PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home 'tat1 ,, : 1, E a • ~ 1a11 I [ ~11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here

Actor Briefing

You are Lisa Flint, a 68 year old, who 6 months ago underwent an
emergency Hartmanns procedure for a perforation of the bowel
secondary to cancer.
You have been left with a defunctioning end colostomy.

Please be responsive to the candidate's requests, but do not give them

any verbal information other than to tell them you are not in pain if
asked.

Next question <+

v
 PassTheMRCS x ;i, - ~

,+
_,,__~_www
__.p_as_st h_e_m_rc_s._co_.u_kf_s_ta_tio_n_s/_14_6/_q_ue_st_io_n_s/_21_26_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _ _---:P]
_P~ ~ 1£:1 .. ~ • -A ~ • --
Pass the MRCS Ho me ' t a11, ,, : 11 E a ~ la ''' [ ~ 11 at ~ "'I' C>
- - - . . ...

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here

On general inspection
There is a midline laparotomy scar and a stoma in the left iliac fossa
The stoma bag is empty
The stoma is flush with the skin
It has a single lumen
It appears pink and there are no signs of ulceration/stenosis/necrosis
The surrounding skin looks healthy
There is an associated parastomal hernia

Inspect the patient for scars and the stoma for its site, contents, output,
condition, lumens, shape (spout or flush), the surrounding skin,
associated parastomal hernia and any prolapse or retraction.

Next question <+

v
 PassTheMRCS x ;i, - ~

,+
_,,__~_www
__.p_as_st_he_m_rc_s._co_.u_kf_s_ta_tio_n_s/_14_6/_q_ue_st_io_n_s/_21_27_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _ _---:P]
_P~ ~ 1£:1 .. ~ • -A ~ • --
Pass the MRCS Ho me ' t a11, ,, : 11 E a ~ la ''' [ ~ 11 at ~ "'I' C>

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
On palpation
When you insert a finger into the stoma it does not appear to be stenosed.
When you shine a pen torch into the stoma the mucosa is intact.

Digital stoma examination: remove bag and insert your finger into the
stoma to assess for patency and any stenosis.

Transilluminate to assess mucosa for ulcerations

Reattach the bag, thank the patient and wash your hands

Next question <+

v
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_12_8_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
·_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
What wou ld you do to complete your examination?

Abdominal examination
Inspect perineum for scars and patency of anus
Assess stoma position when standing and sitting

Next question -+ ]
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_12_9 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
Please present your findings

Mrs Flint has a single lumen stoma in the left iliac fossa . The stoma
itself looks healthy and is flush with the skin. There is no surrounding
skin irritation. The stoma bag is empty and I am unable to comment on
the stoma output rate. There is an associated parastomal hernia and a
midline laparotomy scar.

Next question <+

 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_130_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
Can you put all of this together to explain what has happened to Mrs Flint?

My findings are consistent with an end colostomy as a result of a

Hartmann's procedure.

Next question -+
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_13_1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
Why is this patient likely to have had this operation?

This procedure is carried out after emergency resection of rectosigmoid

lesions. The proximal end of bowel is made into an end colostomy to
defunction the distal bowel. The remaining distal rectal stump is over
sewn.

Next question -+
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_13_2_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
What are the two likely pathologies requiring a Hartmann's procedure?

Obstructing/perforated left sided bowel cancer

Perforated diverticulitis

Next question -.
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_13_3_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
Why didn't she have a primary anastomosis?

Primary anastomosis is unfavourable due to local inflammation, faecal

contamination/peritonitis making it more likely for the anastomosis to
fa il.

Next question -+ ]
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_13_4 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home 'tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11 at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here

What is a stoma?

A stoma is the Greek word meaning 'mouth' or 'opening' created to

connect a portion of the body cavity to the external environment.

Next question -+
 PassTheMRCS x ;i, - ~

,+.../-_~_www
__.p_as_st h_e_m_rc_s.c_o_.ukf_s_ta_tio_n_s/_14_6/_qu_e_sti_on_s/_21_35_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_ le _ _ _ _ _ _ _ _---:P]
_P~ ~ 1£:1 • ~ • ~ ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
How are stomas classified?

Loop v End

Temporary v Permanent

Anatomical site

Next question -+
 PassTheMRCS x ;i, - ~

,+.../-_~_www
__.p_as_st h_e_m_rc_s.c_o_.ukf_s_ta_tio_n_s/_14_6/_qu_e_sti_on_s/_21_36_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_ le _ _ _ _ _ _ _ _---:P]
_P~ ~ 1£:1 • ~ • ~ ~ • IE
Pass the MRCS Home 'tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11 at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
If the stoma was in the left upper quadrant, what type of stoma is it likely to
be?

Transverse loop co lostomy

Next question -+
 PassTheMRCS x ;i, - ~

,+
__./-_~_www
__.p_a_ss_th_em_r_cs_.c_o._ukf_s_ta_tio_n_s/_14_6/_qu_e_st_io_ns_/2_13_7_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_
BE
•_G_oog
_le_ _ _ _ _ _ _ _---:P]
~ .P ~ 1£:1 .. ~ • -A ~ • IE
Pass the MRCS Home ' tat1 ,, : 1, E a • ~ 1a11 I [ ~ 11at ~ 11t,, C>

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here

What is important to consider when siting an abdominal stoma?

It needs to be:
Away from bony prominences, dominant skin folds and scars.
Within the rectus abdominus muscle
Away from the belt line
Visible to the patient
Supplied w ith good vascu lature

Ensure to mark the site with the patient sitting and standing.

Next question <+

v
 PassTheMRCS x ;i, - ~

,+
__,,._~_www
__.p_a_ss_th_em_rc_s._co_.u_kf_s_ta_tio_n_s/_14_6_/q_u_es_ti_on_s_/2_1_38_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ~[_•
BE
_Goog
_l_e_ _ _ _ _ _ _ _ _---:P]
_P ~ ~ 1£:1 .. ~ • -A ~ • --
Pass the MRCS Ho me ' ta11, ,, : 11 E a ~ la''' [ ~ 11at ~ "'I' C>

Click here
What are the possible complications of a stoma?

Early
lschaemia/necrosis
High output +/- electrolyte imbalance
Retraction
Obstruction

Late
Obstruction
Stoma retraction or prolapse
Stenosis of the stoma
Parastomal hernia
Parastomal granulomas
Mucocutaneous separation
Fistula formation

Next question <+

v
Pass the MRCS Ho me · ·· = - - = - -· - · 0

Stoma Examination

Mrs Flint is a 68 year old lady who has undergone abdominal surgery and has a stoma. Please examine this patient's stoma.

Click here
Key Information

Introduction

Wash your hands

Introduce yourself
Permission - may I examine you today please?
Ask for a nurse chaperone
Ensure adequate privacy
Exposure - abdomen adequately exposed
Reposition - lie patient flat with one pillow
Ask the patient if they have any pain

Inspection

Inspect from the end of the bed and the patient's right hand side
-Site: quadrant
-Scars
-Contents - liquid stool (ileostomy), formed stool (colostomy), urine
(ileal conduit/urostomy/nephrostomy)
-Output - high, normal, low (high output is associated with ileostomies)
-Lumen - single (end stoma) or double (loop stoma)
-Type - Spout (ileostomy) or flush (colostomy)
-Stoma health - pink, necrotic ulcerations, stenotic
-Surrounding skin - erythematous, excoriation (usually as a resu lt of
ileostomy output)
-Retracted or prolapsed
-Parastomal herniation - ask the patient to lift their head off the bed

Palpation

-Digital stoma examination: remove bag and insert your finger into the
stoma to assess for patency and any stenosis.
-Transilluminate to assess mucosa for ulcerations
-Reattach the bag, thank the patient and wash your hands

Further considerations

-Abdominal examination
-Inspect perineum for scars and patency of anus
-Assess stoma position when standing and sitting

A Hartmann's Procedure is the surgical resection of the rectosimoid

colon with formation of an end colostomy and a distal rectal stump to
manage emergency presentations of obstructing/perforated left sided
colon cancer or perforated diverticulitis.

Primary anastamosis is avoided due to high fai lure rate associated with
co-existent inflammation/peritonitis.

A stoma is the Greek word meaning 'mouth' or 'opening' created to

connect a portion of the body cavity to the external environment

Stomas are classified by

Loop v End
Temporary v Permanent
Anatomical site

SITE STOMA
Right lower quadrant Colostomy
Left upper quadrant Transverse loop colostomy
Right iliac fossa lleostomy/Urostomy

Site a stoma:

Away from bony prominences, dominant skin folds and scars.

Within the rectus abdominus muscle
Away from the belt line
That is visible to the patient
It needs to have a good blood supply

Complications of a stoma:

Early
lschaemia/necrosis
High output +/- electrolyte imbalance
Retraction
Obstruction

Late
Obstruction
Stoma retraction or prolapse
Stenosis of the stoma
Parastomal hernia
Parastomal granulomas
Mucocutaneous separation
Fistula formation

,+ Return to module list