LAPAROSCOPY Colectomy

laparoscopy Colectomy

The Condition

A colectomy is the removal of a section of the large intestine (colon) or bowel. This operation is done to treat diseases of the bowel, including Crohn’s disease and ulcerative colitis; and colon cancer

common symptoms?

Symptoms may include diarrhea, constipation, abdominal cramps, nausea, fever, chills, weakness, or loss of appetite and/or weight loss, or bleeding

There may be no symptoms. This is why screening is essential.

Treatment Options

Surgical procedure

open colectomy An incision is made in the abdomen and the section of the diseased colon is removed. The two divided ends of the colon are sutured (sewn) or stapled together in an anastomosis. If the colon cannot be sewn back together, it is brought up through the abdomen to form a colostomy

laparoscopic colectomy A light,camera, and instruments are inserted through small holes in the abdomen to remove the diseased colon or tumor.

Non-surgical procedure

Some diseases of the colon are treated with antibiotics, steroids, or drugs that affect the immune system

Benefits and Risks of Your Operation

Benefits—Removal of diseased or cancerous sections of the intestine will relieve your symptoms and can reduce your risk of dying from cancer

Risks of not having an operation—Your symptoms may continue or worsen, and your disease or cancer may spread

possible risks include temporary problems with the intestine that may require a stoma; leakage from the colon into the abdomen; lung problems including pneumonia; infection of the wound, blood, or urinary system; blood clots in the veins or lung; bleeding; fistula; or death.

Expectations

Before your operation—Evaluation may include a colonoscopy, blood work, urinalysis, chest X-ray, or CAT Scan (CT) of the abdomen. 1 Your surgeon and the anesthesia provider will discuss your health history, home medications, and postoperative pain control options

The day of your operation—You will not eat for 4 hours but may drink clear liquids up to 2 hours before the operation. Medication to clean out your intestines and an antibiotic may be started the day before. Most often you will take your normal medication with a sip of water.

Your recovery—The average length of stay is 3 days for a laparoscopic or open colectomy. 2 The time from your first bowel movement to eating normally is about 3 to 4 days

Call your surgeon if you have continued nausea, vomiting, leakage from the wound, blood in the stool, severe pain, stomach cramping, chills, or a high fever (over 101°F or 38.3°C), odor or increased drainage from your incision, a swollen abdomen or no bowel movements for 3 days.

The Condition, Symptoms, and Diagnostic Tests

The Condition

There are different types of conditions and diseases that may affect the intestine

Inflammatory bowel diseases include ulcerative colitis and Crohn’s disease.

Ulcerative colitis presents as ulcers (tiny open sores) in the inner layer of the colon and includes bloody diarrhe

Crohn’s disease is the infl ammation of the entire lining of the digestive tract, with 15% of cases in the colon only. This usually presents with continual diarrhea and abdominal pain.

Diverticulitis is an infl ammation or infection of small, bulging pouches (diverticula) located in the colon.

Colorectal polyp is any growth on the lining of the colon or rectum.

Colorectal cancer is a malignant (cancerous) tumor in the colon or rectum.

Procedure

There are diff erent procedures to treat diseases of the bowel and intestines:

A colectomy is an operation to remove a part of the intestine (bowel) that is diseased. The name of the procedure depends on what section of the intestine is removed.

Right hemicolectomy is the removal of the ascending (right) colon.

Left hemicolectomy is the removal of the descending (left) colon

Sigmoidectomy is the removal of the lower part of the colon which is connected to the rectum.

Low anterior resection is the removal of the upper part of the rectum.

Abdominal perineal resection is the removal of the sigmoid colon, rectum and anus and construction of a permanent colostomy

Total colectomy is when the entire colon is removed and the small intestine is connected to the rectum. Transverse Colon Ascending Colon

Total proctocolectomy is the removal of the rectum and all or part of the colon

Symptoms

The most common symptoms of a hernia are:

constipation, abdominal cramps, nausea, loss of appetite, or weight loss

Fever, chills, or weakness

Common Tests

History and Physical

You will be given a physical exam and asked about you and your family’s complete medical history, including symptoms, pain, and stomach problems.

Additional Tests (see Glossary)

Other tests may include:

Digital rectal exam

Blood tests

Urinalysis

Electrocardiogram (ECG)—for patients over 45 or if high risk of heart problems

Ultrasound

The Surgical and Nonsurgical Treatment

Surgical Treatment

A colectomy can be done by open or laparoscopic repair. The type of operation will depend on the condition, size of the diseased area or tumor, and location. Your health, age, anesthesia risk, and the surgeon’s expertise are also important.

Open Colectomy

An incision is made in the abdomen and the diseased section of the colon is removed. The healthy parts of the colon are then stitched or stapled together (anastomosis). If the colon cannot be sutured back together, the colon is brought up through an opening in the abdominal wall (stoma) to form an ostomy. Waste will empty through the ostomy into a pouch that is fixed around the stoma on the abdomen.

Laparoscopic Colectomy

Laparoscopic Colectomy Several small incisions are made in the abdomen. Ports or hollow tubes are inserted into the openings. Surgical tools and a lighted scope are placed through the ports. The abdomen inflated with carbon dioxide, which allows the surgeon to see the intestines and organs clearly. Small instruments inserted through the ports are used to remove diseased colon or a tumor. If the colon cannot be sewn back together, the ends of the intestine are joined together or a stoma is created

Benefits of Laparoscopic Colectomy

benefits include less scarring, earlier return of colon function, less pain, and shorter hospital stays. 6 There has been no difference between laparoscopic and open colectomy for 5-year cancer survival rates. 7 New studies using enhanced recovery protocols with the laparoscopic approach are showing decreasing complications, hospital stay, and decreasing readmissions

Nonsurgical Treatment

Some diseases of the intestines may be treated with medication. Depending on the stage of cancer, radiation and chemotherapy may also be part of the treatment plan.



Keeping You Informed

Conversion

Your surgeon may need to convert from a laparoscopic colectomy to an open colectomy. This may be needed due to:

Adhesions from prior surgery

Bleeding

Obesity

Inability to see important structures

Presence of a large tumor

Inability to complete the operation

Patients whose operations were converted from laparoscopic to an open colectomy did not have adverse short- or long-term effects. 9 A conversion to an open the colectomy may occur in 230 of 1,000 patients having a laparoscopic colectomy.

Risks of this Procedure

Risks Based on the ACS Risk Calculator

Risks from Outcomes Reported in the Last 10 Years of Literature Percent for Average Patient Keeping You Informed
Pneumonia: Infection in the lungs 2.3% Stopping smoking before your operation and taking deep breaths plus getting up and walking after can help prevent pneumonia.
Heart complication: Heart attack or sudden stopping of the heart 1.1% Problems with your heart or lungs can sometimes be worsened by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.
Urinary tract infection: Infection of the bladder or kidneys 12.4% A Foley catheter may remain in the bladder a few days after surgery to drain the urine. Adequate fluid intake and catheter care decrease the risk of bladder infection.
Renal (kidney) failure: Kidneys no longer function in making urine and/or cleaning the blood of toxins 1.1% Pre-existing renal insufficiency, fluid imbalance, Type 1 diabetes, over 65 years of age, antibiotics, and other medications may increase the risk.
Return to surgery 6.1% Bleeding or a bowel leakage may cause a return to surgery. Your surgical and anesthesia team is prepared to reduce all risks of a return to surgery..
Blood clot: 2% Longer surgery and bed rest increase the risk. Getting up, walking 5 to 6 times/day, and wearing support stockings reduce the risk.
Immediate postoperative pain There is no difference in pain scores when comparing suture vs. mesh vs. laparoscopic repair by postoperative day The laparoscopic approach avoids a long incision. There may be a feeling of tightness in your abdomen because the muscle has been pulled together. Your pain will be managed with nonsteroidal anti-inflammatory medications and by resting and avoiding straining or lifting.
Recurrence: A hernia can recur after the repair All patients 1% to 17% 11 Open 4.9% Laparoscopic 10.1% Recurrence occurs half as often when a mesh is used versus non-mesh repair. 2 Laparoscopic repairs is recommended for recurrent hernias because the surgeon avoids previous scar tissue. There is a higher rate of recurrence in older men with laparoscopic repair.

Expectations: Preparing for Your Operation

Preparing for Your Operation

Home Medication

Bring a list of all of the medications, vitamins, and nutritional supplements that you are taking. Your medication may have to be adjusted before your operation. Some medications can affect your recovery, blood clotting, and response to the anesthesia. Most often you will take your morning medication with a sip of water.

Anesthesia

Let your anesthesia provider know if you have allergies, neurologic disease (epilepsy, stroke), heart disease, stomach problems, lung disease (asthma, emphysema), endocrine disease (diabetes, thyroid conditions), or loose teeth; if you smoke, drink alcohol, use drugs, or take any herbs or vitamins; or if you have a history of nausea and vomiting with anesthesia If you smoke, you should let your surgical team know. You should plan to quit. Quitting before your surgery can decrease your rate of respiratory and wound complications and increase your chances of staying smoke-free for life

Lenght of stay

You may stay in the hospital for about 2 nights after a laparoscopic repair or longer after an open colectomy. 13 You may have a catheter in place in your bladder to measure and drain your urine for a few days. Severe nausea, vomiting, or the inability to pass urine may result in a longer stay.

The Day of Your Operation

Do not eat for 4 hours or drink anything but clear liquids for at least 2 hours before the operation.

Shower and clean your abdomen and groin area with a mild antibacterial soap

Brush your teeth and rinse your mouth out with mouthwash

Do not shave the surgical site; your surgical team will clip the hair nearest the incision site

What to Bring

Insurance card and identification

Advance directives (see Glossary)

List of medicines

Loose-fitting, comfortable clothes

Slip-on shoes that don’t require that you bend over

Leave jewelry and valuables at home

What You Can Expect

An identification (ID) bracelet and allergy bracelet with your name and hospital/ clinic number will be placed on your wrist. These should be checked by all health team members before they perform any procedures or give you medication. Your surgeon will mark and initial the operation site.

Fluids and Anesthesia

An intravenous line (IV) will be started to give you fluids and medication. For general anesthesia, you will be asleep and pain-free during the operation. A tube may be placed in your throat to help you breathe during the operation. For spinal anesthesia, a small needle with medication will be placed on your back alongside your spinal column. You will be awake during the operation but pain-free

After Your Operation

You will be moved to a recovery room where your heart rate, breathing rate, oxygen saturation, blood pressure, and urine output will be closely watched. Be sure that all visitors wash their hands

Preventing Pneumonia and Blood Clots

Movement and deep breathing after your operation can help prevent postoperative complications such as blood clots, fluid in your lungs, and pneumonia. Every hour, take 5 to 10 deep breaths and hold each breath for 3 to 5 seconds When you have an operation, you are at risk of getting blood clots because of not moving during anesthesia. The longer and more complicated your surgery, the greater the risk. This risk is decreased by getting up and walking 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and, for high-risk patients, taking a medication that thins your blood.

Questions to Ask


About My Home Medications:

What medications should I stop taking before my operation?

Should I take any medicines on the day of my operation?

About My Operation:

What are the side effects and risks of anesthesia?

What procedure will be used to repair the colon? Laparoscopic or open?

Will the colon be sutured or do I need to be trained how to care for an ostomy?

What are the risks of this procedure?

Will you be performing the entire procedure yourself?

How long will it be before I can return to my normal activities (work, driving, lifting)?

Your Recovery and Discharge

Your Recovery and Discharge

Thinking Clearly

If general anesthesia is given or if you need to take narcotics for pain, it may cause you to feel diff erent for 2 or 3 days, have diffi culty with memory, or feel more tired. You should not drive, drink alcohol, or make any big decisions for at least 2 days.

Nutrition

If you follow an enhanced recovery protocol, the aim is to return to a normal diet as soon as possible. Right after surgery, you will be able to drink water and be provided with anti-nausea medication if you need it. On postoperative day 1, you can eat a normal diet. IV fluids will continue for 1 to 2 days after the surgery. For up to 4 weeks, a low-residue/low-fiber diet is recommended to reduce the amount and frequency of stools. This reduces trauma to the healing intestinal reconnection. 14 Continue to drink about 8 to 10 glasses of fluid per day. A dietician can help you understand your diet.

Activity

After surgery, you will sit in a chair. The next day, you should be up and walk the hallway. Your pain should be managed with pain medication. Get up and walk every hour or so to prevent blood clot formation.

You may be able to resume most normal activities in 1 or 2 weeks. These activities include showering, driving, walking up stairs, working, and engaging in sexual activity. 15 Work and Retu

Work and Return to School

You may return to work after you feel healthy, usually 1 to 2 weeks after laparoscopic repair and 2 to 3 weeks for open procedures.

You will not be able to lift anything over 10 pounds, climb, or do strenuous activity for 4 to 6 weeks following surgery.

Wound Care

Always wash your hands before and after touching near your incision site

You will be instructed on how to care for your wound before you go home.

Do not soak in a bathtub until your stitches, Steri-Strips®, or staples are removed. You may take a shower after the second postoperative day unless you are told not to.

If you have Steri-Strips in place, they will fall off in 7 to 10 days.

If you have a glue-like covering over the incision, allow the glue to fl ake off on its own.

Avoid wearing tight or rough clothing. It may rub against your incisions and make it harder for them to heal.

Protect the new skin, especially from the sun. The sun can burn and cause darker scarring.

Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year.

Bowel Movements

In the first 2 weeks, your bowel movements may be more frequent and looser than usual until you fully resume eating solid food. Avoid straining with bowel movements. Be sure you are drinking 8 to 10 glasses of fluid each day.

Pain

The amount of pain is different for each person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during your anesthesia.

When to Contact Your Surgeon

Contact your surgeon if you have:

Pain that will not go away

Pain that gets worse

A fever of more than 101°F or 38.3°C

Continuous vomiting

Swelling, redness, bleeding, or bad-smelling drainage from your wound site

Strong or continuous abdominal pain or swelling of your abdomen

No bowel movement 2 to 3 days after the operatio

Pain control

The amount of pain you have after a colectomy will depend on your other health factors and how much of your colon was removed. After your surgery, you may have a patient-controlled anesthesia pump (PCA). You will have a button that you push when you start to feel it’s time for pain medicine. The pump is set so that you cannot get too much medicine. You may have this pump until you are able to eat and take pain medicine by mouth. Non-Narcotic Pain Medication Everyone reacts to pain in a different way. A scale from 0 to 10 is used to measure pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. Following a laparoscopic procedure, pain is sometimes felt in the shoulder. This is due to the gas inserted into your abdomen during the procedure. Moving and walking help to decrease the gas and the shoulder pain

Common Medicines to Control Pain

Narcotics are used for severe pain. Possible side effects of narcotics are sleepiness; lowered blood pressure, heart rate, and breathing rate; skin rash and itching; constipation; nausea; and difficulty urinating. Some examples of narcotics include morphine and codeine.

Non-Narcotic Pain Medication

As your pain lessens, over-the-counter pain medicines such as acetaminophen (Tylenol) or ibuprofen (Advil) can be used. Like ibuprofen, most non-opioid analgesics are classified as non-steroidal anti-inflammatory drugs (NSAIDs). Possible side effects of NSAIDs are the upset stomach, bleeding in the digestive tract, and fluid retention. These side effects usually are not seen with short- term use. Let your doctor know if you have heart, kidney, or liver problems. Request pain medication if needed to help you increase activity, promote digestion, and prevent pneumonia and blood clots.

Keeping You Informed

Pain Control without Medicine

Distraction helps you focus on other activities instead of your pain. Listening to music, playing games, or other engaging activities can help you cope with mild pain and anxiety.

guided imagery helps you direct and control your emotions. Close your eyes and gently inhale and exhale. Picture yourself in the center of somewhere beautiful. Feel the beauty surrounding you and your emotions coming back to your control. You should feel calmer