Description of a Simple Method of Stoma Protection During Prone Positioning

Surgeries conducted with the patient in the prone position are frequent and can be lengthy. Abdominal stomas and suprapubic catheters require protection for the complete duration of the procedure to avoid complications such as stomal ischemia, bleeding, or mucocutaneous separation. Standard protection strategies such as pillows and wedges can easily fail.In the course of managing several patients who had sustained ostomy complications following surgery in a prone position, a simple method of stoma protection was devised. Instead of discarding the foam headrest typically used during induction by anesthesia staff, this device is placed with its central recess over the stoma and secured to the patient’s abdominal wall with gentle tape just before turning the patient into a prone position. This method, used in more than 80 patients, has been found to effectively relieve pressure, and no complications have been observed. The foam shape also enables unobstructed drainage of fluids, facilitating collection and preventing leakage and contamination of the surgical field. Because the device is widely used by anesthesia, it is readily available and does not add any extra cost.

The incidence of newly formed stomas is estimated to exceed 130,000 yearly, and the number of people in the United States currently living with an ostomy is estimated to be more than 1,000,000.¹ These include colostomies, ileostomies, jejunostomies, gastrostomies, and urostomies; the resulting stomas, as well as suprapubic catheters, generally are positioned on the anterior abdominal wall and can be temporary or permanent. Among the numerous indications for stoma creation are chronic or acute bowel obstruction, trauma or perforation, rectal cancer, radiation, inflammatory bowel diseases, bladder cancer, spinal cord injury, immobility, major surgery of the digestive tract, gastrectomy, and nutritional insufficiency.^2,3 

In the authors’ parent academic institution, prone positioning is commonly employed during trauma, orthopedic, plastic reconstructive, or neurosurgical interventions.⁴ Many surgical and nonsurgical interventions that require protracted periods of prone positioning can prove challenging when faced with a ventrally located conduit or stoma. This is particularly true with a newly created stoma. In addition to meticulous preventive efforts to protect delicate soft tissues such as those over bony prominences, eyes, and face, stoma protection also is needed to prevent complications due to compression, shearing, and inadequate drainage. The latter may lead to stomal injury and/or disruption of the appliance. Stoma complications can include ischemia, bleeding, dermatitis, retraction, and mucocutaneous separation.^5,6 To the authors’ knowledge, the incidence of stoma complications related to surgery has not been reported. However, the authors have observed that kinking of the collection bag may result in inadequate evacuation and drainage as well as inaccurate volumetric recording of output during surgical cases. Damaged or dislodged stomal appliances can result in contamination of the operative field and the surrounding tissues. 

Before considering using the foam head rest for ostomy protection, the senior author had cared for several patients who had suffered ostomy-related complications after prone positioning. These complications included cases of dislodgement of the collection system with local soilage and contamination of the surgical field as well as a case of dehiscence in a newly established stoma. On careful review, several cases showed evidence of local trauma to the stoma and/or hematoma formation following a surgical procedure that required prone positioning. These complications, observed during postoperative patient care and through staff discussions, developed despite careful efforts by the operative team to protect and offload the stoma with the use of pillows and cushions. During the procedure, cushions would migrate, shearing forces would manifest, and local injury, kinking of drains, or obstruction would complicate care management and ostomy integrity. In some observed cases, further supportive attempts utilizing a larger number of additional cushions for further intraoperative stoma protection posed the potential for attenuation of respiratory excursions in paralyzed patients and poor offloading of pressure points. 

Approximately a decade ago, the senior author developed a technique to protect the stoma when the patient is in the prone position. The technique involves using a standard foam headrest routinely utilized by anesthesia professionals. The headrest has a circular, central recess to stabilize the patient’s head and offload occipital pressure during the induction of anesthesia (see Figure 1). The largest diameter of the foam headrest usually utilized in the authors’ institution is 9 inches (228.6 mm), the diameter of the central recess is 4.5 inches (114.3 mm), and the height of the headrest is 2 inches (50.8 mm). When a patient with a stoma is transferred to a prone position, instead of discarding the device, it is repurposed to protect the stoma. 

The recessed portion of the foam serves as a repository for the stoma appliance and its contents, while the broad cylindrical foam cushion minimizes the likelihood of shearing and offloads compressive forces. The foam can easily be trimmed to fit nearly any stomal appliance or tubing, and given the wide variety available, this “one-size fits all” solution is particularly appropriate.

In the authors’ experience, use of the headrest appears to ensure safe and secure prone patient positioning, particularly if the clinician complies with the following guidelines (see Figure 2 and Figure 3): 

1. The clinicians should empty contents of the ostomy bag before the start of the procedure, either before or after the induction of anesthesia. This will minimize possible spillage and facilitate handling. 
2. The foam headrest should be oriented to surround the appliance. It may be trimmed to fit and accommodate effluent tubing.
3. If the stoma appliance is a bag, it can be accordion-folded into the foam’s central aperture or loosely inset so contents may still collect in the bag.
4. The clinician should ensure adequate space for the stoma appliance and the contents in the vertical plane.
5. Once the device is correctly placed, the foam should be secured to the abdominal wall with gentle tape.
6. Once the patient is positioned prone, the clinician should ensure the headrest is properly positioned with no compressive forces acting on either the stoma or headrest and that respiratory excursion is not impaired.

Protecting the stoma is a critical element in the care and positioning of the surgical patient. Injury to these delicate, surgically created structures can have serious consequences. Dislodgement of collection devices and/or soilage of the operative field can compromise the integrity of the surgical field and local tissues while impairing drainage and monitoring efforts of stool, urine, and drainage output.

In the authors’ experience, repurposing the patient’s normally discarded foam headrest has proven to be an effective method of protecting both the patient and his/her stoma during prone positioning. The headrests are readily available; they are repurposed to the same individual at no additional cost to the patient. The foam is easily customized to accommodate a wide variety of applications, tubing, and connectors. The cushion protects the stoma from both direct and indirect trauma, minimizing the likelihood of dislodgement, soilage, maceration, or surgical field contamination while affording drainage and output monitoring when required. The foam ring is disposable, used exclusively on the same patient as well as on intact skin, and never reused. This technique, developed a decade ago, has gained wide acceptance throughout the authors’ institution and over the past 5 years has been adopted by multiple surgical specialties for intraoperative stoma protection in prone positioning. The senior author has utilized this technique in 80 patients for a variety of challenges, particularly in patients who have suffered pressure ulcers as well as patients being treated for major abdominal and spinal injuries. 

Guidelines for pressure relief over bony prominences generally advocate against the use of dense foam products. Moreover, properly designed stomas should be positioned appropriately to decrease chances of pressure injury.⁷ The headrest ring itself does not alter the patient’s positioning and creates minimal pressure on surrounding areas. The authors utilize standard established supportive positioning methods for securing and protecting the patient with particular attention paid to bony prominences, soft tissue, neurovascular structures, and eye protection while optimizing respiratory excursion. As with the application of any medical device or intervention, individualized considerations and judicious management are accordingly prioritized in the care of patients.

The stoma cap offers a preventive option.⁸ However, the foam headrest affords several advantages. The stoma cap does not allow for continued evacuation, drainage, or monitoring of effluences (eg, in the case of a urostomy). In addition, stoma caps are hard, fixed, and insufficiently cushioned to reduce pressure on the stoma or the surrounding skin.⁷ Finally, the stomal cap incurs additional cost to the patient.

In more than a decade of use by the senior author, the authors have not noted any complications from the technique. On rare occasions, an additional piece of tape was needed before turning the patient into the prone position to secure the foam before the start of surgery and after prone positioning to ensure the device is properly positioned.

Many hospitals in the United States utilize the same type of foam headrest during the induction of anesthesia; therefore, it is commonly available, making this technique easily and potentially widely implementable.

In the authors’ experience, using the patient’s discarded foam headrest is an effective method to protect his/her stoma during prolonged surgery in the prone position. Since employing this technique, no stomal complications from surgery have been noted following surgery in prone-positioned patients. This method is inexpensive, easily applied, and involves equipment that is readily available.

Dr. Mackert is a plastic and reconstructive surgery resident, Department of Hand, Plastic, and Recontructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, University of Heidelberg, Heidelberg, Germany. Dr. Reid is a plastic and reconstructive surgery resident; Dr. Dobke is Chief; and Dr. Tenenhaus is a Clinical Professor, Department of Surgery, Division of Plastic Surgery, University of California San Diego Medical Center, San Diego, CA.

Please address correspondence to: Mayer Tenenhaus, MD, University of California San Diego, Department of Surgery, Division of Plastic Surgery, UC San Diego Medical Center, 200 W. Arbor Drive #8890, San Diego, CA 92103; email: m.tenenhaus@sbcglobal.net.