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In elective cases where stoma creation is planned, patients should be seen by enterostomal nurses for ostomy marking and preoperative education. In an emergency situation, or if the stoma creation wasn’t anticipated preoperatively, consider following a few simple rules.

Start by identifying the landmarks of the stoma triangle (Figure 4-1), which is formed by the umbilicus, symphysis pubis, and the anterior superior iliac spine. The patient should be examined in sitting, standing, and supine positions. Bedridden patients or patients in wheelchairs should be marked while they are in the position in which they plan to change their stoma bags.

Figure 4-1

The optimal location of the stoma is through the stoma triangle, which is bounded by the umbilicus, anterior superior iliac spine, and symphysis pubis.

There are many factors that should be taken into consideration to determine the best site for the stoma:

  • Patient-related factors include body mass index (BMI), fat distribution (the upper abdomen has less thickness of the abdominal wall than the lower abdomen), bony prominences, skin folds, valleys, and surgical scars. The stoma location should be in the line of sight of the patient. Note that an obese patient may not be able to see the ostomy if the site of the stoma is marked below the protuberant abdomen.

  • Surgical factors include stoma type (colostomy versus ileostomy) and duration (permanent versus temporary).

The stoma location should be away from any fold, bulge, valley, or bony prominence because this will cause problems with fitting stoma appliances and lead to leakage of enteric content. This is a devastating problem for patients and will affect their quality of life. In high-BMI patients, preoperative computed tomography (CT) scanning should be examined. The thickness of the abdominal wall in the upper and lower abdomen should be assessed. Typically, the lower abdominal wall is thicker than the upper abdominal wall, and hence more length is needed to bring out the ileum or the colon through the lower abdomen compared to the upper; sometimes, the length is not adequate to bring up a stoma especially if we want to Brooke it, In such situations, it is better to bring up a stoma in the upper abdomen.

The stoma should be brought through the rectus muscle to decrease the incidence of parastomal hernia. Ask the patient to lift their head from the bed, which will help you to identify the rectus muscle.

In addition, note the following points:

  • The stoma site should be approximately 5 cm away from the planned midline incision.

  • Make sure that it’s on a flat surface to ensure adequate pouching, and that the patient can see the stoma site.

  • The patient should be examined while lying flat, while sitting and standing. Use a marking pen to ...

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