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Stoma site selection in a patient with multiple enterocutaneous fistulae.

A55-year-old Hispanic man was admitted to an acute care facility for surgical treatment of several enterocutaneous fistulae that had developed following the repair of an incisional hernia 3 months previously. The surgeon consulted the WOC nurse preoperatively for stoma siting for possible intestinal diversion. The patient’s pertinent medical/ surgical history included a liver transplantation 3 years ago following hepatic failure related to hepatitis C. The patient was unemployed. He was married and the primary caregiver to his 2 young grandsons. He was receiving home hyperalimentation, managing the enterocutaneous fistulae with a large one-piece fistula pouching system and eating as desired. His wife changed the pouching system, because the patient could not see the area to provide self care. The output from the fistulae varied from 1000 to 2000 mL per 24 hours, depending on his oral intake. Janice C. Colwell, RN, MS, CWOCN: An appointment to meet with the patient and his wife was scheduled the day before the surgery. Before the meeting, a consultation held with the surgical team revealed that several options were being considered: primary surgical repair of the fistula without diversion, primary surgical repair of the fistulae with small bowel diversion, or small bowel resection with exclusion of the fistula site with or without diversion. The surgical incision of choice was to be midline. The location of the incision was important because the patient’s abdomen had several previous scars, and these scars as well as the new incision might limit the stoma site selections. The multiple fistulae were located at the terminal ileum. This information indicated that any potential stoma would probably originate several inches from the terminal ileum. Important information was elicited from the patient. He currently wore his belt just above the fistulae openings to avoid compressing the pouching system. Prior to the hernia repair surgery, he wore his belt at the level of his umbilicus. He wished to manage his stoma independently following surgery, and his wife supported this request. Enabling the patient to view his stoma and provide self-care were the main objectives in siting the stoma. Initial abdominal assessment included viewing the abdomen in sitting and supine positions to determine the location of the abdominal folds and palpating the rectus abdominis muscles. Avoiding deep folds and creases is important because these areas can interfere with the seal of the pouching system. Placing a stoma through the rectus abdominis muscles is thought to prevent peristomal hernia formation.1 The small bowel fistulae were located in the right middle abdominal area and measured approximately 7 inches left to right and 3 inches from top to bottom (Figure 1). With the patient sitting, his abdomen was again assessed and a marking disc (Hollister stoma siting template–65 mm, Libertyville, Ill) was used to determine at least a 2-inch flat plane that would provide an adequate pouching surface. A 2to 3-inch surface is thought to be advisable to obtain a pouching system seal.2 The marking disc was held over several possible sites. The right side of the abdomen would not provide a suitable stoma location because less than 2 inches of pouching surface was available. If the small bowel fistula were not resected during this surgery, the patient would not be able to see his stoma. The left side of the abdomen showed several Janice C. Colwell, RN, MS, CWOCN, is a Clinical Nurse Specialist in wound, ostomy and skin care at the University of Chicago Hospitals, Chicago, Illinois.