procedures basic format: colon resection and anastomosis
TRANSCRIPT
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Procedures
Basic Format:
Colon Resection and Anastomosis
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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.
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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.
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Terms and Definitions: GI Surgery
• Adhesion• Anastomosis• Colon• Diverticula• Resection• Sphincter• Volvulus• Intussusception
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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
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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
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Anatomy/Blood Supply of Colon/Rectum
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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
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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
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Types of anastomoses
• Side to side
• End-to-end
• End-to-side
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Right Colectomy
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Right Hemicolectomy
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Transverse Colectomy
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Left Colectomy
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Left Hemicolectomy
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Abdominoperineal Resection
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Diagnostics: Exams
• Barium Enema
• IVP if renal involvement is suspected
• CT Scan/MRI
• Sigmoidoscopy/Colonoscopy
• Hemoccult/Guaiac
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Diagnostics: Preoperative Testing
• Medical History• Blood work (Normal values Alexander p. 338-339)
– CBC– Electrolytes– PT/PTT
• Urinalysis
• Chest-x ray
• ECG
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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
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Surgical Intervention: Anesthesia
• Method: General anesthesia
• Equipment: Typical monitors: BIS, Respirator, EKG, BP, warming blanket
• Anesthesia will insert a Nasogastric tube after intubation
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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
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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
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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)
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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
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Surgical Intervention: Supplies cont’d
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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)
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Surgical Intervention: Equipment
• General: Electrosurgical Unit, Suction
• Specific
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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
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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
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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!
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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.
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Counts
• Initial: Sponge, needle & blades, instruments, small items (bovie cleaner)
• First closing: Sponges, needles, blades• Final closing
– Sponges – Sharps– Instruments– Small items
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Dressing, Casting, Immobilizers, Etc.
• Types & sizes– 4 x 4’s and ABD for abdomen
• Type of tape or method of securing—silk or paper
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Specimen & Care
• Identified as specific type of colon
• Handled: routine, etc.– May receive specimen in a basin and keep
contained
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Postoperative Care
• Destination– PACU and med-surg unit
• Expected prognosis (Good, Depends on Dx)
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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
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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