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Stoma siting before APR: why a spot is marked on your tummy | CION Cancer Clinics
The mark on your tummy shows the surgeon where the stoma should come out. A stoma nurse draws it before an abdominoperineal resection, after watching how your tummy looks when you sit, stand and bend, and where your belt or petticoat cord sits. A well-chosen spot is easier to see, keeps a bag sealed for longer and leaks less. This page explains how the site is chosen and what to ask at that visit. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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The short answer
Why is a spot marked on your tummy before surgery?
The mark shows the surgeon where the stoma should come out. A stoma nurse draws it on your skin the day before, or the morning of, an abdominoperineal resection (APR), after watching how your tummy looks when you sit, stand and bend. A stoma placed on a well-chosen spot is easier to see, easier to keep a bag stuck to, and less likely to leak.
Why the surgeon does not simply choose during the operation
On the operating table you are flat, asleep and stretched out. Skin folds, the belt line and the way the tummy hangs when you sit are all invisible in that position. That is why the marking is done while you are awake and moving.
What the mark is, and what it is not
It is a small circle in permanent marker, usually on the lower left side of the tummy for a colostomy after APR, covered with a clear dressing so it survives the shower. It is the nurse's recommendation. The surgeon will use it if the inside of the tummy allows, and will move it only if there is a reason.
If nobody has marked you and your operation is tomorrow, ask. It is a short visit and it matters for years.What happens
How is the stoma site chosen?
A look at you lying down
The nurse finds the straight muscle that runs down each side of the tummy, called the rectus muscle. The stoma is planned to come out through this muscle, because that gives the strongest support around it later on.
Then sitting, standing and bending
You will be asked to sit on the edge of the bed, stand up, lean forward and twist. The nurse is watching where creases form and where the tummy folds over. A spot that disappears into a fold is crossed off.
Your clothes are checked
Where does your trouser belt sit? Where is the petticoat cord or the dhoti tie? Wear what you normally wear to this visit, because the mark needs to sit clear of anything that presses on the tummy all day.
You confirm you can see it
You need to be able to see the stoma without a mirror to change the bag on your own. If your tummy is large, the mark is placed higher than people expect, so that it is visible when you look down.
The mark is drawn and covered
A circle in permanent marker, sometimes two so the surgeon has a second choice, covered with a clear film. If it fades, tell the ward before you go to theatre.
Not sure whether this applies to you?
Ask an oncologistChoosing the spot
What a good stoma site keeps away from
Each of these makes the bag harder to stick or harder to keep sealed. The nurse is steering between all of them at once.
The belt line
A waistband or belt rubbing across the stoma all day loosens the seal and can injure the stoma. The mark usually sits below the belt line for trousers, and clear of a petticoat cord or dhoti knot for those who wear them.
Skin folds and creases
A bag will not stay stuck across a fold. When you sit, a stoma in a crease bends and leaks. This is why you are asked to sit and bend during the marking, and why the spot may look oddly placed while you are lying flat.
Old scars, the navel and bony points
Scars and the navel are uneven, so the baseplate lifts at the edge. The hip bone and the lower ribs are hard and move with you. The nurse keeps a flat margin of skin all the way round the planned circle.
Also avoided
- Skin that has had radiotherapy, if possible
- The planned line of the main cut
Anywhere you cannot see
If you cannot see the stoma, you cannot change the bag alone, and independence is the whole point. For someone with a large tummy or poor eyesight the site moves up, and for a wheelchair user it is marked while seated.
Tell the nurse about arthritis, a tremor or weak eyesight. It changes where the mark goes.Side by side
What a well-sited and a poorly-sited stoma feel like later
Well-sited stoma
Poorly-sited stoma
The bag stays on for its full wear time in most weather
Frequent leaks, especially when sitting or in summer
You can see it and change it on your own
You need a mirror or another person for every change
Clothes sit as they did before
Belts and cords press on it, so clothing has to change
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Commonly believed
Four things families ask about the mark
"The mark means the stoma is definitely happening."
For an APR, yes: a permanent colostomy is part of the operation and the mark is planning for it. For some other bowel operations a mark is drawn in case a stoma is needed and then never used. Ask your surgeon which applies to you.
"It should be as low down as possible, to hide it."
Low and hidden usually means in a fold, under a waistband and out of your own sight. A stoma you can see and keep sealed is far easier to live with than one hidden where it leaks. The nurse is choosing for the next twenty years, not for the mirror.
"The surgeon can put it anywhere the nurse marks."
Usually, but not always. If the bowel will not reach the marked spot comfortably, or scar tissue is in the way, the surgeon chooses the nearest safe place. That is why a second mark is sometimes drawn, and why the site is a plan, not a promise.
"An emergency operation can be marked just as well."
It often cannot, because there is no time and the patient is too unwell to sit and stand. Stomas made in an emergency are more often awkwardly placed for this reason. It is one of the practical advantages of planned surgery.
Being straight with you
What this page cannot tell you
It cannot tell you where your own stoma will be. That depends on your build, your clothes, the scars you already have and what the surgeon finds inside. The marking visit is where those things are weighed, and it is worth going to with the questions below rather than reading about it afterwards.
Questions worth asking at the marking
Ask to see the mark in a mirror while standing and sitting. Ask which bag type is planned and whether you can hold one now. If you wear a saree, a lungi or a dhoti every day, put it on and show the nurse where the cord sits.
If you were not marked
Some people reach the ward without a marking visit, particularly when surgery was arranged at short notice. Ask the ward nurse to arrange it before you go to theatre. If that is not possible, tell the surgeon where your belt sits and where you can see.
A stoma that is hard to manage after surgery is not your failure. Ask the stoma nurse about different bags, seals and belts before assuming nothing can be done.Questions we are asked
Common questions about stoma site marking
Who does the marking?
Usually a stoma care nurse, sometimes the surgeon. In many Indian hospitals the surgeon and the nurse do it together at the pre-operative visit. If nobody has mentioned it and your operation date is set, ask who will mark you and when.
Does the marking hurt or need any preparation?
No. It is a pen on skin and takes a short time. The only preparation is wearing the clothes you normally wear, so the nurse can see where a belt, cord or waistband sits. Bring your glasses if you use them, so you can confirm you can see the spot.
Why is the mark on the left side?
Because after an APR the end of the large bowel that is brought to the skin is on the left side of the body. The mark follows the bowel. For other operations, such as an ileostomy, the mark is usually on the right for the same reason.
Can I ask for the stoma to be somewhere else?
You can, and you should say if the mark sits under a cord or somewhere you cannot see. The nurse will explain why a spot was chosen and whether your preference is workable. Some preferences, such as very low placement, cause leaks later and will be explained rather than simply agreed to.
What if the mark washes off before surgery?
Tell the ward nurse as soon as you notice, and they will re-mark it or call the stoma nurse. Do not try to redraw it yourself from memory. The clear dressing over the mark is there to stop this happening, so leave it in place when you shower.
I have a big tummy. Will that be a problem?
It changes where the mark goes, not whether a stoma can be made. On a larger tummy the site usually sits higher than people expect, above the fold, so that you can see it and the bag lies flat. Convex bags and belts are also available if the stoma sits in a dip.
Will the stoma end up exactly where the mark is?
Usually close to it. The surgeon moves it only if the bowel will not reach or something inside is in the way, and a second mark is sometimes drawn as a fallback. If your stoma is not on the mark, ask why at the first follow-up so you understand the reason.
Can my son or daughter be there for the marking?
Yes, and it is a good idea if they will be helping with bag changes at first. They will see where the stoma will be and hear how it is chosen. Ask them to note the name of the stoma nurse and how to reach that person after you go home.
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Dr. Owais Mohammed
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Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
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Dr. Vinay Mamidala
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Sources
- Cancer Research UK — Living with a colostomy
- NHS — Colostomy: what happens
- Macmillan Cancer Support — Living with a stoma
- American Cancer Society — Colostomy guide
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Why some rectal cancers need a permanent stomaWhy the stoma is part of an APR at allParastomal hernia after APRThe bulge that a good site through the muscle helps preventThe days before your operationEverything else that happens in the same weekWorking and travelling with a permanent stomaWhy a stoma you can see and seal matters for yearsAbdominoperineal Resection (APR)The operation this page prepares you for
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Surgery booked and not yet marked?
Tell us your operation date and what has been planned so far. A CION stoma nurse or surgical oncologist will explain what should happen before the day. One helpline serves every CION centre.