
line, clothing choices may be somewhat more limited. It may be necessary
to wear loose clothing to conceal the appliance more fully.
After the site has been chosen and its accessibility confirmed, it is
marked. This can be accomplished with an India ink tattoo, and indelible
marker, or subcutaneous injection of methylene blue. Once the patient is
asleep and in the operating room, the site should be scratched with a needle
to make sure that the site will not be lost during the skin preparation process.
SPECIAL CONSIDERATIONS
Physical Disabilities
Patients who are incapable of caring for their own stomas do not need to
have a site that they can visualize or touch. In such cases it is more impor-
tant to ensure that placement is done to facilitate the caregiver’s needs in
managing the stoma. This might mean a higher or lower stoma site than
would otherwise be selected.
For patients confined to a wheelchair, it is essential that the selection
and marking of a stoma site be done while they are in their chairs. Fre-
quently, these patients will require a higher stoma placement than would
otherwise be used in order to better visualize and manage the stoma while
the patient is in a sitting position.
Patients with physical conditions that require them to wear a brace or
other device for back support or other musculoskeletal problems should
have a stoma site selected with the brace in place. This will obviate prob-
lems from later impingement of the brace on the stoma, with subsequent
risk of stoma injury.
Preoperative Considerations 61
Other Health Problems
Patients with portal hypertension are at increased risk of developing para-
stomal varices. Alternatives to stoma surgery should be considered in these
patients. Patients with chronic ulcerative colitis and primary sclerosing chol-
angitis who are scheduled for colectomy should consider an ileoanal pouch
or ileorectal anastomosis, since there have not been reports of perianasto-
motic bleeding in these patients, while over 50% of these patients who have
stomas will develop stomal variceal bleeding [5].
With cancer patients who have a history of radiation or who are candi-
dates for radiation, care should be taken to avoid placing stomas within the
radiation field. Mucositis and severe skin complications can occur in both
the acute and chronic settings. Ostomy sites, which are placed within a
radiated field based on standard selection criteria, should be modified to
fall out of the radiated field by being placed higher on the abdominal wall.
In severely obese patients, visualization of a stoma located below the
umbilicus may not be possible when the patient is standing or lying down.
High stoma placement may be necessary in such patients. High placement
may be advantageous in these patients for another reason: since the abdomi-
nal wall is usually much thinner high above the umbilicus, it may be much
easier to deliver a satisfactory length of bowel through the abdominal wall
and thus to fashion a stoma with a satisfactory profile.
Some patients require more than one stoma. In cancer patients undergo-
ing pelvic exenteration, both a urostomy and fecal diversion are necessary.
Keeping the two stomas at differing levels will avoid potential problems
with pouching belts, one of which could cause injury to the complementary
stoma. It is generally preferred to have the urostomy as the highest stoma.
In addition, the two stomas should be located on opposite sides of the abdo-
men (Fig. 2).
Although the right and left lower quadrants are the ideal sites for
ileostomies and colostomies, respectively, these sites will not always be
available. Prior stoma surgery, multiple surgical scars, nonhealing skin le-
sions, obesity, and other factors may make alternative siting necessary. In
these difficult circumstances, preoperative marking becomes even more im-
portant. Alternate sites include the left and right upper quadrants, the umbi-
licus, the midline above and below the umbilicus (particularly useful in
infants), and even the left and right lumbar areas (choices of last resort)
(Fig. 3).
In selecting of an alternate site, the general principles are followed as
closely as possible. The stoma should pass through the rectus muscle (or
the linea alba in the case of midline stomas). It should be positioned 6 cm
away from the costal margin or iliac crest, and it should be placed to avoid
prior scars or other stoma sites. Occasionally, a stoma may be brought
through the surgical wound, but only when no other viable option exists.
Such placement increases the chance of hernia formation and makes appli-
62 Thorson
Figure 2 Urostomy and colostomy sited on the abdominal wall. The urostomy
is to the right of the midline and slightly higher.
cation of the pouch very difficult. After a stoma site has been selected,
the patient should wear an ostomy management system for 24 to 28 hr
preoperatively to assess the acceptability of its position.
Miscellaneous Situations
A patient’s employment should always be noted. In some instances, modifi-
cation of the siting may be necessary. For instance, a carpenter may wear
a tool belt. Depending on where it is worn in relation to the belt line, it
may be necessary to modify the site to above or below the belt line to accom-
modate the tools and prevent trauma to the stoma. In a similar fashion,
a police officer may need to modify a stoma site in order to accommodate
a gun holster.
Finally, there is the special situation that will occasionally occur de-
spite our best efforts to avoid it. That is the need to select a stoma site
Preoperative Considerations 63
Figure 3 A. Potential stoma sites. B. Lumbar sites for limited, rare circum-
stances.
intraoperatively because unexpected findings are encountered at time of
operation. Unfortunately the best one can do in this situation is to follow
all of the guidelines previously outlined. These include maintaining a dis-
tance of at least 5 cm from any bony prominence or other surface defect,
including scars, creases, and wrinkles. The ostomy should be brought
through the rectus muscle. Planned open wounds should be kept at least 5
cm from the stoma if at all possible. Identification of the infraumbilical fat
pad should be done to the best of one’s ability and the stoma placed slightly
cephalad in order to ensure good patient visualization. If no landmarks are
available to guide placement in the lower quadrants, it may be best to utilize
the upper quadrants.
CONCLUSIONS
The best way to achieve success in maximizing quality of life following
stoma surgery is to adequately prepare the patient preoperatively. An appro-
priate approach to this problem includes counseling patients in realistic ex-
pectations, correcting misconceptions and myths, properly siting the stoma
to minimize complications related to appliance disruption and leakage, and
providing adequate support postoperatively. Proper siting is done in the
preoperative setting, taking care to assess the abdominal wall in the supine,
64 Thorson
sitting, and standing positions. Proper identification of an adequate area of
flat, smooth skin unencumbered by creases, wrinkles, or a bony prominence
is critical. The development of the stoma within the confines of the rectus
abdominis muscle remains the preference of most surgeons. The few min-
utes necessary to achieve these goals may prevent years of impaired quality
of life and complications often associated with a poorly located stoma.
REFERENCES
1. Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in
stoma patients. Dis Colon Rectum 1999; 42:1569–1574.
2. Bass EM, Del Pino A, Tan A, Pearl RK, Orsay CP, Abcarian H. Does preoper-
ative stoma marking and education by the enterostomal therapist affect out-
come? Dis Colon Rectum 1997; 40:440–442.
3. Martin L, Foster G. Parastomal hernia. Ann R Coll Surg Engl 1996; 78:81–84.
4. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal
complications following colostomy. Dis Colon Rectum 1994; 37:916–920.
5. Sentovich SM, Thorson AG. Stomal varices. In: Wexner SD, Vernava AM III,
eds. Clinical Decision Making in Colorectal Surgery. New York: Igaku-Shoin,
1995:463–465.
4
Stoma Therapy
Ian C. Lavery and Paul Erwin-Toth
The Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.
INTRODUCTION
Optimum care of a patient with stoma is achieved through active participa-
tion of both the surgeon and the enterostomal therapy (ET) nurse. This
participation should begin in the preoperative period with physical exami-
nation and preoperative preparation of the patient.
The ET nurse who provides ostomy care should determine from the
surgeon and staff nurse what information has been communicated to the
patient and family and their level of understanding. This knowledge pro-
vides the basis for anticipatory care.
In addition, the patient needs counseling and psychological prepara-
tion for surgery. The surgeon should not abdicate responsibility in this area,
because such preparation can influence the patient’s outcome appreciably.
The most common problems that may occur are related to placement
of the stoma and parastomal sepsis. Incorrect placement of the stoma pre-
disposes the patient to problems that cannot be managed conservatively
(i.e., with a change in equipment). Although correct siting of the stoma is
a fundamental consideration, it is often ignored or forgotten in the myriad
of things that need to be accomplished in preparation for surgery. Discus-
sion of the patient’s concerns about activity, odor, diet, employment, and
intimacy are topics that are commonly addressed during preoperative prepa-
ration.
The objective of stoma construction is to provide an anatomically sta-
ble opening allowing placement of an ostomy management system that will
maintain a seal of stool and gas for 4–7 days. If every abdomen were flat,
muscular, and unscarred, placement of the stoma would not be a major
problem. In reality, many patients have a protuberant abdomen and lax
musculature. Often they have incision lines that were placed in different
directions and have created creases and weak muscles from neurovascular
interruption. Under these circumstances the time taken to plan the site for
65
66 Lavery and Erwin-Toth
a stoma is crucial because it can minimize the number of postoperative
problems.
Siting of the stoma is done with the patient awake. An ostomy man-
agement system or a specially prepared disk of the same dimensions as the
system is used. The patient is positioned in various ways—supine, sitting,
and bending. When the optimum site has been determined, the skin is tat-
tooed with a 27-gauge sterile needle and India ink so that, when the abdo-
men is opened and the anatomic relationships are distorted, the chosen site
will not be mistaken. The stoma must be constructed so that it is visible to
the patient (i.e., not located on the inferior surface of the pendulous abdo-
men) (Fig. 1). The stoma should be located away from the umbilicus, skin
creases, scars, and bony prominences. Areas of skin damaged by irradiation
or skin grafts also should be avoided.
In the immediate postoperative period, a pectin skin barrier is used
for end stomas. A karaya washer is used for loop stomas because, when the
karaya reaches body temperature, it molds itself over the rod and creates a
seal. A temporary ostomy pouch is used until the rod has been removed.
When the rod is removed, the patient is fitted with an ostomy management
system and given instructions on care of the stoma and the equipment. The
patient must be competent and comfortable with care of the stoma before
Figure 1 A. The optimum site for an ileostomy is the apex of the subumbilical
fat roll through the rectus muscle. B. In patients with a pendulous abdomen, the
stoma needs to be located in the upper abdomen so that it can be seen by the pati ent .
It also needs to be placed in an area of skin that is flat.
Stoma Therapy 67
hospital discharge, because deficiencies in care can have serious psycholog-
ical and physical consequences for the patient. Follow-up in the clinic usu-
ally takes place 1 month after discharge, so that the situation can be as-
sessed and the stoma can be remeasured as postoperative edema resolves.
If necessary, self-care instruction can be continued by a home care ET nurse.
Since construction of a stoma creates an abnormal anatomical situa-
tion, complications may occur. However, such complications can be mini-
mized through the surgeon’s understanding of physiology and correct con-
struction of the stoma.
GASTROINTESTINAL FUNCTION
Jejunostomy
Jejunostomy function usually begins with in the first 48 hr after s urgery.
Initially the effl uent is watery, clear, and dark green. Because t he volume
of output may approach 2400 mL in 24 hr, the patient should be moni-
tored closely for signs of electrolyte imb alance. Absorption capacity de-
pends o n the length and functioning of the proximal bowel. Absorption
of nutrients, fluids, and electrolytes may be deficient in the pat ient with a
jejunostomy.
Ileostomy
An ileostomy generally begins to function within the first 48–72 hr after
surgery. The initial effluent is viscous, green, and shiny. An ileostomy cre-
ated via a laparoscopic approach may begin to function within 24 hr. Such
output does not necessarily indicate return of peristalsis; rather, it may rep-
resent the elimination of secretions that have collected in the distal small
bowel. Once peristalsis has returned, the patient may enter a period of high-
volume output known as the adaptation phase. Output during this period
exceeds 1000 mL/day and frequently reaches 1500 to 1800 mL/day. The
physiological basis for this high-output phase is loss of the colon’s absorp-
tive surface coupled with loss of the ileocecal valve. During this period the
patient must be monitored closely for signs and symptoms of fluid and
electrolyte imbalance. Replacement therapy, which is necessary at this time,
can be managed via the intravenous route or with oral electrolyte replace-
ment solutions, depending on the status of bowel function.
Over a period of days to weeks, the proximal small bowel increases
fluid absorption and the bowel adapts; gradually the volume of output de-
creases and the stool thickens to a toothpaste-like consistency and is light
to medium brown. Initially the output from an ileostomy can vary from 500
to 1500 mL in a 24-hr period. After adaptation, the average output de-
creases to between 500 and 800 mL daily.