Laparoscopic Colectomy in India :
Minimally Invasive Surgery
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What is a colectomy?
The colon (large intestine) is the last part of your digestive tract. This part of the bowel works to soak up water and store food waste. The colon is a tube-like muscle. This tube has a very smooth lining. The lining is made up of millions of cells. The colon in an adult is about 4 - 6 feet long. The rectum is the last 6 inches of the colon. A colectomy is surgery to remove all or part of your colon.
Part or all of the ascending colon and cecum are removed. The colon is then reconnected to the small intestine.
Part or all of the descending colon is removed. The transverse colon is then reconnected to the rectum.
Part or all of the sigmoid colon is removed. The descending colon is then reconnected to the rectum.
Low Anterior Resection
The sigmoid colon and a portion of the rectum is removed. The descending colon is reconnected to the remaining rectum.
Abdominal Perineal Resection
Part of or all of the sigmoid colon and the entire rectum and anus are removed. A colostomy will be made. A colostomy creates an opening in your stomach wall so waste can pass from the body.
Why would I need a colectomy?
This is done to remove the disease causing your symptoms, such as :
For most people, this will cure the problem or at least greatly reduce their symptoms.
- Irritable bowel disease
- Rectal prolapsed
Symptoms of colorectal diseases include bleeding from the rectum, abdominal pain, change in bowel habits (new diarrhea, constipation, stool size, etc.), weight loss, anemia, cramping, vomiting, fever, among many others. Prior to undergoing surgery, your primary doctor or your surgeon will usually do tests (blood work, colonoscopy, barium enema, CT scan, etc.) to decide the cause of your symptoms. If you are found to have a disease that requires surgery, that is when a laparoscopic colorectal operation will be considered.
Minimally invasive or laparoscopic surgery involves using multiple trocars (thin tubes) placed through 3 to 5 small incisions. These incisions are usually less than 0.5 cm (less than ľ inch). Carbon dioxide gas is then used to slowly inflate the abdomen. A thin telescope is placed through one of the trocars. This allows the surgical team to view the inside of the abdomen on a TV monitor. Specialized instruments are placed through the other trocars to perform the operation. For colon surgery, one of the incisions is enlarged to remove the piece of colon. This larger incision can also be made initially, allowing one hand to be placed within the abdomen along with the camera and long instruments to assist with the operation. The procedure is performed under general anesthesia.
Results are different for each procedure and each patient. Some common advantages of minimally invasive colorectal surgery are :
Many patients qualify for laparoscopic or minimally invasive surgery. However, some conditions may decrease a patientís eligibility, such as previous abdominal surgery, cancer (in some situations), obesity, variations in anatomy or advanced heart, lung or kidney disease.
- Shorter hospital stay
- Shorter recovery time
- Less pain from the incisions
- Faster return to normal diet
- Faster return to work or normal activity
- Better cosmetic healing
What happens before surgery?
The doctorís secretary will give you the date of your surgery and the time and place to report to that day. Your surgeon will do a physical exam before surgery. If you need other testing, such as a chest x-ray, blood tests or an EKG to check your heart, you will be told when and where those are scheduled. If you are taking aspirin, Coumadin, Plavix or any other type of medication that may thin your blood, please tell your doctor. You will need to stop this medication before surgery.
Day before surgery
You will need to do a bowel prep to clean the stool out of your colon. Your doctor or nurse will give you more instructions based on the type of prep. You should not eat or drink anything after midnight the evening before your surgery.
Morning of surgery
Bring all your medicines in their original containers with you to the hospital. You will meet with the anesthesiologist. This doctor will talk to you about general anesthesia. This is a controlled sleep while the surgery is being done so you will not feel any pain or remember the surgery. You will have an IV or intravenous line put in to give you fluid and medicine during your surgery. When it is time for you to go to surgery, your family will be asked to wait in the waiting area. Your doctor will talk to your family there after your surgery is done.
What happens during surgery?
Right sided colon removal requires a 1/2 inch incision near the umbilicus to place the camera. Instruments are placed through three 1/4 inch incision and the colon is extracted using an incision about three inches long.
Left sided colon removal requires a 1/2 inch incision near the umbilicus to place the camera. Instruments are placed through two 1/4 inch incision and the colon is extracted using an incision about three inches long.
This procedure is performed under general anesthesia, which means you will be completely asleep. After you go to sleep, a tube will be put into your nose and down your throat into your stomach. This is called a nasogastric tube or NG. It is used to remove secretions in your stomach until your stomach and bowel begin to work again after surgery. You will also have a tube put in to drain your bladder of urine. This is called a Foley catheter. This will stay in for a few days after your surgery.
Compression devices are used to help keep your blood circulating in your legs. These are wraps placed around your legs. There is a pump attached that will put air into the wraps. The air is pumped in one part of the wrap and then another so that your leg is squeezed to help keep the blood in your veins moving, much like your leg muscles would do if you were up walking. This is done to lessen your chance of getting blood clots. These will be used after surgery until you are able to be up and walking.
Once everything is in position, the surgical team will work together to perform the operation. Monitors are used to observe your vital signs throughout the surgery. There will be stitches used to close the layers inside. You may have staples on the outside of the incision to hold it together after the surgery is done. When the operation is complete the breathing tube is removed. Most patients do not remember this.
What happens after surgery?
After your surgery is done, you will be taken to the Post-Anesthesia Care Unit, or PACU. You will be there for 1-2 hours. When you are ready, you will be moved to your hospital room where your family will be able to see you. The nurses will continue to check your heart rate, blood pressure, temperature, breathing and your incision.
They will also be checking your tubes :
For pain control, there may be a pump attached to your IV. This is called a PCA or patient controlled analgesia pump. You will have a button that you push when you start to feel itís time for pain medicine. The pump is set so that you cannot get too much medicine. Often you will use this pump until you are able to eat and take pain medicine by mouth. The compression devices will stay on your legs while you are in bed during your hospital stay to lessen your risk of blood clots.
- NG to drain your stomach. This is sometimes removed in the operating room but otherwise will stay in for about 1-4 days.
- Foley catheter to drain your urine. This stays in for 2-3 days.
- IV for fluids and medicine. This will stay in until you are able to eat again.
That afternoon or, at the latest, on the first day after your surgery, you will be helped out of bed to sit in a chair. By the second day, you will need to walk in the hallway. Walking helps lessen your risk of getting a lung infection or blood clots. It also speeds up your recovery.
You will not be able to eat or drink anything at first. You may be given some ice chips at times. Once the NG tube is removed, you will start on a clear liquid diet the next day. Your diet will be changed each day, as you are better able to eat foods.
Complications are possible with any surgical procedure. The following are some complications related to laparoscopic colorectal surgery :
If the operation cannot be completed laparoscopically, the surgeon will make a traditional, larger incision. Reasons for this include bleeding and the inability of the surgeon to clearly view the operative area. This should never be considered a failure, but rather a prudent decision by the surgical team to safely complete the operation.
- Adverse reaction to anesthesia
- Bleeding in the abdomen
- Infection in the abdomen or wounds
- Intestinal obstruction due to scar tissue
- Leakage from the bowel
- Heart attack or pneumonia
- Blood clots in the legs or lungs
- Injury to other organs
When will I leave the hospital?
You will be able to leave the hospital when you are :
Most people are able to go home 4-7 days after their surgery.
- Able to eat a regular diet and drink fluids
- Passing gas or you have had a bowel movement
- Passing urine
- Not having a fever or other signs of infection
- Walk for short distances
What can I expect after discharge?
These guidelines give you an overview of what you may expect as part of your care after you leave the hospital. Be sure to follow your doctorís discharge instructions if they are different from what is listed here.
It is fairly common to feel weak and tired immediately after discharge from the hospital. The body needs time to recover from the stress of a major operation.
Walking is permitted and encouraged beginning the next day after surgery. At home, start short, daily walks and gradually increase the distance you walk.
Going up and down stairs is permitted. Initially, have someone assist you.
You may lift light objects (less than 10lbs.) after your discharge. This may be increased gradually after one month. If lifting an object causes discomfort, you should discontinue the activity. This restriction helps prevent hernias at the sites of your incisions.
Showers are permitted 2 days after surgery. Wash over your incisions gently with soap and water. Be careful to rinse well. Pat the incisions dry.
Driving is not permitted for 2 weeks after surgery or your first follow-up visit with your surgeon. If you are taking prescription pain medications or narcotics, DO NOT DRIVE.
Sexual intercourse may be resumed as your comfort level permits.
Return to work
People with sedentary jobs have returned to work as early as two weeks postoperatively. A physically demanding job may require 4-6 weeks before returning to work. This may be determined by you and your employer. Some people have residual fatigue several weeks after surgery.
Your bowel habits
You may have different bowel habits after your surgery. Loose stools are common for the first week or two after surgery. If you have watery diarrhea, call your surgeon. This may be a sign of a bowel infection. Severe constipation should be avoided. See the section below on medicines for constipation.
There are generally no dietary restrictions following surgery. Avoid foods that cause diarrhea or digestive discomfort. You will eventually be able to resume your regular diet. A dietary supplement or drink can be used.
Your medicines : Take the medicines you were taking before surgery, unless your doctor has made a change.
Your surgeon will order a prescription pain medicine for you after surgery. As your pain lessens, over the counter pain medicines such as acetaminophen (Tylenol) or ibuprofen (Advil) can be used. They can also be used instead of your prescription for mild pain.
Prescription pain medicines can cause constipation. Your doctor may order docusate (Colace) as a stool softener to prevent this. You should be back to your normal bowel routine in about 2 weeks. If the stool softener does not work, take Milk of Magnesia. If you still are not getting relief, call your surgeon.
Call your doctor's office right away if you have :
- Diarrhea that lasts more than three days
- Nausea and vomiting that will not go away
- Pain in your abdomen that gets worse or isnít eased by the pain medicine
- Pus drainage or redness around your incision
- Fever with a temperature of 100.5 or higher
In order to identify and treat any complications as they may arise, close, lifetime follow-up is essential. Follow-up after surgery is extremely important. Patients usually make an appointment to see their surgeon 2 weeks after discharge. At this visit, further plans are made and the patient may be cleared for full activities such as driving.
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