1. Basic Format: Colon Resection and Anastomosis
Procedures
Basic Format:
Colon Resection and Anastomosis

2. 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.

3. 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.

4. Terms and Definitions: GI Surgery
Adhesion
Anastomosis
Colon
Diverticula
Resection
Sphincter
Volvulus
Intussusception
See MAVCC Info Page
Intussusception: slipping of one part of the intestine into another part just below it—becoming ensheathed. It is noted more often with children and usually occurs in the ileocecal region; in adults, an intraintestinal tumor or polyp may become the leading portion of the Intussusception. In come cases, the process may be reduced by low pressure enema. Surgery may be needed if process continues. This is an emergency—if not corrected within 24 hrs, mortality is high. Prognosis is good if treated immediately.

5. 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
See STST page 425 and Table 14-14
Fuller: In this procedure, a section of the large intestine is removed and its continuity restored. It is performed to remove cancerous lesions or to correct other conditions, such as ulcerative colitis or diverticula of the colon.

6. Relevant A & P: Small Intestine and Colon
Begins at pyloric sphincter
Duodenum
Jejunum
Ileum
Mesenteric small intestine
Colon
Cecum
Appendix
Ascending colon
Transverse colon
Descending colon
Rectum, anus
See STST Figure Colon Resection Options: Right Colectomy; Right Hemicolectomy; Transverse Colectomy, Left colectomy, Left hemicolectomy, Abdominoperineal Resection
Colon page 391: See Figure 14-5
For intestinal procedures: the small intestine extends from the pylorus to the ileocecal valve. The three sections include the duodenum (proximal portion), the jejunum (middle section), and the ileum (distal portion that joins the large intestine). It is responsible for absorption of nutrients and provides a barrier from harmful ingested environmental agents.
The large colon is commonly divided into the proximal cecum, the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum. The wall of the colon has 4 layers: muscosa, submucosa, muscularis, and serosa. What is the function of the large intestine? Absorption of water and electrolytes, compaction of fecal waste, and production of Vitamin K by its intestinal flora. The left colon mostly serves as a storage area—no role in digestion and absorption. Note details of blood supply and nerve innervation pp Vessels encountered during colon resection include right, middle, and left colic arteries, inf and sup mesenteric arteries, the intercolonic and sigmoid arteries, and superior rectal artery.

7. Complete Student Supplement 2: Review Anatomy of large intestine

8. Anatomy/Blood Supply of Colon/Rectum
Figure 14-5 page 392

9. Pathophysiology Pseudomembranous enterocolitis Polyps
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
Taber’s Medical Dictionary Reference
Polyp: a tumor with a pedicle: commonly found in vascular organs such as the nose, uterus, colon, and rectum. Polyps bleed easily; if there is a possibility they will become malignant, they should be removed surgically.
If they are benign, they do not require intestinal resection.
OR: Outward growth from a mucous membrane

10. Again, here are indications for resections of the small and large intestines

11. Pathophysiology Mechanical Lesions Trauma: Blunt and Penetrating
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
Volvulus: torsion of a loop of intestine causing obstruction (with or without strangulation)
Diverticula: small, blind pouches that form in the lining and wall of a canal or organ, especially the colon
Intusseption: invagination of proximal intestine into the lumen of the distal intestine causing intestinal obstruction

12. Types of anastomoses Side to side End-to-end End-to-side
MAVCC Information Sheet with pictures: Type is based on surgeon preference, pt condition, and location of lesion

13. Right Colectomy

14. Right Hemicolectomy

15. Transverse Colectomy

16. Left Colectomy

17. Left Hemicolectomy

18. Abdominoperineal Resection

19. Diagnostics: Exams Barium Enema IVP if renal involvement is suspected
CT Scan/MRI
Sigmoidoscopy/Colonoscopy
Hemoccult/Guaiac
See Lemone and Burke p. 670
CT/MRI to assess tumor depth and involvement of other organs by direct extension or metastasis
Sigmoidoscopy and colonoscopy are primary diagnostic tests used to detect and visualize tumors—allows for tissue collection for biopsy
Tissue Biopsy: at time of endoscopy to confirm cancerous tissue and evaluate cell differentiation.

21. Diagnostics: Preoperative Testing
Medical History
Blood work (Normal values Alexander p )
CBC
Electrolytes
PT/PTT
Urinalysis
Chest-x ray
ECG
See page 670 Lemone and Burke to explain these
CBC to detect chronic blood loss
Chest to detect possible anastomosis

22. 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
MAVCC INFO pages —See specific considerations
Fuller: In all procedures involving the large intestine, special precautions are taken to prevent contamination of the field by the bowel contents. Once the bowel has been opened, all contaminated instruments, sponges, and other equipment are kept separate from equipment that is used for closure. It is required in some facilities that you set up a separate mayo stand for closure with needed instruments and suture. Fresh, new irrigation is required—and in this case, some surgeons may ask for sterile water for irrigation –theory being that it will aid in lysis of cancer cells. May need new draping materials. These items are not touched until the bowel has been closed and the team has been regloved and regowned according to the OR policy. During the procedure the area for anastomosis is isolated with lap sponges or drapes, or both, to minimize spillage of bowel contents.
Fuller: following accepted bowel technique, you are now responsible for directing changeover from a possibly contaminated field to a sterile one. Remove all lap sponges from the wound, remove the suction and cautery off the field, and pull the “dirty” Mayo stand from the field. The circulator provides clean gowns and gloves to the STSR. The circ assists ST in disrobe procedure and ST dons new sterile gown and gloves and then assists surgeons.
Pt may be re-draped over dirty drape…new suction, cautery, sponges are received. Usually surgeon assists with this.

23. Surgical Intervention: Anesthesia
Method: General anesthesia
Equipment: Typical monitors: BIS, Respirator, EKG, BP, warming blanket
Anesthesia will insert a Nasogastric tube after intubation

24. 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

25. 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

26. 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)

27. 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

28. Surgical Intervention: Supplies cont’d

29. 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)

30. Surgical Intervention: Equipment
General: Electrosurgical Unit, Suction
Specific

31. 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

32. 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

33. 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
Fuller page 256
Incision is made—usually midline for best exposure
Surgeon explores loops of intestine to identify portion to be removed. If the lesion is cancerous, a wide margin of intestine on either side of the lesion is also removed.
To free the bowel from its peritoneal and mesenteric attachments, the surgeon dissects them with Metzenbaum scissors (Fuller Fig 19-34). You should have a good supply of Mayo clamps and ties of the surgeon’s choice (often 2-0 and 3-0 silk).
Portions of the mesentary are double-clamped, divided, ligated. Large vessels are controlled with suture ligatures.
The surgeon frees up the bowel, or continues this mobilization procedure, along the full length of the bowel to be resected. Many surgeons use a long penrose drain around the loop of bowel for resection.
Once the bowel is isolated, the segment is double-clamped at each end with intestinal clamps. Using the cautery pencil, the surgeon divides the bowel between each set of clamps and passes the specimen to the technologist.
At this point, the bowel is open and there is great potential for fecal contamination. To help prevent this, the surgeon may place 2 lap sponges around the base of the intestinal stumps or use rubber bands to seal off the openings of the stumps.
Next, to initiate anastomosis, the assistant places the 2 bowel ends in close approximation, and t he first layer of interrupted sutures is placed, usually with fine CR needles.
Be sure to use multiple resources: concise but complete!

34. 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.
Fuller page 256: during anastomosis, be sure to place returned needles on a magnetic needle board asap as the surgeon returns to you. There is rapid exchange of needles and so they are easily lost. Know that the first and the last sutures of the initial suture layer are left long to be used in traction. After making double incisions in the bowel, the surgeon places a second layer of 3-0 chromic catgut suture, swages to a fine GI needle. The surgeon continues until the 2 intestinal lumens are joined.
The intestinal clamps are then removed and a final reinforcing suture layer of interrupted silk is placed.
The final step is to close the mesentery. Usually interrupted sutures of silk or chromic catgut, size 3-0, are used.

35. Counts
Initial: Sponge, needle & blades, instruments, small items (bovie cleaner)
First closing: Sponges, needles, blades
Final closing
Sponges
Sharps
Instruments
Small items

36. Dressing, Casting, Immobilizers, Etc.
Types & sizes
4 x 4’s and ABD for abdomen
Type of tape or method of securing—silk or paper

37. Specimen & Care Identified as specific type of colon
Handled: routine, etc.
May receive specimen in a basin and keep contained

38. Postoperative Care Destination
PACU and med-surg unit
Expected prognosis (Good, Depends on Dx)

39. 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

40. Resources Alexander pp. 378-383 Berry & Kohn pp. 658-663
Fuller pp
STST Ch 14 pp
MAVCC Unit 4 Information Sheets
Taber’s Cyclopedic Medical Dictionary
See also Lemone and Burke pp : The Patient with Colorectal Cancer