Digestive Diseases: Laparoscopic Surgery and Hand-Assisted Laparoscopic Surgery

Laparoscopy can be used to treat the following conditions

• Crohn's disease unresponsive to medical therapy or causing a blockage
• Colorectal cancer
• Diverticulitis with recurrent attacks or failure of medical therapy
• Familial polyposis, a condition causing multiple colon polyps that puts you at higher risk of colorectal cancer, which then requires total colonectomy (removal of the colon)
• Bowel incontinence
• Rectal prolapse
• Ulcerative colitis unresponsive to medical treatment
• Colon polyps that are too large to remove by colonoscopy
• Chronic severe constipation that is not successfully treated with medication may require shortening the length of the colon by removing a part of the colon using surgery.

Three or more small (5-10 mm) incisions are made in the abdomen to allow access ports to be inserted. The laparoscope and surgical instruments are inserted through these ports. The surgeon then uses the laparoscope, which transmits a picture of the abdominal organs on a video monitor, allowing the operation to be performed.

Laparoscopic intestinal surgery can be used to perform the following operations:

• Proctosigmoidectomy. Surgical removal of a diseased section of the rectum and sigmoid colon. Used to treat cancers and noncancerous growths or polyps, and complications of diverticulitis.
• Right colectomy or Ileocolectomy. During a right colectomy, the right side of the colon is removed. During an ileocolectomy, the last segment of the small intestine - which is attached to the right side of the colon, called the ileum, is also removed. Used to remove cancers, noncancerous growths or polyps, and inflammation from Crohn's disease.
• Total abdominal colectomy. Surgical removal of the large intestine. Used to treat ulcerative colitis, Crohn's disease, familial polyposis and possibly constipation.
• Fecal diversion. Surgical creation of either a temporary or permanent ileostomy (opening between the surface of the skin and the small intestine) or (colostomy (opening between the surface of the skin and the colon). Used to treat complex rectal and anal problems, including poor bowel control.
• Abdominoperineal resection. Surgical removal of the anus, rectum and sigmoid colon. Used to remove cancer in the lower rectum or in the anus, close to the sphincter (control) muscles.
• Rectopexy. A procedure in which stitches are used to secure the rectum in its proper position. Used to correct rectal prolapse.
• Total proctocolectomy. This is the most extensive bowel operation performed and involves the removal of both the rectum and the colon. If the surgeon is able to leave the anus and it works properly, then sometimes an ileal pouch can be created so that you can go to the bathroom. An ileal pouch is a surgically created chamber made up of the lowest part of the small intestine (the ileum). However, sometimes, a permanent ileostomy (opening between the surface of the skin and the small intestine) is needed particularly if the anus must be removed, is weak, or has been damaged.

Your surgeon will meet with you to answer any questions you may have. You will be asked questions about your health history and a general physical examination will be performed. Your intestine will require cleaning and 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 may also have an ECG (electrocardiogram), a chest X-ray, lung function tests, or other tests. You may also need to meet with another doctor before surgery.

Finally, you will meet with an anesthesiologist, who will discuss the type of pain medication (anesthesia) you will be given for surgery, and you will learn about pain control after the operation.

The evening before surgery you will need to take the prescribed laxative medicine. 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.

An intravenous (IV) tube will be inserted into a vein in your arm to deliver medications and fluids. You will be taken to the operating room when it is available and ready.

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 port just below your bellybutton and advance the port into your abdominal cavity. This port is connected to sterile tubing and carbon dioxide is passed into the abdominal cavity through the tubing. The gas lifts the wall of your abdomen away from the organs below. This space will give your surgeon a better view of your abdominal cavity once the laparoscope is in place. The laparoscope is placed through the port and is connected to a video camera. The image your surgeon sees on 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 may not be done include multiple adhesions (scar tissue from previous surgery), infection or other abdominal diseases.

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 operation you are having.

If needed, one of these small incisions may 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.

If necessary, your surgeon will begin the removal of part of the intestine 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 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 surface 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, which is attached to the stoma and must be worn at all times.

Most of the time, 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 positions staples to join the ends of the intestine. Or, the surgeon may 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 is no bleeding, rinse out the abdominal cavity, release the gas from the abdomen, and close the small incisions.

When you wake up from the operation, 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 that helps eliminate the remaining anesthesia from your system and soothes your throat. Your throat may be sore from the breathing tube that provided you with air and anesthetic gases during the operation, but this soreness usually subsides after a day or two.

Once you are more alert, the nurse may 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 may need to keep the oxygen in place for a while. The nurse will check the amount of oxygen in your blood (oxygen saturation) by placing a soft clip on one of your fingers (pulse oximetry).

Pain medication will be given as you recover.

After your operation, the nurses will begin to 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 the operation.

The tube that was passed from a nostril into your stomach (a nasogastric tube) during surgery will be removed in the recovery room, if it has not been removed already. You may begin to drink liquids the evening of the operation and will resume a solid diet the next morning. If you become nauseated or begin to vomit, your nasogastric tube may be reinserted. If this happens, don't be alarmed. Nausea and vomiting happen in approximately 5% or 10% of people and occur because your intestines are temporarily disabled from the operation. In addition, anesthesia makes many people nauseous. For this reason, food and drink are given slowly for the first few days.

You will be encouraged to get out of bed and walk, starting the first day after the operation. The more you move the less chance for complications such as pneumonia or the formation of blood clots in your leg veins. The quicker you pass gas or move your bowels, the quicker you may return home.

The length of your hospital stay will depend on the type of procedure you have and how quickly you recover. For example, the average hospital stay for a laparoscopic rectopexy ranges from 1 to 2 days and for a laparoscopic bowel resection, 1 to 3 days.

You will be encouraged to steadily increase your activity 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 stay clear. Avoid constipation by using stool softeners, as pain medications usually can cause constipation.

Reviewed by The Cleveland Clinic Department of Colorectal Surgery and Thomas E. Garofalo, MD, (2005).

Edited by Cynthia Dennison Haines, MD on March 01, 2006.

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