Colon ResectionRuth Balle & Sydney Glazier

Relevant Anatomy● Sigmoid Colon

● Iliac & Sigmoid Mesocolon

● Colon Layers

○ Serosa

○ Muscular

○ Submucosa

○ Mucosa

● Vessels

○ Left Colic Artery

○ Inferior Mesenteric Artery

○ Sigmoid Arteries

http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&ti=355631

PhysiologyLargest amount of transient flora in the body which can requires prophylactic IV

antibiotics

Pathophysiology● Blockage in the intestine due to scar tissue

● Colon cancer

● Diverticular disease (disease of the large bowel)

● Familial polyposis

● Injuries that damage the large bowel

● Intussusception (when one part of the intestine pushes into another)

● Precancerous polyps

● Severe gastrointestinal bleeding

● Twisting of the bowel (volvulus)

● Ulcerative colitis

http://www.medicinenet.com/diverticulosis/page3.htm

Diagnostic Exams● H & P

● Abdominal X-rays

● Barium Studies

● Fiberoptic Endoscopy

https://www.drugs.com/health-guide/diverticulosis-and-diverticulitis.html

Surgical Interventionopen colon resection of the sigmoid colon finishing with a colostomy or anastomosis

Special Considerationsbowel technique-instruments, sponges and gloved hands that come in contact with the

open bowel are considered contaminated.(It's recommended the ST create two mayo

set ups, one for surgical wound and colon resection and the other for wound closure.)

Resection of cancerous colon requires a distal margin of at least 5 cm and proximal

margin is determined by the colonic blood supply and a greater portions of mesentery

are removed.

AnesthesiaGeneral with nasogastric tube inserted

https://www.jptrev.com/frequently-asked-questions/what-is-general-anesthesia/

PositioningStart in supine and then switch to lithotomy for anastomosis

https://www.slideshare.net/shylu/patient-positioning

Skin PrepAbdominal and perineal if anastomosis is performed

As far laterally as possible

https://medlineplus.gov/ency/presentations/100171_3.htm

DrapingMay use incise drapes followed by lap sheet or four folded towels to square off( edge

of upper towel placement chest lateral towels place using anterior superior iliac spine

as guides and edge of lower towel place just above line of symphysis pubis) and a

laparotomy sheet. For anastomosis add under the buttocks and legging drapes.

http://www.halyardhealth.com/solutions/surgical-solutions/surgical-drapes-packs/surgical-drapes-packs-by-procedure.aspx

Incision midline incision

http://slu.adam.com/content.aspx?productId=617&pid=3&gid=100158

Supplies● Large number of large diameter ties

● Foley catheter

● Active Drain (Hemovac or Jackson-Pratt)

For colostomy -glass rod and tubing with colostomy bag and loop colostomy

http://www.philmedicalsupplies.com/v2/jackson-pratt-drain.html

Equipmentbovie unit,extra mayo stand, stirrups, and suction

Instruments● Major set

○ Extra crile hemostats

○ Extra large hemostats

● Long & deep sets

● GI instrument set with bowel clamps

● GI Staplers

● Large self retaining retractors

http://www.medtronic.com/covidien/products/surgical-stapling/circular-staplers

Procedural Steps● Vertical midline incision & laparotomy opening. Balfour retractor often used.

Surgeon runs the colon.

● Colon is freed. Window created in mesentery and division begins. Colon is

mobilized

*surg tech will need many peans & silk ties in sizes 1-0, 2-0, and 3-0available

● colon is covered with saline soaked sponges

● 4 intestinal clamps placed. 10 blade or bovie divides colon between clamps

handing the bowel section to the tech (linear cutter to transect and staples may

also be used). Bowel is placed into a sterile basin and passed to circulator.

*Surg tech remember clamps may still be on the specimen when counting

Procedural steps ( cont. For colostomy)● End bowel technique

● A stoma site is created

- The circular incision is made with a 10 blade then the

subcutaneous tissue is removed using a bovie pencil,dissecting

down to the anterior fascia then the muscle fibers are split then

transversalis fascia and peritoneal fat are dissected in the

peritoneum is opened

● The end segments of colon are brought through the stoma site

and extended beyond skin surface

● The colon is sutured to the peritoneal defect and then to the

skin surrounding the stoma

● Laparotomy closure performed

http://www.myflexicare.com/uk/ostomy/typesofcolostomy.php

Procedural steps (cont. For anastomosis)-if linear cutter was used corners of the bowel are removed so the stapler can fit back

in. Bowel ends are brought together. Surgeon uses silk or vicryl to suture together

interrupted or a stapler

*tech should have multiple packs of staples ready

-second layer of absorbable suture is placed and continued until anastomosis is

complete

-third layer of suture is placed (interrupted vicryl or silk)

-bowel technique ends

Procedural steps (cont. For anastomosis)-remove sponges, bovie, suction, & contaminated instruments from field

-Regown & glove. Redrape. New suction, bovie, laps, & instruments brought to field

-Laparotomy closure performed.

Counts● Prior to the skin incision

● When closure of peritoneum is initiated or any first layer of a cavity

● When closure of fascia is initiated or layer before subcutaneous

● As soon as skin closure is initiated

Dressing MaterialMay need pillow bolster for when pressure will be applied like when patient needs to

cough or sneeze.

-vaseline gauze

- ABD pad

-transpore tape

Specimen Care(if taken out because of cancer) excised colon taken to the lab to check margins in

basin.

Prognosisno complications- return to most normal activities in 6-8 weeks. Somewhat altered

lifestyle and diet. Bowel habit may be altered depending on the location of resection.

Complications● incisional hernia

● Internal bleeding

● Dehiscence

● Scar tissue

● Death

● SSI

● Thrombophlebitis

● Leaking from anastomoses

● Stump rupture from colostomy

● Damage to ureter

● Hemorrhage

● Post op adhesions may cause obstruction

http://medical-dictionary.thefreedictionary.com/dehiscence

Wound ● Class 2 or 3 depending on if it was planned and a bowel prep was used