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About laparoscopic intestinal
surgery
If you need colorectal surgery, you might be a candidate for laparoscopic
intestinal surgery, a "minimally invasive" technique for treating colorectal
disorders. Laparoscopy has been used successfully to treat gynecological problems and
gallbladder disease for many years. Today, colorectal surgeons are using laparoscopic
techniques to perform intestinal surgery.
Laparoscopy versus traditional
intestinal surgery
The word "laparoscopy" means to look inside the abdominal cavity with a special
camera or "scope." Laparoscopy, also known as "keyhole" surgery, has
been used for many years to diagnose medical conditions inside the abdominal cavity.
Intestinal laparoscopic surgery uses this same technique to remove diseased sections of
the intestinal organs for selected patients.
Traditional intestinal surgery requires a long incision down the center
of the abdomen and a lengthy recovery period. Laparoscopic intestinal surgery eliminates
the need for this large incision. As a result, the patient might experience less pain and
scarring after surgery, more rapid recovery, and less risk of infection. Colorectal
surgeons have used laparoscopy to treat the following:
Figure 1
- Crohn's disease
- Certain colorectal cancers
- Diverticulitis
- Familial polyposis
- Fecal incontinence
- Rectal prolapse
- Ulcerative colitis
To perform laparoscopy, five or six small (5-10 mm) incisions are made in the abdomen.
The laparoscope and surgical instruments are inserted through these incisions. The surgeon
is then guided by the laparoscope, which transmits a picture of the intestinal organs on a
video monitor (figure 1).
Laparoscopy can be used to remove diseased tissue
from many areas of the intestines. (Figure 2 shows the anatomy of a healthy
intestinal system.) Your surgeon and colorectal nurse will help you understand the
procedure and how it will improve your condition. You will also be given more detailed
information describing the surgery.
Figure 2
Laparoscopic intestinal surgery can be used to perform:
Proctosigmoidectomy - This is the surgical removal of a diseased section of the rectum and
sigmoid colon. It is used to treat cancers, non-cancerous growths, and complications of diverticulitis.
Right colectomy, or ileocolectomy - This is the surgical removal of a section of the
colon that is adjacent to the small intestine. It is used to remove cancers, non-cancerous
growths, and inflammation from Crohn's disease.
Total abdominal colectomy - This is the surgical removal of the large intestine.
It is used to
treat ulcerative colitis, Crohn's disease, and familial polyposis.
Fecal diversion - This is the surgical creation of an ileostomy (opening between the surface
of the skin and the small intestine) or colostomy (opening between the surface of the skin
and the colon). It is used to treat complex rectal and anal problems, including poor bowel
control.
Abdominoperineal resection - This is the surgical removal of the anus, rectum, and sigmoid
colon. It is used to remove cancer in the lower rectum or in the anus, close to the sphincter
(control) muscles.
Rectopexy - This is a procedure in which stitches are used to secure the rectum in its
proper position. It is used to correct rectal prolapse.
Preparing for surgery
Your surgeon will meet with you to answer any questions you might have. You
will be asked questions about your health history, and a general physical examination will
be performed. If your intestine requires cleaning, you will be given a prescription for a
laxative medicine to take the evening before the surgery.
All patients are generally asked to provide a blood sample. Depending
on your age and general health, you might also have an EKG (electrocardiogram), a chest
X-ray, lung function tests, or other tests. You might also need to meet with another doctor
prior to surgery.
Finally, you will meet with an anesthesiologist who will discuss the
type of pain medication (anesthesia) you will be given for surgery. You will also learn
about pain control after the operation, which might include a PCA pump (patient controlled
analgesia).
The evening before your surgery
You will need to take the prescribed laxative medicine the evening before
surgery. It is important to follow the directions carefully and drink all of this
medicine. This step will decrease your risk of developing an infection from bacteria
normally present in the intestine.
Do not eat or drink anything by mouth after midnight the evening before
surgery.
The day of surgery
An intravenous (IV) tube will be inserted into a vein in your arm to deliver
medicines and fluids.
Once the surgeon is ready for you, you will be taken to the operating
room.
Laparoscopic surgery
Preliminary laparoscopy
When you arrive in the operating room, the nurses will help you onto the operating
table. The anesthesiologist will inject medicine into your IV that will put you to sleep.
After you are asleep, the nurses will clean your abdomen with antibacterial soap and cover
you with sterile drapes.
Your surgeon will place a small needle just below your belly
button
(umbilicus) and insert the needle into your abdominal cavity. This needle is connected to
sterile tubing, and carbon dioxide is passed into the abdominal cavity through the tubing.
The gas lifts the abdominal wall away from the organs below. This space will give your
surgeon a better view of your abdominal cavity once the laparoscope is in place.
Next, a small incision will be made near your belly button. The
laparoscope is placed through this incision and is connected to a video camera. The image
your surgeon sees in the laparoscope is projected onto video monitors placed near the
operating table.
Before starting the surgery, your surgeon will take a thorough look at
your abdominal cavity to make sure that laparoscopy will be safe for you. Some reasons why
laparoscopy might not be done include multiple adhesions, infection, or any wide-spread
abdominal disease.
Figure 3
If your surgeon decides that laparoscopic surgery can be safely
performed, additional small puncture incisions will be made, which will give your surgeon
access to the abdominal cavity. The number and location of the incisions depend on the
type of surgery you are having. These incisions are usually located as
shown in figure 3.
If needed, one of these small incisions might be enlarged to enable your
surgeon to remove the diseased section of intestine or to create an anastomosis
(connection) between two ends of your intestine.
The intestinal surgery
Your surgeon will begin the main intestinal surgery by closing the larger blood
vessels serving the diseased section of the small or large intestine. Next, he or she will
separate the fatty tissue (mesentery) that holds the intestine in place. Once the diseased
section of intestine is freed from its supporting structures, it can be removed.
The procedure occasionally requires the creation of a temporary or
permanent stoma, an opening of part of the intestine to the outside of the abdomen. The
stoma acts as an artificial passageway through which stool (feces) can pass from the
intestine to outside the body where it collects in an external pouch. The pouch is attached to
the stoma and must be worn at all times.
In most cases, the surgeon will reconnect the two ends of
intestines. The intestine can be rejoined in a number of ways. One method uses a stapling
device that uses stainless steel or titanium staples to join the ends of the intestine.
Or, the surgeon might pull the intestinal ends up through one of the small incisions and
stitch (suture) the ends together. Your surgeon will choose the best method at the time of
your surgery. Finally, your surgeon will check that there are no areas of bleeding, rinse
out the abdominal cavity, release the gas from the abdomen, and close the small incisions.
Recovering from anesthesia
When you wake up from surgery, you will be in a recovery room. You will
have an oxygen mask covering your nose and mouth. This mask delivers a cool mist of oxygen,
which helps eliminate the remaining anesthesia from your system and soothes your throat.
Your throat might be sore from the breathing tube that was present during your surgery, but
this soreness usually subsides after a day or two.
Once you are more alert, the nurse might switch your oxygen delivery
device to a nasal cannula, small plastic tubing that hooks over your ears and lies beneath
your nose. Depending on the percentage of oxygen measured in your blood, you might need to
keep the oxygen in place. The nurse will check the oxygen content of your blood (oxygen
saturation) by placing a soft clip on one of your fingers (pulse oximetry).
Pain medication will be given as you recover from surgery.
Recovering in your hospital room
After your surgery, the nurses will begin to measure your "intake and
output." They will document all the fluids that you drink and measure and collect any
urine or fluids you produce, including those from tubes or drains placed during surgery.
The tube that was passed from a nostril into your stomach (a
nasogastric tube) during surgery will be removed in the recovery room. You may begin to
drink liquids the morning after surgery. Once you have passed gas from the rectal area or
have had a bowel movement, you will resume a solid diet. If you become nauseated or begin
to vomit, your nasogastric tube might be reinserted. If this happens, don't be alarmed.
Nausea and vomiting are common and occur because your intestines are temporarily disabled
from the surgery and the effects of anesthesia. For this reason, food and drink are given
slowly for the first few days after surgery.
You will be encouraged to get out of bed, starting the first day after
surgery. The more you move, the less chance for complications such as pneumonia or the
formation of blood clots in your leg veins.
The length of your hospital stay will depend on the type of procedure
you had and how quickly you recover. For example, the average hospital stay for a
laparoscopic rectopexy ranges from two to three days and for a laparoscopic partial
colectomy, three to six days.
Your recovery at home
You will be encouraged to steadily increase your activity level once you
are home. Walking is great exercise. Walking will help your general recovery by
strengthening your muscles, keeping your blood circulating to prevent blood clots, and
helping your lungs remain clear. If you are fit and did regular exercise before surgery,
you may resume exercising when you feel comfortable. There are only two things you are not
permitted to do for six weeks after surgery: lift or push anything heavier than 30 pounds or do
abdominal exercises such as sit-ups.
You will follow a soft diet at home, which means you can eat almost
everything except raw fruits and vegetables. A registered dietitian can provide more
specific guidelines. You should follow this diet until your follow-up visit with your
health care provider. If you have problems with constipation, call your health care
provider.
Glossary
Abdominoperineal resection: Surgical removal of the anus, rectum,
and sigmoid colon, resulting in the need for a permanent colostomy.
Adhesions: Fibrous bands that cause surrounding organs or tissue to abnormally
stick together. Also called "scar tissue," which is common after
abdominal/intestinal surgery.
Anastomosis: A new surgical connection between two otherwise separated organs
(in abdominal surgery, usually between two ends of the intestine).
Cannulas: Tubes that hold the laparoscope and instruments, and allow access to
the abdominal cavity for performance of laparoscopic surgery.
Colectomy: Surgical excision of all or part of the colon.
Colon: The last three or four feet of your intestine (except for the last eight
inches, which is called the rectum). Synonymous with the "large intestine" or
"large bowel."
Colostomy: The surgical creation of an opening between the surface of the skin
and the colon. Also referred to as a large intestine stoma.
Crohn's disease: An inflammatory bowel disease that involves all layers of the
intestinal wall. Crohn's disease might affect any portion of gastrointestinal tract,
including the anus, rectum, colon, and small intestine.
Diverticulitis: An inflammation of small sacs (diverticula) of the inner lining
of the intestine, which protrude through the intestinal wall.
Epidural catheter: A small tube (catheter) passed into the space between the
spinal cord and spinal column. Pain medication is then delivered through the tube, numbing
the lower abdominal area.
Familial polyposis: A rare condition, tending to run in families, in which the
moist layer of tissue lining the colon (mucosa) is covered with polyps (growths).
Fecal diversion: Surgical creation of an opening of part of the colon
(colostomy) or small intestine (ileostomy) to the surface of the skin. The opening
provides a passageway for stool to exit the body.
Fecal incontinence: Inability to retain feces, resulting in bowel accidents.
Ileocolectomy: Surgical removal of a section of the terminal ileum and colon
lying close to the ileum (the lower most part of the small intestine).
Ileostomy: The surgical creation of an opening between the surface of the skin
and the ileum, the lower most section of the small intestine.
Laparoscopy: Surgery that utilizes a telescope-like instrument (a laparoscope)
passed through a small incision at the umbilicus (bellybutton). The laparoscope enables
the surgical team to visualize the abdominal organs. Also called minimal access surgery.
Mesentery: Membranous tissue that carries blood vessels and lymph glands, and
attaches various organs to the abdominal wall.
PCA: Abbreviation for Patient Controlled Analgesia.
A method of administering pain medication directly into a patient's circulatory system
through a vein (usually in the arm or hand) or directly to the nerves that perceive lower
abdominal pain (epidural area). Delivery of pain medicine is activated by the patient
pushing a request button.
Proctosigmoidectomy: Surgical removal of at least part of the rectum and sigmoid
colon. It occasionally results in the creation of a temporary or permanent stoma.
Pulse oximetry: Photoelectric device that measures the percent of oxygenation
in the blood using a clip on the finger. Also measures the heart rate.
Rectal prolapse: Dropping down of the rectum to outside of the anus.
Rectopexy: Surgical placement of internal sutures (stitches) to secure the
rectum in its proper position.
Stoma: An artificial opening of the intestine to outside of the abdominal wall.
(See colostomy.)
Total abdominal colectomy: Surgical removal of the entire colon.
Trocar: Sharp, pointed instrument used to make a puncture incision in the
abdominal wall. Used for placement of cannulas.
Ulcerative colitis: An inflammatory bowel disease involving the moist layer of
tissue lining the colon (mucosa). The mucosa becomes marked with ulcers.
Resources
For further information, contact:
Crohn's and Colitis Foundation of America Inc.
386 Park Avenue South, 17th Floor
New York, NY 10016-8804
1 (800) 343-3637
National Digestive Diseases Information Clearinghouse
2 Information Way, Bethesda, MD 20892-3570
(301) 654-3810
United Ostomy Association
19772 McArthur Blvd., #200, Irvine, CA 92612-2405
1 (800) 826-0826
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