The careful siting of a stoma, whether temporary or permanent, plays an essential role in the rehabilitation of the patient. In elective cases, whatever the reason for a stoma, it is usual for the stoma care nurse to site the stoma preoperatively and to counsel the patient about the possible outcomes. All this takes place in a far more relaxed atmosphere where the patient can ask coherent questions about what is going to happen to him- or herself. Often, in the case of diverticulitis where surgical intervention will be as an emergency, the stoma is not sited preoperatively because the patient goes to theatre for surgery via the accident and emergency department (A&E), often during unsocial hours. The problems that can arise from a badly sited stoma can include the patient being unable to see the stoma because of bodily protrusions, and therefore being unable to manage the appliance, causing leakage and sore skin. There may be retraction or prolapse of the stoma, or a parastomal hernia may occur.
In 1981, Breckman suggested that, before the advent of stoma care nurses in the UK, the siting of the stoma was left to the surgeon and was often decided after the patient had been anaesthetized, and at the end of the surgery. Yet, in 1989, Wade found, in her study of stoma care nurses and their patients, that very little had changed in the siting of the patient's stoma. As one ward sister in the study stated:
It is usually done by the surgeon with the patient on the operating table, so you can imagine the problems that therefore result.
The stomas created in emergency surgery are often more difficult. They are always far too near the main wound site or far too high up under the rib cage, which causes difficulty once the patient has regained consciousness and sits up. In Wade's research (1989), one surgeon commented in his interview:
. . . although the stoma care nurse sites the elective preoperative patients for the stoma, I always move it by a centimetre to assert my independence.
Although it would be expected that stomas sited electively would be easier to see and manage, emergency stomas did not fare too badly. In the Wade study, A Stoma is for Life (1989), of the patients who had stomas raised as an emergency, 81.5% stated that they could see their stomas easily compared with 86.9% who underwent elective surgery.
The importance of having a stoma sited correctly cannot be stressed enough (CORCE, 1997). For most caucasian patients the stoma will be sited below the umbilicus, but patients from ethnic minorities may need the stoma to be sited on a different area of the abdomen. If the patient is to have elective surgery, as some patients with diverticular disease do, after the decision by the surgeon has been made the patient will often be seen in hospital by the stoma care nurse who is a member of the multidisciplinary colorectal team. If there is no stoma care nurse, sometimes an experienced ward sister on the colorectal unit will site the patient's stoma. When first assessing the patient the nurse will mentally be taking in images of the patient's body and physique. The nurse will discuss with the patient his or her lifestyle, work and leisure pursuits. For patients who are working the nature of their employment is important, because the nurse should be aware if the patient is expected to do heavy lifting or work of a heavy manual nature. In situations such as these it is important to consider the planned stoma area in view of possible postoperative parastomal herniation or prolapse.
To site the patient, the nurse or stoma care nurse will require the patient to lie flat on the bed and expose the abdomen. The abdomen is examined for creases, weight loss indications, previous scars and bony prominences, skin problems and the natural waistline. If the stoma is to be a colostomy it will be sited in the left iliac fossa or, if an ileostomy, in the right iliac fossa. A small mark is placed on the correct side for the appropriate stoma. The patient will then be asked to sit up on the edge of the bed for the nurse to see if the mark is in the correct place for the patient to be able to care for him- or herself and to make sure that there are no rolls of adipose tissue falling over the potential stoma site and therefore occluding the stoma. If there are gullies or rolls of adipose tissue the appliance will not fit securely and leakage leading to sore skin will become a problem for the patient. While assessing the correct site, the nurse will be explaining to the patient what she is doing and why. Enquiries are made of the patient on what sort of clothes he or she wears, where the waistline is, and if a man where his trouser line comes and whether he wears braces or a belt. Many older women become concerned because they may wear a support girdle or pants. They should be assured that a hole can be made in the girdle for the appliance to come through. Patients who require a support girdle are allowed three a year on prescription and this is not just a prerogative of women, men may also need a support girdle if they do heavy lifting. If it appears that siting of the stoma may be difficult because of the patient's shape, the patient should put on normal clothes and the stoma site be reassessed wearing everyday clothes. If the patient is likely to lose weight over time after surgery, and it must be remembered that some will be lost postoperatively, the stoma must not disappear into skinfolds. Once the site of the stoma has been agreed with the nurse and patient, the nurse uses a skin marker pen to mark the spot and cover with clear tape to maintain the mark until surgery. Biro and felt-tip pens are unsuitable because they contain colophony which may cause skin allergies.
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