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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