Laparoscopic Bowel Resection Surgery
Morbidity and Mortality Rates
Bowel resection is a surgical procedure in which a diseased part of the large intestine is removed. The procedure is also known as colectomy, colon removal, colon resection, or resection of part of the large intestine.
The large bowel, also called the large intestine, is a part of the digestive system. It runs from the small bowel (small intestine) to the rectum, which receives waste material from the small bowel. Its major function is to store waste and to absorb water from waste material. It consists of the following sections, any of which may become diseased:
* Colon. The colon averages some 60 in (150 cm) in length. It is divided into four segments: the ascending colon, transverse colon, descending colon, and sigmoid colon. There are two bends (flexures) in the colon. The hepatic flexure is where the ascending colon joins the transverse colon. The splenic flexure is where the transverse colon merges into the descending colon.
* Cecum. This is the first portion of the large bowel that is joined to the small bowel. The appendix lies at the lowest portion of the cecum.
* Ascending colon. This segment is about 8 in (20 cm) in length, and it extends upwards from the cecum to the hepatic flexure near the liver.
* Transverse colon. This segment is usually more than 18 in (46 cm) in length and extends across the upper abdomen to the splenic flexure.
* Descending colon. This segment is usually less than 12 in (30 cm) long and extends from the splenic flexure downwards to the start of the pelvis.
* Sigmoid colon. An S-shaped segment that measures about 18 in (46 cm); it extends from the descending colon to the rectum.
The wall of the colon is composed of four layers:
* Mucosa. This single layer of cell lining is flat and regenerates itself every three to eight days. Small glands lie beneath the surface.
* Submucosa. The area between the mucosa and circular muscle layer that is separated from the mucosa by a thin layer of muscle, the muscularis mucosa.
* Muscularis propria. The inner circular and outer longitudinal muscle layers.
* Serosa. The outer, single-cell, thick covering of the bowel. It is similar to the peritoneum, the layer of cells that lines the abdomen.
The large intestine is also responsible for bacterial production and absorption of vitamins. Resection of a portion of the large intestine (or of the entire organ) may become necessary when it becomes diseased. The exact
To remove a portion of the colon, or large intestine, and incision is made in the abdomen to expose the area (A). Tissues and muscles connecting the colon to surrounding organs are severed (B). The area to be removed is clamped and severed (C). The remaining portions of the bowel, the ileum (small intestine) and transverse colon, are connected with sutures (D). Muscles and tissues are repaired (E).
reasons for large bowel resection in any given patient may be complex and are always carefully evaluated by the treating physician or team. The procedure is usually performed to treat the following disorders or diseases of the large intestine:
* Cancer. Colon cancer is the second most common type of cancer diagnosed in the United States. Colon and rectum cancers, which are usually referred to as colorectal cancer, grow on the lining of the large intestine. Bowel resection may be indicated to remove the cancer.
* Diverticulitis. This condition is characterized by the inflammation of a diverticulum, especially of diverticula occurring in the colon, which may undergo perforation with abscess formation. The condition may be relieved by resecting the affected bowel section.
* Intestinal obstruction. This condition involves a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through. It is usually treated by decompressing the intestine with suction, using a nasogastric tube inserted into the stomach or intestine. In cases where decompression does not relieve the symptoms, or if tissue death is suspected, bowel resection may be considered.
* Ulcerative colitis. This condition is characterized by chronic inflammation of the large intestine and rectum resulting in bloody diarrhea. Surgery may be indicated when medical therapy does not improve the condition. Removal of the colon is curative and also removes the risk of colon cancer. About 25–40% of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer.
* Traumatic injuries. Accidents may result in bowel injuries that require resection.
* Pre-cancerous polyps. A colorectal polyp is a growth that projects from the lining of the colon. Polyps of the colon are usually benign and produce no symptoms, but they may cause rectal bleeding and develop into malignancies over time. When polyps have a high chance of becoming cancerous, bowel resection may be indicated.
* Familial adenomatous polyposis (FAP). This is a hereditary condition caused by a faulty gene. Most people discover that they have it at a young age. People with FAP grow many polyps in the bowel. These are mostly benign, but because there are so many, it is really only a question of time before one becomes cancerous. Since people with FAP have a very high risk of developing bowel cancer, bowel resection is thus often indicated.
* Hirschsprung's disease (HD). This condition usually occurs in children. It causes constipation, meaning that bowel movements are difficult. Some children with HD cannot have bowel movements at all; the stool creates a blockage in the intestine. If HD is not treated, stool can fill up the large intestine and cause serious problems such as infection, bursting of the colon, and even death
Bowel resection can be performed using an open surgical approach (colectomy) or laparoscopically.
Following adequate bowel preparation, the patient is placed under general anesthesia, which ensures that the patient is deep asleep and pain free during surgery. Because the effects of gravity to displace tissues and organs away from the site of operation are important, patients are carefully positioned, padded, and strapped to the operating table to prevent movement as the patient is tilted to an extreme degree. The surgeon starts the procedure by making a lower midline incision in the abdomen or, alternatively, he may prefer to perform a lateral lower transverse incision instead. He proceeds with the removal of the diseased portion of the large intestine, and then sutures or staples the two healthy ends back together before closing the incision. The amount of bowel removed can vary considerably, depending on the reasons for the operation. When possible, the procedure is performed to maintain the continuity of the bowel so as to preserve normal passage of stool. If the bowel has to be relieved of its normal digestive work while it heals, a temporary opening of the colon onto the skin of abdominal wall, called a colostomy, may be created. In this procedure, the end of the colon is passed through the abdominal wall and the edges are sutured to the skin. A removable bag is attached around the colostomy site so that stool may pass into the bag, which can be emptied several times during the day. Most colostomies are temporary and can be closed with another operation at a later date. However, if a large portion of the intestine is removed, or if the distal end of the colon is too diseased to reconnect to the proximal intestine, the colostomy is permanent.
Laparoscopic bowel resection
The benefits of laparoscopic bowel resection when compared to open colectomies include reduced postoperative pain, shorter hospitalization periods, and a faster return to normal activities. The procedure is also minimally invasive. When performing a laparoscopic procedure, the surgeon makes three to four small incisions in the abdomen or in the umbilicus (belly button). He inserts specialized surgical instruments, including a thin, telescope-like instrument called a laparoscope, in an incision. The abdomen is then filled with gas, usually carbon dioxide, to help the surgeon view the abdominal cavity. A camera is inserted through one of the tubes and displays images on a monitor located near the operating table to guide the surgeon as he works. Once an adequate view of the operative field is obtained, the actual dissection of the colon can start. Following the procedure, the small incisions are closed with sutures or surgical tape.
All colon surgery involves only three maneuvers that may vary in complexity depending on the region of the bowel and the nature of the disease. These three maneuvers are:
* retraction of the colon
* division of the attachments to the colon
* dissection of the mesentery
In a typical procedure, after retracting the colon, the surgeon proceeds to divide the attachments to the liver and the small bowel. Once the mesenteric vessels have been dissected and divided, the colon is divided with special stapling devices that close off the bowel while at the same time cutting between the staple lines. Alternatively, a laparoscopically assisted procedure may be selected, in which a small abdominal wall incision is made at this point to bring the bowel outside of the abdomen, allowing open bowel resection and reconnection using standard instruments. This technique is popular with many surgeons because an incision must be made to remove the bowel specimen from the abdomen, which allows the most time-consuming and risky parts of the procedure (from an infection point of view) to be done outside the body with better control of the colon.
Key elements of the physical examination before surgery focus on a thorough examination of the abdomen, groin, and rectum. Other common diagnostic tools used to evaluate medical conditions that may require bowel resection include imaging tests such as gastrointestinal barium series, angiography, computerized tomography (CT), magnetic resonance imaging (MRI), and endoscopy.
As with any surgery, the patient is required to sign a consent form. Details of the procedure are discussed with the patient, including goals, technique, and risks. Blood and urine tests, along with various imaging tests and an electrocardiogram (EKG), may be ordered. To prepare for the procedure, the patient is asked to completely clean out the bowel. This is a crucial step if the bowel is to be opened safely within the peritoneal cavity, or even manipulated safely through small incisions. To empty and cleanse the bowel, the patient is usually placed on a low-residue diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing taken by mouth after midnight. A series of enemas and/or oral preparations (GoLytely or Colyte) may be ordered to empty the bowel of stool. Preoperative bowel preparation involving mechanical cleansing and administration of intravenous antibiotics immediately before surgery is the standard practice. The patient may also be given a prescription for oral antibiotics (neomycin, erythromycin, or kanamycin sulfate) the day before surgery to decrease bacteria in the intestine and to help prevent post-operative infection. A nasogastric tube is inserted through the nose into the stomach during surgery and may be left in place for 24–48 hours after surgery. This removes the gastric secretions and prevents nausea and vomiting. A urinary catheter (a thin tube inserted into the bladder) may be inserted to keep the bladder empty during surgery, giving more space in the surgical field and decreasing chances of accidental injury.
Postoperative care for the patient who has undergone a bowel resection, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia and the patient's reluctance to breathe deeply and experience pain that is caused by the abdominal incision. The patient is instructed how to support the operative site during deep breathing and coughing, and is given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube will remain in place, attached to low intermittent suction until bowel activity resumes. Fluids and electrolytes are infused intravenously until the patient's diet can gradually be resumed, beginning with liquids and advancing to a regular diet as tolerated. The patient is generally out of bed approximately eight to 24 hours after surgery. Most patients will stay in the hospital for five to seven days, although laparoscopic surgery can reduce that stay to two to three days. Postoperative weight loss follows almost all bowel resections. Weight and strength are slowly regained over a period of months. Complete recovery from surgery may take two months. Laparoscopic surgery can reduce this time to one to two weeks.
The treating physician should be informed of any of the following problems after surgery:
* increased pain, swelling, redness, drainage, or bleeding in the surgical area
* headache, muscle aches, dizziness, or fever
* increased abdominal pain or swelling, constipation, nausea or vomiting, rectal bleeding, or black, tarry stools
Potential complications of bowel resection surgery include:
* excessive bleeding
* surgical wound infection
* incisional hernia (an organ projecting through the surrounding muscle wall, it occurs through the surgical scar)
* thrombophlebitis (inflammation and blood clot to veins in the legs)
* narrowing of the opening (stoma)
* pulmonary embolism (blood clot or air bubble in the lung blood supply)
* reaction to medication
* breathing problems
* obstruction of the intestine from scar tissue
Complete healing is expected without complications after bowel resection, but the period of time required for recovery from the surgery varies depending on the initial condition that required the procedure, the patient's overall health status prior to surgery, and the length of bowel removed.
Morbidity and Mortality Rates
Prognosis for bowel resection depends on the seriousness of the disease. For example, primary treatment for colorectal cancer consists of wide surgical resection of the colon cancer and lymphatic drainage after the bowel is prepared. The choice of operation for rectal cancer depends on the tumor's distance from the anus and gross extent; overall surgical cure is possible in 70% of these patients. In the case of ulcerative colitis patients, the colitis is cured by bowel resection and most people go on to live normal, active lives. As for Hirschsprung's disease patients, approximately 70–85% eventually achieve excellent results after surgery, with normal bowel habits and infrequent constipation.
Alternatives to bowel resection depend on the specific medical condition being treated. For most conditions where bowel resection is advised, the only alternative is medical treatment with drugs. In cases of cancer of the bowel, drug treatment alone will not cure the disease. Occasionally, it is possible to remove a rectal cancer from within the back passage without major surgery, but this only applies to very special cases. As for other conditions such as mild or moderate ulcerative colitis, drug therapy may represent an alternative to surgery; a combination of the drugs sulfonamide, sulfapyridine, and salicylate may help control inflammation. Similarly, most acute cases of diverticulitis are first treated with antibiotics and a liquid diet.