doi:10.1111/codi.12469
Original article
Stoma siting and the ‘arcuate line’ of Douglas: might it be of relevance to later herniation? H. Al-Momani, C. Miller and B. M. Stephenson Department of Surgery, Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Wales, UK Received 26 April 2013; accepted 30 August 2013; Accepted Article online 24 October 2013
Abstract Aim Preoperative stoma site marking aims to select an appropriate location for stoma positioning but there are no fixed anatomical points of reference. A stoma raised below the arcuate line (AL) of the posterior rectus sheath may be a contributing factor to later herniation.
or below the AL. Of 44 patients who had their site marked above the AL, 23 (53%) were within 2 cm of the AL. In obese patients and those with a waist circumference greater than 100 cm over 50% had their site marked at or within 2 cm of the AL.
Method The patients’ preferred position for a stoma was marked preoperatively by a nurse stomatherapist in 75 unselected cases. The position of the AL was determined in relation to standard anatomical landmarks (umbilicus, xiphoid process, pubic symphysis and the anterior superior iliac spines).
Conclusion To ensure a stoma site is above the AL of the posterior rectus sheath its centre should be at least 4 cm above a horizontal line between the anterior superior iliac spines. This might reduce later herniation rates.
Results The proportion of patients whose stoma trephine was sited below the AL varied with the anatomical landmark examined. Measurements of symphysis pubis to xiphoid process or height above the iliac spines revealed 36 41% of chosen sites were at or below the AL. In 16 of 29 (55%) women the marked sites were at
Introduction Preoperative stoma marking aims to locate the most appropriate site. Stomatherapists are trained to place it within the linea semilunaris at the outer border of the rectus abdominis muscle, to be away from scars, creases, bony prominences and the belt line. The siting is essentially a joint decision between patient and stomatherapist but there are no fixed anatomical points of reference. The absolute position of the stoma site, however, is the responsibility of the operating surgeon. The posterior sheath of the rectus abdominis muscle ends at a variable level below the umbilicus. The arcuate Correspondence to: Brian M. Stephenson, MS, FRCS, Department of Surgery, Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Wales NP20 2UB, UK. E-mail: [email protected] This work was presented at the British Hernia Society, Manchester, October 2012.
Keywords Stoma siting, posterior rectus sheath, arcuate line, parastomal herniation, prevention What does this paper add to the literature? This is the first study to examine the stoma site with regard to the anatomy of the anterior abdominal wall and indicates that the position of a traditionally sited trephine may contribute to later parastomal herniation.
line (AL) of Douglas, named after the renowned Scottish obstetrician and anatomist James Douglas, is not always well defined. However, this transition in the integrity of the posterior aspect of the anterior abdominal wall is clinically relevant. In another context it is prudent to ascertain the location of the AL to reduce later abdominal wall weakness, bulging and herniation when harvesting rectus abdominis myocutaneous flaps [1]. The AL is traditionally described as lying approximately halfway between the umbilicus and the symphysis pubis [2] but according to Rizk, another anatomist, it may not exist at all [3]. However, recent cadaveric [4,5] and post-mortem [6] dissections have questioned this dilemma. Using surface anatomical landmarks the consensus reached by these contemporary studies [4–6], in over 200 dissections, is not only that the AL exists but that it is in fact much higher than conventionally taught. Given that the presence of a posterior rectus sheath at the site of a stoma should lessen the chance of
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 141–143
141
H. Al-Momani et al.
Stoma siting and the ‘arcuate line’ of Douglas
a later parastomal hernia we examined the relationship between marked stoma sites and the AL of Douglas.
Method Prior to various elective operations that might necessitate a stoma, patients were seen by one of three stomatherapy nurses and the site of a stoma was marked in the usual fashion. The centre of the site, agreed by patient and nurse, was then measured by two of the authors with respect to specific anatomical landmarks including the pubic symphysis (PS), xiphoid process (Xi), umbilicus (Umbo) and the anterior superior iliac spine (ASIS). The surface marking of the AL of Douglas can be defined by these landmarks [4,5] and includes a ratio of the distance between either the pubic symphysis to the xiphoid process (PS-Xi), the pubic symphysis to the umbilicus (PS-Umbo) and the distance above a line between both ASISs. The most commonly documented position of the AL, as previously reported [4,5], is outlined in Table 1.These distances and ratios allowed calculation of the relative position of the marked stoma site and the AL as illustrated in Fig. 1.
A
B
Results After siting by the nurse stomatherapist, 75 consecutive unselected patients (46 men, mean age 62, range 21 84 years) were measured with respect to the surface markings of the AL. The indication for surgery was colorectal malignancy in 41 (55%). The median body mass index (BMI) of the patients was 26.5 (19 40) kg/m2 and their median waist circumference was 86.4 (71 112) cm. The centre of the proposed stoma trephine had been marked at or below the AL in a variable percentage of patients depending on the anatomical landmarks used to define the AL (Table 2). This varied most (11 29%) when the distance between the pubic symphysis and umbilicus was used as the indicator of the AL. When measurements of the pubic symphysis to the xiphoid Table 1 Position of the arcuate line of Douglas (AL). References
PS-Xi*, %
PS-Umbo†, %
ASIS‡
Cunningham et al. [4] Loukas et al. [5]
32.7 33.9
74.6 70.2
1.8 2.1
*Ratio of distance of pubic symphysis (PS) to xiphoid (Xi) process (cm). †Ratio of distance of pubic symphysis to umbilicus (Umbo) (cm). ‡Distance above a line between the two anterior superior iliac spines (ASIS) in centimetres.
142
Figure 1 Representation of anterior abdominal wall; filled black circle is marked site of stoma, A is the distance (cms) from Xiphoid process (Xi) to symphysis pubis (PS) and B is the distance (cms) from umbilicus (Umbo) to PS.
process or the height above the anterior superior iliac spines were used as the indicator of the AL there was no disagreement between the two data sets. Table 2 Marked stoma site with respect to landmarks of the arcuate line (AL) in 75 patients. References
PS-Xi
Cunningham et al. [4] Above AL >2 cm 47 2 cm 44 30 kg/m2) the site was at the AL in 14 (67%) and above it in seven (three within 2 cm). In 12 patients with a waist circumference greater than 100 cm six had the stoma site marked at the AL and six above it (four within 2 cm).
Stoma siting and the ‘arcuate line’ of Douglas
hernias irrespective of whether a mesh had or had not been used at closure [1]. A low parastomal hernia rate, at least in the short term, has been reported where the stoma trephine has been purposely positioned well above the AL [8]. In summary our results suggest that a stoma trephine might be best marked at least 4 cm above a horizontal line between both anterior iliac spines. We appreciate that future clinical studies will be required to confirm or refute these observations.
Discussion There are many reasons why a patient may later develop a weakness, bulge or hernia at the site of their stoma. However and despite the careful construction of a stoma, which equates to an ‘iatrogenic’ hernia, it is often difficult to fathom why some patients subsequently develop herniation. Indeed we have all been taken aback at the size of the abdominal wall defect when we repair a symptomatic hernia around a stoma that we had constructed so very carefully. Is it serendipity alone or had the stoma been raised below the AL of Douglas? Although this last question is difficult to answer it may well be part of the quandary. To the best of our knowledge the present study is the first to look at the relationship between a stoma site agreed by patient and stomatherapist and the anatomical landmarks of the AL. We found that the centre of the proposed stoma trephine had been marked at or below the surface markings of the AL in at least a third of patients. In addition, of those who had the site marked above the AL, many were within 2 cm of the AL. In other words an alarmingly high proportion of planned stoma sites (40% or more) might have been sited in a position where there was no posterior sheath. In addition, in obese patients and those with a waist circumference over 100 cm [7], there was a tendency for the site to have been marked either at the exact level or just above the AL. Our observations have several limitations. Despite our findings and interpretation that a stoma sited above the AL might be related to a lower incidence of later herniation, we have no firm evidence for this. Furthermore the anatomical landmarks of the AL may vary in different ethnic groups [6] and cadaveric and postmortem studies may not be an ideal group for comparison [4–6]. Furthermore the exact position of the AL was not identified at surgery. Nevertheless the clinical importance of being able accurately to locate the AL derives from the need to know where the stoma is in relation to the abdominal wall [4] which may be related to the closure of any defects. Complications that may occur during post-TRAM follow-up are most commonly
Acknowledgements We are grateful to our nurse stomatherapists, Anne Gibbon, Jayne Coyne and Karen Perry, for informing us of the patients that they were asked to see. We would also like to thank our medical illustrator Jan Sharp.
Conflict of interest None declared.
Author contributions BS was responsible for conception of the study. H A-M and CM collected and analysed the data and wrote the paper with BS. All authors reviewed and approved the manuscript.
References 1 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124: 752–64. 2 Sinnatamby CS. (2000 10th edtion) Last’s Anatomy, pp. 218–9. Churchill Livingstone, Edinburgh. 3 Rizk NN. The arcuate line of the rectus sheath does it exist? J Anat 1991; 175: 1–6. 4 Cunningham SC, Rosson GD, Lee RH et al. Localization of the arcuate line from surface anatomic landmarks: a cadaveric study. Ann Plast Surg 2004; 53: 129–31. 5 Loukas M, Myers C, Shah R et al. Arcuate line of the rectus sheath: clinical approach. Anat Sci Int 2008; 83: 140–4. 6 Mwachaka PM, Saidi HS, Odula PO, Awori KO, Kaisha WO. Locating the arcuate line of Douglas: is it of surgical relevance? Clin Anat 2010; 23: 84–6. 7 De Raet J, Delvaux G, Haentjens P, Van Nieuwenhove Y. Waist circumference is an independent risk factor for the development of parastomal hernia after permanent colostomy. Dis Colon Rectum 2008; 51: 1806–9. 8 Evans MD, Thomas C, Beaton C, Williams GL, McKain ES, Stephenson BM. Lowering the incidence of stomal herniation: further follow up of the lateral rectus abdominis positioned stoma. Colorectal Dis 2011; 13: 716–7.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 141–143
143
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Original article
Stoma siting and the ‘arcuate line’ of Douglas: might it be of relevance to later herniation? H. Al-Momani, C. Miller and B. M. Stephenson Department of Surgery, Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Wales, UK Received 26 April 2013; accepted 30 August 2013; Accepted Article online 24 October 2013
Abstract Aim Preoperative stoma site marking aims to select an appropriate location for stoma positioning but there are no fixed anatomical points of reference. A stoma raised below the arcuate line (AL) of the posterior rectus sheath may be a contributing factor to later herniation.
or below the AL. Of 44 patients who had their site marked above the AL, 23 (53%) were within 2 cm of the AL. In obese patients and those with a waist circumference greater than 100 cm over 50% had their site marked at or within 2 cm of the AL.
Method The patients’ preferred position for a stoma was marked preoperatively by a nurse stomatherapist in 75 unselected cases. The position of the AL was determined in relation to standard anatomical landmarks (umbilicus, xiphoid process, pubic symphysis and the anterior superior iliac spines).
Conclusion To ensure a stoma site is above the AL of the posterior rectus sheath its centre should be at least 4 cm above a horizontal line between the anterior superior iliac spines. This might reduce later herniation rates.
Results The proportion of patients whose stoma trephine was sited below the AL varied with the anatomical landmark examined. Measurements of symphysis pubis to xiphoid process or height above the iliac spines revealed 36 41% of chosen sites were at or below the AL. In 16 of 29 (55%) women the marked sites were at
Introduction Preoperative stoma marking aims to locate the most appropriate site. Stomatherapists are trained to place it within the linea semilunaris at the outer border of the rectus abdominis muscle, to be away from scars, creases, bony prominences and the belt line. The siting is essentially a joint decision between patient and stomatherapist but there are no fixed anatomical points of reference. The absolute position of the stoma site, however, is the responsibility of the operating surgeon. The posterior sheath of the rectus abdominis muscle ends at a variable level below the umbilicus. The arcuate Correspondence to: Brian M. Stephenson, MS, FRCS, Department of Surgery, Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Wales NP20 2UB, UK. E-mail: [email protected] This work was presented at the British Hernia Society, Manchester, October 2012.
Keywords Stoma siting, posterior rectus sheath, arcuate line, parastomal herniation, prevention What does this paper add to the literature? This is the first study to examine the stoma site with regard to the anatomy of the anterior abdominal wall and indicates that the position of a traditionally sited trephine may contribute to later parastomal herniation.
line (AL) of Douglas, named after the renowned Scottish obstetrician and anatomist James Douglas, is not always well defined. However, this transition in the integrity of the posterior aspect of the anterior abdominal wall is clinically relevant. In another context it is prudent to ascertain the location of the AL to reduce later abdominal wall weakness, bulging and herniation when harvesting rectus abdominis myocutaneous flaps [1]. The AL is traditionally described as lying approximately halfway between the umbilicus and the symphysis pubis [2] but according to Rizk, another anatomist, it may not exist at all [3]. However, recent cadaveric [4,5] and post-mortem [6] dissections have questioned this dilemma. Using surface anatomical landmarks the consensus reached by these contemporary studies [4–6], in over 200 dissections, is not only that the AL exists but that it is in fact much higher than conventionally taught. Given that the presence of a posterior rectus sheath at the site of a stoma should lessen the chance of
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 141–143
141
H. Al-Momani et al.
Stoma siting and the ‘arcuate line’ of Douglas
a later parastomal hernia we examined the relationship between marked stoma sites and the AL of Douglas.
Method Prior to various elective operations that might necessitate a stoma, patients were seen by one of three stomatherapy nurses and the site of a stoma was marked in the usual fashion. The centre of the site, agreed by patient and nurse, was then measured by two of the authors with respect to specific anatomical landmarks including the pubic symphysis (PS), xiphoid process (Xi), umbilicus (Umbo) and the anterior superior iliac spine (ASIS). The surface marking of the AL of Douglas can be defined by these landmarks [4,5] and includes a ratio of the distance between either the pubic symphysis to the xiphoid process (PS-Xi), the pubic symphysis to the umbilicus (PS-Umbo) and the distance above a line between both ASISs. The most commonly documented position of the AL, as previously reported [4,5], is outlined in Table 1.These distances and ratios allowed calculation of the relative position of the marked stoma site and the AL as illustrated in Fig. 1.
A
B
Results After siting by the nurse stomatherapist, 75 consecutive unselected patients (46 men, mean age 62, range 21 84 years) were measured with respect to the surface markings of the AL. The indication for surgery was colorectal malignancy in 41 (55%). The median body mass index (BMI) of the patients was 26.5 (19 40) kg/m2 and their median waist circumference was 86.4 (71 112) cm. The centre of the proposed stoma trephine had been marked at or below the AL in a variable percentage of patients depending on the anatomical landmarks used to define the AL (Table 2). This varied most (11 29%) when the distance between the pubic symphysis and umbilicus was used as the indicator of the AL. When measurements of the pubic symphysis to the xiphoid Table 1 Position of the arcuate line of Douglas (AL). References
PS-Xi*, %
PS-Umbo†, %
ASIS‡
Cunningham et al. [4] Loukas et al. [5]
32.7 33.9
74.6 70.2
1.8 2.1
*Ratio of distance of pubic symphysis (PS) to xiphoid (Xi) process (cm). †Ratio of distance of pubic symphysis to umbilicus (Umbo) (cm). ‡Distance above a line between the two anterior superior iliac spines (ASIS) in centimetres.
142
Figure 1 Representation of anterior abdominal wall; filled black circle is marked site of stoma, A is the distance (cms) from Xiphoid process (Xi) to symphysis pubis (PS) and B is the distance (cms) from umbilicus (Umbo) to PS.
process or the height above the anterior superior iliac spines were used as the indicator of the AL there was no disagreement between the two data sets. Table 2 Marked stoma site with respect to landmarks of the arcuate line (AL) in 75 patients. References
PS-Xi
Cunningham et al. [4] Above AL >2 cm 47 2 cm 44 30 kg/m2) the site was at the AL in 14 (67%) and above it in seven (three within 2 cm). In 12 patients with a waist circumference greater than 100 cm six had the stoma site marked at the AL and six above it (four within 2 cm).
Stoma siting and the ‘arcuate line’ of Douglas
hernias irrespective of whether a mesh had or had not been used at closure [1]. A low parastomal hernia rate, at least in the short term, has been reported where the stoma trephine has been purposely positioned well above the AL [8]. In summary our results suggest that a stoma trephine might be best marked at least 4 cm above a horizontal line between both anterior iliac spines. We appreciate that future clinical studies will be required to confirm or refute these observations.
Discussion There are many reasons why a patient may later develop a weakness, bulge or hernia at the site of their stoma. However and despite the careful construction of a stoma, which equates to an ‘iatrogenic’ hernia, it is often difficult to fathom why some patients subsequently develop herniation. Indeed we have all been taken aback at the size of the abdominal wall defect when we repair a symptomatic hernia around a stoma that we had constructed so very carefully. Is it serendipity alone or had the stoma been raised below the AL of Douglas? Although this last question is difficult to answer it may well be part of the quandary. To the best of our knowledge the present study is the first to look at the relationship between a stoma site agreed by patient and stomatherapist and the anatomical landmarks of the AL. We found that the centre of the proposed stoma trephine had been marked at or below the surface markings of the AL in at least a third of patients. In addition, of those who had the site marked above the AL, many were within 2 cm of the AL. In other words an alarmingly high proportion of planned stoma sites (40% or more) might have been sited in a position where there was no posterior sheath. In addition, in obese patients and those with a waist circumference over 100 cm [7], there was a tendency for the site to have been marked either at the exact level or just above the AL. Our observations have several limitations. Despite our findings and interpretation that a stoma sited above the AL might be related to a lower incidence of later herniation, we have no firm evidence for this. Furthermore the anatomical landmarks of the AL may vary in different ethnic groups [6] and cadaveric and postmortem studies may not be an ideal group for comparison [4–6]. Furthermore the exact position of the AL was not identified at surgery. Nevertheless the clinical importance of being able accurately to locate the AL derives from the need to know where the stoma is in relation to the abdominal wall [4] which may be related to the closure of any defects. Complications that may occur during post-TRAM follow-up are most commonly
Acknowledgements We are grateful to our nurse stomatherapists, Anne Gibbon, Jayne Coyne and Karen Perry, for informing us of the patients that they were asked to see. We would also like to thank our medical illustrator Jan Sharp.
Conflict of interest None declared.
Author contributions BS was responsible for conception of the study. H A-M and CM collected and analysed the data and wrote the paper with BS. All authors reviewed and approved the manuscript.
References 1 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124: 752–64. 2 Sinnatamby CS. (2000 10th edtion) Last’s Anatomy, pp. 218–9. Churchill Livingstone, Edinburgh. 3 Rizk NN. The arcuate line of the rectus sheath does it exist? J Anat 1991; 175: 1–6. 4 Cunningham SC, Rosson GD, Lee RH et al. Localization of the arcuate line from surface anatomic landmarks: a cadaveric study. Ann Plast Surg 2004; 53: 129–31. 5 Loukas M, Myers C, Shah R et al. Arcuate line of the rectus sheath: clinical approach. Anat Sci Int 2008; 83: 140–4. 6 Mwachaka PM, Saidi HS, Odula PO, Awori KO, Kaisha WO. Locating the arcuate line of Douglas: is it of surgical relevance? Clin Anat 2010; 23: 84–6. 7 De Raet J, Delvaux G, Haentjens P, Van Nieuwenhove Y. Waist circumference is an independent risk factor for the development of parastomal hernia after permanent colostomy. Dis Colon Rectum 2008; 51: 1806–9. 8 Evans MD, Thomas C, Beaton C, Williams GL, McKain ES, Stephenson BM. Lowering the incidence of stomal herniation: further follow up of the lateral rectus abdominis positioned stoma. Colorectal Dis 2011; 13: 716–7.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 141–143
143
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
