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8/4/2019 Operative Review
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In Partial Fulfillments on the requirements inNCM-103 and Related Learning Experiences
(OR Rotation)
Operative Review onSigmoid Resection; Anastomosis
Submitted to:Izrafahd U. Basnsuan RN MN
Clinical Instructor
Submitted by:John Nichole S.Gaji SN
BSN13-CGroup # 8
Date Submitted:September 2011.
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Introduction:
Although inappropriate diet & unhealthy lifestyle considerably add to the
risks of sigmoid colon cancer, the disease may also be influenced by an
underlying genetic predisposition. Sigmoid colon cancer statistics reveal that 5 %
of colon cancers globally are caused solely through genetic dysfunctions and
physiological abnormalities. Depending upon their underlying cause, sigmoid
colon cancers may be either unexpected (sporadic colon cancers), or genetically-
inherited. The majority of cases of sigmoid colon cancer occur because of
formation of polyps in different regions of the large bowel (the colon). Colonic
polyps are well-known soft tissues which may become malignant. There are
numerous types of hereditary sigmoid colon cancer; a lot are caused by colonicpolyps. The most common kinds of genetically-inherited sigmoid colon cancers
are adenomatous polyposis and “Gardner’s Syndrome”. Non-polyphonies colon
cancer is alsocommon among hereditary forms of the disease. Unlike other types
of genetically-inherited colon cancer, non-polyposis sigmoid colon cancer does
not always involve the formation of polyps. Uncommon varieties of hereditary
sigmoid colon cancer include juvenile polyposis and Peutz-Jeghers Syndrome.
Unlike non-hereditary types of colon cancer that usually develop in those
older than fifty, hereditary sigmoid colon cancers can arise in younger people. In
fact, some types of the genetically-inherited sigmoid colon cancers are
developed by children and teenagers.
Patients requiring sigmoid or rectosigmoid resection for all colonic
pathologies were included. Criteria for exclusion from an attempted laparoscopic
sigmoid colectomy were body mass index >35 and prior major abdominal
surgeries (exclusive of hysterectomy, cholecystectomy, or appendectomy). Data
collected included age, gender, indication for surgery, American Society of
Anesthesiology class, body mass index, operative duration, length of hospital
stay, complications, mortality, and 30-day readmission.
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Both obtained (sporadic) and hereditary sigmoid colon cancers can be life-
threatening diseases; they should be revealed as soon as is feasible in order to
reduce the risk of morbidity. Colon cancers encompass an unpredictable
prototype of evolution, and the development is strongly prejudiced by genetically-
inherited abnormalities. While lifestyle improvements and vigorous diet can
diminish those risks of developing sigmoid colon cancer, people with underlying
physiological abnormalities of the large bowel may still be vulnerable to
developing problems. However, this is not to say that good dietary and lifestyle
choices should be disregarded. On the contrary, they should be embraced; they
can benefit any person with concerns relating to sigmoid colon health.
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Definition of Terms:
• Resection
is the medical term for surgically removing part or all of a tissue, structure
or organ. One very common type of resection is a sigmoid resection, a procedurewhere one or more segments of the large intestine is removed. A resection can
be performed on many different areas of the body and is done for a wide variety
of reasons. Also Known As: resect, resected, surgical resection, resection
surgery.
• Anastomosis
is to join together two hollow organs ( viscus ), usually to restore continuity
after resection , or to bypass an unresectable disease process. Historically such
procedures were performed with suture material, but increasingly mechanical
staplers and biological glues are employed. While an anastomosis may be end-
to-end, equally it could be performed side-to-side or end-to-side depending on
the circumstances of the required reconstruction or bypass .
• Bowel resection and Anastomosis
resection of diseased
intestinal tissue (colectomy)
and anastomosis of the
remaining segments help
treatments help treat
localized obstructive
disorders, including
diverculosis, intestinal
polyps, bowel adhesions,
and malignant or benignintestinal lesions. This
procedure is the preferred surgical technique for localized bowel cancer, but not
for widespread carcinoma, which usually requires massive resection with
creation of temporary or permanent colectomy.
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Discussion of Surgical Procedures:
• Liver resection
surgical removal of part of the liver . This operation is for some types
of liver cancer and for certain cases of metastatic colorectal cancer . Up to half of
your liver can be removed as long as the rest is healthy. During a liver resection ,
the part of your liver that contains cancer is removed, along with some healthy
liver tissue on either side. If the right side of your liver is removed,
your gallbladder , which is attached to the liver, is also is the taken out.
• Large bowel resection
is surgery to remove all or part of your large bowel. This surgery is alsocalled colectomy. The large bowel is also called the large intestine or colon.
Removal of the entire colon and the rectum is called a proctocolectomy. Removal
of part or all of the colon but not the rectum is called subtotal colectomy. The
large bowel connects the small intestine to the anus. Normally, stool passes
through the large bowel before leaving the body through the anus.
• Transurethral resection of the prostate (TURP)
is a surgical procedure by which portions of the prostate gland are
removed through the urethra. TURP is the treatment of choice for BPH, and the
most common surgery performed for the condition.
• Craniotomy for Brain Tumor Resection
is a neurosurgical procedure by which a bone window is created to gain
access to the inside of the skull. Once the patient has been put to sleep by theanesthesiologist, the surgeon shaves and then marks on the scalp where the
incision will go. After the scalp is opened, the bone is opened using special drills.
Then the tumor/lesion is accessed in order to perform the surgery. The bone is
then usually reattached to the skull at the end of surgery using either sutures or
miniature plates.
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Anastomosis are typically performed on:
• Blood vessels:
Arteries and veins . Most vascular procedures, including all arterialbypass operations (e.g. coronary artery bypass ), aneurysmectomy of any type,
and all solid organ transplants require vascular anastomoses. An anastomosis
connecting an artery to a vein is also used to create an arteriovenous fistula as
an access for hemodialysis.
• Gastrointestinal (GI) tract:
Esophagus , stomach , small bowel , large bowel , bile ducts , and pancreas .Virtually all elective resections of gastrointestinal organs are followed by
anastomoses to restore continuity; pancreaticoduodenectomy is considered a
massive operation, in part, because it requires three separate anastomoses
(stomach, biliary tract and pancreas to small bowel). Bypass operations on the GI
tract, once rarely performed, are the cornerstone of bariatric surgery . The
widespread use of mechanical suturing devices (linear and circular staplers)
changed the face of gastrointestinal surgery.
• Urinary tract:
Ureters , urinary bladder , urethra . Radical prostatectomy and radical
cystectomy both require anastomosis of the bladder to the urethra in order to
restore continuity.
• Microsurgery :
The advent of microsurgical technique allowed anastomoses previously
thought impossible, such as so-called "nerve anastomoses" (not strictly an
anastomosis according to the above definition), and operations to restore fertility
after tubal ligation or vasectomy .
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Anatomy and Physiology:
The sigmoid colon (pelvic colon) is the part of the large intestine that is
closest to the rectum and anus. It forms a loop that averages about 40 cm. in
length, and normally lies within the pelvis , but on account of its freedom of
movement it is liable to be displaced into the abdominal cavity .
It’s major functions are to dry out the indigestible food residue by
absorbing water and to eliminate these residues from the body as feces. The
colon is a long muscular tube located at the end of the intestinal tract after the
stomach and small intestine digest food the remaining material passes through
the colon were water and electrolytes are absorbed the residual stool passes into
the 6 inches of colon known as rectum were it is stored to release.
Most of the conditions treated by the colon resection occur into the layer of
cells that cover the inside of the colon known as the mucosal lining.
It begins at the superior aperture of the lesser pelvis , where it is
continuous with the iliac colon , and passes transversely across the front of
the sacrum to the right side of the pelvis. (The name sigmoid aptly means S -
shaped.) It then curves on itself and turns toward the left to reach the middle line
at the level of the third piece of the sacrum , where it bends downward and endsin the rectum .
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Cancer of the sigmoid colon, as with other types of colorectal cancer,
often has few, if any, symptoms in its early stages. So an absence of symptoms
is no indication that cancer is not present. However, possible symptoms of this
form of cancer include blood in the stool, diarrhea, a bowel obstruction, narrowstools and unexplained anemia and/or weight loss.
Because sigmoid cancer is often asymptomatic, particularly during its
early stages, it is important to schedule regular examinations to ensure that no
problems have developed. This type of examination is called a sigmoidoscopy,
and it is done with a scope that provides the doctor with a close-up look at the
linings of the sigmoid colon and rectum.
Sigmoid colon cancer is classified by stages, each of which is determined by the
size of the tumor involved and the degree to which it has penetrated the affected
tissue. Stage 1 cancer is characterized by one or more small tumors that have
not yet penetrated the mucosal layer of the colon's lining. In stage 2 cancer, the
tumors are slightly larger and have penetrated the muscle wall of the sigmoid
colon. Stage 3 cancer indicates the presence of even larger malignant growths
and the spread of cancerous cells to nearby lymph nodes.
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Pathophysiology:
Anything that increases your chance of getting a disease is called a risk
factor . Having a risk factor does not mean that you will get cancer ; not having
risk factors doesn’t mean that you will not get cancer. People who think they
may be at risk should discuss this with their doctor. Risk factors include the
following:
• Age 50 or older.
• A family history of cancer of the colon or rectum .
•
A personal history of cancer of the colon,rectum, ovary , endometrium , or breast .
• A history of polyps (small pieces of bulging tissue) in the colon.
• A history of ulcerative colitis (ulcers in the lining of the large
intestine) or Crohn disease .
• Certain hereditary conditions, such as familial adenomatous
polyposis and hereditary nonpolyposis colon cancer (HNPCC; Lynch
Syndrome).
These and other symptoms may be caused by colon cancer . Other conditions
may cause the same symptoms. A doctor should be consulted if any of the
following problems occur:
• A change in bowel habits.
• Blood (either bright red or very dark) in the stool.
• Diarrhea , constipation , or feeling that the bowel does’t empty
completely.
• Stools that are narrower than usual.
• Frequent gas pains, bloating, fullness, or cramps.
• Weight loss for no known reason.
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• Feeling very tired.
• Vomiting .
The three ways that cancer spreads in the body are:
• Through tissue . Cancer invades the surrounding normal tissue.
• Through the lymph system . Cancer invades the lymph system and
travels through the lymph vessels to other places in the body.
• Through the blood . Cancer invades the veins and capillaries and
travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel
through the lymph or blood to other places in the body, another (secondary)
tumor may form. This process is called metastasis . The secondary (metastatic)
tumor is the same type of cancer as the primary tumor. For example, if breast
cancer spreads to the bones, the cancer cells in the bones are actually breast
cancer cells. The disease is metastatic breast cancer, not bone cancer .
In stage 0 , abnormal cells are found inthe mucosa (innermost layer) of
the colon wall. These abnormal cells may
become cancer and spread. Stage 0 is also
called carcinoma in situ .
In stage I , cancer has formed in
the mucosa (innermost layer) of
the colon wall and has spread to the
submucosa (layer of tissue under the
mucosa). Cancer may have spread to the
muscle layer of the colon wall.
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Stage II colon
cancer is divided
into stage IIA,
stage IIB, and
stage IIC.• StageIIA: Cancer hasspread throughthe muscle layer of the colon wall to the serosa (outermost layer) of the colonwall.• Stage IIB: Cancer has spread through the serosa (outermost layer) of the colon wall but has not spread to nearby organs .• Stage IIC: Cancer has spread through the serosa (outermost layer) of
the colon wall to nearby organs.
In stage IIIA:
• Cancer may havespread throughthe mucosa (innermostlayer) of the colon wall tothe submucosa (layer of tissue under the mucosa)and may have spread to themuscle layer of the colonwall. Cancer has spread toat least one but not morethan 3 nearby lymphnodes or cancer cells haveformed in tissues near the lymph nodes; or • Cancer has spread through the mucosa (innermost layer) of the colonwall to the submucosa (layer of tissue under the mucosa). Cancer has spread toat least 4 but not more than 6 nearby lymph nodes.
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• Cancer has spreadthrough the muscle layer of
the colon wall tothe serosa (outermost layer) of the colon wall or has spreadthrough the serosa but not tonearby organs . Cancer hasspread to at least one but notmore than 3 nearby lymphnodes or cancer cells haveformed in tissues near thelymph nodes; or • Cancer has spread to the muscle layer of the colon wall or to the serosa
(outermost layer) of the colon wall. Cancer has spread to at least 4 but not morethan 6 nearby lymph nodes; or • Cancer has spread through the mucosa (innermost layer) of the colonwall to the submucosa (layer of tissue under the mucosa) and may have spreadto the muscle layer of the colon wall. Cancer has spread to 7 or more nearbylymph nodes.
• Cancer has spreadthroughthe serosa (outermost layer)of the colon wall but has notspread to nearby organs. Cancer has spread to atleast 4 but not more than 6nearby lymph nodes ; or • Cancer has spreadthrough the muscle layer of the colon wall to the serosa (outermost layer) of thecolon wall or has spread through the serosa but has not spread to nearby
organs. Cancer has spread to 7 or more nearby lymph nodes; or • Cancer has spread through the serosa (outermost layer) of the colon walland has spread to nearby organs. Cancer has spread to one or more nearbylymph nodes or cancer cells have formed in tissues near the lymph nodes.
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Instrumentations used in the Surgery:
• Scalpel -Used to cut skin, superficial tissue and deep delicate tissue.
• Straight Mayo Scissors –Used to cut suture and supplies. A.k.a. SutureScissors.
• Curved Mayo Scissors –Used to cut heavy tissue.
• Metzenbaum Scissors -designed for cutting delicate tissue .
• Hemostat –used to clamp blood vessels or tag sutures.
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• Mixter –used to clamp hard to reach vessels and to place sutures behindor around the vessel.
• Allis Forceps –used to grasp tissue and holds intestinal Tissue.
• Babcock – used to grasp delicate tissue (intestines)
• Needle Holder –used to hold needles when suturing.
• Deaver Retractor – used to retract deep abdominal incisions.
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• Army Navy retractor – used to retract shallow or superficial incisions.
• Balfour – used to retract wound edges during deep abdominal procedures.
• Surgical Stapler – used in surgery in place of sutures to close skin wound, connect or remove parts of the bowels or lungs .
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Surgical Procedure Steps:
Sigmoid colectomy surgery is performed after administering general anesthesia.
An incision is made in the lower abdomen. Depending on the spread of the
disease or the infection, the surgeon then removes the diseased part, or entire
sigmoid colon. The two ends are then sewn together. Till the attached ends heal,
the waste is diverted into a colostomy bag through an opening in the abdomen.
There are two ways in which the surgery can be performed. A large incision is
made in the middle section of the lower abdomen and the diseased part is
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removed while performing open sigmoid colectomy. In case of laparoscopic
sigmoid colectomy, four to five small incisions are made and a laparoscope is
inserted in order to view the colon on a monitor. The surgical tools are inserted
through the incisions and the infected part is removed and the ends are attached
together. Since the size of incision is small and laparoscopic colon resection is a
minimally invasive surgery, the chances of sigmoid colectomy complications
arising due to internal bleeding are lower. Colectomy recovery time is also lower,
in case of laparoscopic colectomy.
• STEP 1: Identifying the Colic Lesion
A full intra-abdominal exploration is performed and the findings are recorded very
carefully. The primary lesion is then located, and its characteristics noted. If
extension to the anterior abdominal wall or to the retroperitoneum is noted, the
case is usually converted to an open procedure.
• STEP 2: Mobilization of the Sigmoid Colon
The colon is mobilized by retracting it medially with an ENDO BABCOCK*
instrument. The retroperitoneal attachments are released with blunt dissection.
The ureter is visualized. Hemostasis is controlled. The sites of the colic resection
distal and proximal to the tumor are identified. A mesenteric window is created
under these sites using the ENDO SHEARS* or ENDO DISSECT* instruments.
The windows should be of 1 to 2cm in size.
• STEP 3: Transecting the Colon and Isolating the Specimen
The distal sigmoid colon is transected with an ENDO GIA II* with 60 cartridge (or
a Powered ENDO GIA* 60 or ENDO GIA* 30) passed through the mesenteric
window. The same maneuver is repeated proximally. The colon is then grasped
with an ENDO BABCOCK* instrument and raised upward to expose the
mesenteric support of the sigmoid colon. The mesenteric resection is well-
mapped (V Shape).
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The stapling device is reloaded with a new cartridge, closed around the
mesentery and fired. The mesentery of the resected colon should be resected
widely to include an adequate resection of the supporting lymph nodes. All
oncologic principles should be respected. This procedure is repeated until thecolic specimen has been amputated from the gastro-intestinal tract. Occasional
bleeding sites on the stapled lines will have to be clipped with ENDO CLIP* ML.
The specimen remains until the end of the procedure in the right lower quadrant.
• STEP 4: Creating the Anastomosis
The colic stumps are placed (stapled closed) in proximity to each other. An
atraumatic grasper grasps the corner of the staple line of the bowel stump. Usingan ENDO SHEARS* instrument, the corner is cut (1 cm) and the lumen of the
large bowel is entered. An ENDO BOWEL* Clamp may be used on the proximal
bowel to avoid intraabdominal fecal spillage. (An additional trocar may have to be
inserted for this purpose).
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The same procedure is
performed for the other bowel
stump. Both stumps are then
grasped at the level of the cut
and held by a single grasper
or ENDO BABCOCK* clamp.
The reloaded jaws of the
ENDO GIA II* with 45
cartridge or Powered ENDO
GIA* 60 are inserted into each
bowel limb and are fired. It is then removed. Two atraumatic graspers or ENDOBABCOCK* clamps will grasp the edges of the colic opening and will
approximate the opening in a triangular fashion.
• STEP 5: Retrieving the Specimen
An incision is made to remove the specimen. Two types of incisions can be
made. We prefer a right lateral 1 inch transverse incision at the level of the
umbilicus (as lateral as possible). The specimen is removed and the incisionclosed with a penrose drain. For cosmetic reasons some patients may prefer a
mini-pfannenstiel incision. Once the specimen is removed, a Blake drain is
inserted in the pelvis; the abdomen is desufflated; and all trocars are removed.
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References:http://www.cancer.gov/cancertopics/pdq/treatment/colon/Patient/page2http://www.medical-artist.com/sigmoid-colectomy-medical-illustration.htmlhttp://www.galeon.com/drmarin/cotech.htm
http://www.buzzle.com/articles/sigmoid-colectomy.htmlhttp://www.ehow.com/about_5514523_sigmoid-colon-cancer-symptoms.htmlhttp://www.ehow.com/info_8343080_types-resection.html