colorectal surgery and stomas

Abdominal Surgery and StomasCaroline TaylorOctober 2011

Content•Large bowel anatomy

•Common abdominal procedures

•Complications of surgery

•Stomas

•Complications of stomas

Surgical terms•Laparotomy

•Laparoscopy

Gross anatomy of the bowel

Blood supply of the colon

Colorectal cancers•Right sided

▫Present with anaemia, weight loss, mass▫Later presentation

•Left sided▫Present with altered bowels▫PR bleeding

Dukes staging•A mucosa of the colon or rectum

•B through the muscular propria

•C spread to at least one lymph node in the area

•D metastatic spread

Operations for colorectal cancers•Right Hemicolectomy

•Left Hemicolectomy

•Anterior resection

•Abdomino-perineal resection (APR)

•Hartmann’s procedure

Right hemicolectomy

•Ascending colon, appendix and part of transverse colon

•Superior mesenteric artery

•Ileocolic anastomosis

Left hemicolectomy•Transverse colon and descending colon

•Inferior mesenteric artery

•Primary anastomosis

Anterior resection•=sigmoid colectomy

•Sigmoid colon and part ofrectum

•Primary anastomosis orstoma formations

Abdomino-perineal resection (APR)•Low rectal tumours

•Associated total mesorectal excision (TME)

•Anus closed and rectum removed

•Colostomy formation

Hartmann’s Procedure•Emergency procedure

▫Rests the bowel▫If anastomosis will be poor

•Sigmoid colectomy•Oversewn rectum to form a stump•End colectomy•Reversible

Complications of surgery•Anastomotic leak•Infection/abscess/collection•Bleeding•Paralytic Ileus•Adhesions / stricture formation•Fistulas

Anastomotic leak•7-10 days post-op•Higher risk with lower anastomosis•Contributing factors:

▫Surgeon▫Patient – male▫Pre-op radiotherapy

•Leads to pelvic abscess, fistulation, peritonitis, mortality

Paralytic Ileus•Bowel “goes to sleep!”

•Caused by toxins or handling

•Conservative management

•Most spontaneously resolve

Stomas•“mouth”

•Ileostomy or colostomy (gastrostomy, urostomy)

•To divert faeces from anastomosis or fistula

•Due to removal of distal colon and rectum

Ileostomy•Small bowel

•Right sided

•Spouted

•Temporary – usually a loop•Permanent – usually an end ileostomy

End and loop ileostomies

Colostomies•Large bowel

•Loop or end

•Where rectum or anal canal is not suitable for passing faeces▫Such as abdominal surgery/cancer▫Crohn’s/UC

•Left sided (can be anywhere)

Complications of stomas•Bleeding•Prolapse or retraction•Stenosis•Skin excoriation•Parastomal hernias•Fistulation

Ileostomy v. colostomyFeature Ileostomy Colostomy

Bowel Small Large

Contents Liquid, bilious colour Solid, feculent

Opening Spout Flush to skin

Site Right/higher Left/lower

Output Large vol Small vol

Summary•Large bowel anatomy is key in deciding

on the appropriate operation

•Common surgical procedures

•Ileostomies and colostomies and their differences and complications

Any Questions??