Procedures

Basic Format:

Colon Resection and Anastomosis

Objectives

• Assess the anatomy, physiology, and pathophysiology of the colon

• Analyze the diagnostic and surgical interventions for a patient undergoing a colon resection

• Plan the intraoperative course for a patient undergoing colon resection

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position• Identify the incision used for the procedure• Analyze the procedural steps for colon resection• Describe the care of the specimen• Discuss the postoperative considerations for a

patient undergoing colon resection.

Terms and Definitions: GI Surgery

• Adhesion• Anastomosis• Colon• Diverticula• Resection• Sphincter• Volvulus• Intussusception

Definition/Purpose of Procedure

• Ablative: To remove diseased tissue• Diagnostic: To determine or confirm

diagnosis• Reasons: ileocecal disease, strangulated

bowel, colorectal cancer, perforation, ulcerative colitis, polyp and diverticular disease, mesenteric disease, obstruction, fistula excision, stoma formation

Relevant A & P: Small Intestine and Colon

• Small intestine– Begins at pyloric

sphincter– Duodenum– Jejunum – Ileum– Mesenteric small

intestine

• Colon– Cecum

• Appendix

– Ascending colon– Transverse colon– Descending colon– Rectum, anus

Anatomy/Blood Supply of Colon/Rectum

Pathophysiology

• Pseudomembranous enterocolitis– Inflammation of the small or large bowel, usually as a result of an

infective disease. The most common causative organisms include rotaviruses and other enteric viruses and other enteric viruses, including Salmonella, E. Coli, Shigella, Campylorbacter, and Yersinia species. A potentially severe presentation, Pseudomembranous enterocolitis, may be induced by prolonged use of antibiotics allowing overgrowth of Clostridium difficile.

• Polyps

Pathophysiology

• Mechanical Lesions– Large bowel obstruction

• Band/adhesion

• Malignancy

– Volvulus

– Intussussception

– Fecal Impaction

• Trauma: Blunt and Penetrating

• Inflammatory: Diverticulosis/Diverticulitis, Ulcerative Colitis, Crohn’s disease

• Vascular: Ischemic colitis, vascular occlusion/infarction

arterio-venous malformation

Types of anastomoses

• Side to side

• End-to-end

• End-to-side

Right Colectomy

Right Hemicolectomy

Transverse Colectomy

Left Colectomy

Left Hemicolectomy

Abdominoperineal Resection

Diagnostics: Exams

• Barium Enema

• IVP if renal involvement is suspected

• CT Scan/MRI

• Sigmoidoscopy/Colonoscopy

• Hemoccult/Guaiac

Diagnostics: Preoperative Testing

• Medical History• Blood work (Normal values Alexander p. 338-339)

– CBC– Electrolytes– PT/PTT

• Urinalysis

• Chest-x ray

• ECG

Surgical Intervention:Special Considerations

• Patient Factors– Intestinal antisepsis/Bowel prep– SCD’s to prevent DVT

• Room Set-up• Special Bowel Technique

– The intestinal tract is considered contaminated– Second set up after bowel is closed using basic/minor

procedures tray– Drop technique vs Clean closure technique

• Instruments used on the colon are isolated in basin

Surgical Intervention: Anesthesia

• Method: General anesthesia

• Equipment: Typical monitors: BIS, Respirator, EKG, BP, warming blanket

• Anesthesia will insert a Nasogastric tube after intubation

Surgical Intervention: Positioning

• Position during procedure: Supine with arms on armboards

• Supplies and equipment: Ask re: insertion of foley. Apply electrodispersive pad

• Special considerations: high risk areas: For geriatric, pay particular attention to skin and joints

Surgical Intervention: Skin Prep

• Method of hair removal: Clipper or wet

• Anatomic perimeters: Traditional abdominal from nipple line across chest from table side to table side to mid-thigh

• Solution options: Betadine or alternate: Hibiclens

Surgical Intervention: Draping/Incision

• Types of drapes: Laparotomy T-Sheet

• Order of draping: 4 towels; T-Sheet

• Special considerations

• State/Describe incision – usually midline for best exposure to all segments of

bowel (may depend on location of lesion—could be paramedian or oblique)

Surgical Intervention: Supplies

• General: Basin set, Blades (3) # 10 & (1) # 15, ESU pencil, suction tubing, needle magnet or counter, hemoclips (all sizes); Staples (optional)

• Specific– Suture: have ample supply of free ties of surgeon’s choice. Sizes

2-0 and 3-0 silk are most common. For the anastomosis: Fine silk suture release needles are common (4-0 on CR pack of 8)

– Medications on field (name & purpose)

– Catheters & Drains: may use Penrose drain for retraction

Surgical Intervention: Supplies cont’d

Surgical Intervention: Instruments

• General– Major tray, Long instruments tray, Gastrointestinal

procedures tray

• Specific– Hemoclip appliers, Automatic Stapling Devices (as

requested), Harrington Retractor, Large self-retaining retractor

• What goes on your Mayo stand? – (See Mayo Stand Set-up text)

Surgical Intervention: Equipment

• General: Electrosurgical Unit, Suction

• Specific

Common Features/Principles of Resection and Anastomosis

• Supine position• Midline exposure• Adequate retraction is a must• General anesthesia• Affected bowel must be mobilized (freed)• Pathological tissue is removed with a margin of some

healthy tissue• An adequate blood supply to the remaining bowel must

exist• Relatively equal diameter segments of bowel should be

sewn together

Common Features/Principles of Resection and Anastomosis

• The anastomosis should be tension-free and leak-proof

• The mesenteric defect is closed

• Functional and anatomical continuity is maintained

Surgical Intervention: Procedure Highlights / Steps

• Abominal Incision is created, Achieve Hemostasis, Retract

• Diseased portion of bowel is identified and isolated

• The bowel is cross-clamped and divided

• An end-to-end anastomosis is performed

• Irrigate, Hemostasis, Close Wound in Layers

Be sure to use multiple resources: concise but complete!

Surgical Intervention: Procedure Steps Cont’d

• Anastomosis: assistant places the 2 bowel ends in close approximation and the first layer of interrupted sutures is placed with fine silk CR suture.

Counts

• Initial: Sponge, needle & blades, instruments, small items (bovie cleaner)

• First closing: Sponges, needles, blades• Final closing

– Sponges – Sharps– Instruments– Small items

Dressing, Casting, Immobilizers, Etc.

• Types & sizes– 4 x 4’s and ABD for abdomen

• Type of tape or method of securing—silk or paper

Specimen & Care

• Identified as specific type of colon

• Handled: routine, etc.– May receive specimen in a basin and keep

contained

Postoperative Care

• Destination– PACU and med-surg unit

• Expected prognosis (Good, Depends on Dx)

Postoperative Care• Potential complications

– Hemorrhage– Infection—greater chance of sepsis and obstruction– Key: Ureteral injury, thromboembolism– Other: Depends on type of colectomy – Rt hemicolectomy: Damage to Right ureter, duodenum, inferior

vena cava, common bile duct– Tranverse colectomy: Damage to stomach, pancreas, spleen,

superior mesenteric vessels

• If formation of colostomy, complications assoc w/stoma construction and maintenance.

• Surgical wound classification– 2 to 4

Resources

• Alexander pp. 378-383

• Berry & Kohn pp. 658-663

• Fuller pp. 256- 258

• STST Ch 14 pp. 425-426

• MAVCC Unit 4 Information Sheets

• Taber’s Cyclopedic Medical Dictionary