It is extremely important to have the patient marked for a stoma site preoperatively . This is most true in the obese patient and in the patient that has had previous open surgical incisions. If the patient should have a problem with the distal anastomosis and require diversion for longer than the normal 8 weeks postoperatively, it is imperative to have a stoma located in a location where the appliance will be able to adhere for at least 2-3 days. In patients in whom the ileal J-pouch anal anastomosis is constructed under tension, the superior mesenteric vessels and blood supply leading to the ileal J-pouch is tethered close along the patient's spine. This also tethers the vascular arcades along the anti-mesenteric border of the distal small bowel, so that it can be very difficult to mobilize a loop of bowel to create an end ileostomy. This will of course become easier as one proceeds proximally in the course of the small bowel. More proximal stoma placement will, however, be associated with higher volumes of ileostomy output. Unfortunately, in very heavy patients, the best external site for a loop ileostomy is often in the patient's right upper quadrant, requiring that the loop of bowel chosen for the stoma to be located much more proximally than one would wish.
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