The Importance of Stoma Marking

Stoma site marking is a crucial component of preoperative ostomy care and is associated with a higher quality of life and fewer ostomy-related complications.¹ A 2018 joint position statement¹ from the Wound Ostomy Continence Nurses (WOCN) Society, American Urological Association (AUA), and American Society Colorectal Surgeons (ASCRS) outline the recommendations that stoma site marking should ideally be completed on all patients preoperatively facing the possibility of stoma creation. Several factors can limit the performance of stoma site marking, including emergent surgical indications, access to trained staff able to perform stoma site marking, and applicability of current patient status to long term site outcomes. For example, it can be quite difficult to stoma site mark patients awaiting surgery with very distended abdomens. They may not be able to tolerate appreciating the rectus muscle. If a site is marked, it may not be able to do so in a way that could predict long term stoma placement as normal anatomical variations for the patient, including folds and creases, are not currently present. Patients may also be limited to supine positioning while awaiting surgery and therefore cannot be assessed in the sitting and standing positions. Operative circumstances may also limit the usage of a well-marked stoma site.

Stoma site marking begins by locating the rectus abdominis muscle. A stoma placed within this muscle will have adequate support decreasing the risk of peri-stomal hernia, a common complication of ostomy surgery. Clinicians then assess the abdomen for a flat surface that can accommodate the size of an appliance wafer. This is usually accomplished by placing the wafer in various locations during sitting, standing, and supine positioning. The abdomen will naturally change shape with each position, sometimes creating folds and creases that were not previously present. Additional factors considered in stoma site marking include the umbilicus, boney prominences such as those of the ribs or pelvis, and patient preference for clothing. Stomas or appliances are placed onto a fold, crease, or scar have an increased risk of leaking. The appliance must fight additional physical forces pulling at the adhesive to maintain contact with the base of the fold, and stool or urine has a premade track to follow instead of collecting in the pouch. Leaking appliances are an important quality of life impactor and contribute to adverse outcomes, including peristomal dermatitis, impaired self-image, and social isolation.

Stoma site marking increases the likelihood that a new stoma will be placed both in a place the patient can adequately access to provide self care (usually above the apex of the abdominal bulge) and in a location that decreases the risk of peristomal complications to decrease the risk of appliance leaking.

The outcomes associated with stoma site marking are so crucial to the future quality of life outcomes that the United Ostomy Associations of America (UOAA) revised² their patient bill of rights to include access to stoma site marking as the “gold standard” of care for ostomates. The revised patient bill of rights is an ostomate-centered document containing evidence-based best practice recommendations for ostomates throughout their lifetime. Many ostomy associations, industry partners, and professional organizations have undersigned a support letter,³ demonstrating support for patients to receive the gold standard in ostomy care.  

Access to stoma site marking increases quality of life, decreases hospital readmission rates, and leads to positive patient outcomes. It is now considered a gold standard in ostomy care.

References

1. WOCN Society, AUA, and ASCRS. Position statement on preoperative stoma site marking for patients undergoing ostomy surgery. J Wound Ostomy Continence Nurs. 2021;48(6):533-536. doi:10.1097/WON.0000000000000820
2. Burgess-Stocks J, Gleba J, Lawrence K, Mueller S. Ostomy and Continent Diversion Patient Bill of Rights: Research Validation of Standards of Care. United Ostomy Associations of America. 2021. https://www.ostomy.org/bill-of-rights/
3. Ostomy and Continent Diversion Patient Rights Endorsement Letter. 2021. https://www.ostomy.org/wp-content/uploads/2021/09/PBOR_Endorsement_Letter_2021.pdf