• Clinical science

Bowel surgery

Abstract

Bowel surgery encompasses all surgical procedures of the small and large intestine. The underlying conditions most commonly requiring bowel surgery are malignancies (especially colorectal cancer) and inflammatory processes (e.g., sigmoid diverticulitis). These surgical procedures may require the creation of an artificial bowel outlet (stoma). Depending on the underlying disease process and the planned surgical procedures, a stoma may be temporary or permanent. A permanent stoma is created following a procedure in which continence could not be preserved, whereas a temporary stoma allows for uninterrupted bowel healing (e.g., following surgery). Intestinal stomas are usually loop stomas, consisting of a proximal and a distal end, while end stomas have one opening which functions as an artificial anus. One of the main complications of bowel surgery is anastomosis insufficiency, which may lead to abscess formation, peritonitis, and sepsis.

Further bowel surgery techniques such as left and right hemicolectomy, transverse colectomy, proctocolectomy, and ileal pouch-anal anastomosis are discussed in the learning cards on colorectal cancer and ulcerative colitis.

Procedure/application

Basic surgical approaches

Bowel surgery can either be performed laparoscopically or as a conventional open procedure. The creation of an artificial bowel outlet or stoma (see below) may be necessary.

Elective surgery

The following factors can help maximize surgical efficacy in planned procedures:

  • Time surgery to take place in periods in which possible inflammation is absent or low
  • Optimum treatment of comorbid conditions prior to surgery
  • Adequate preoperative measures to prevent abdominal infection (e.g., antibiotic prophylaxis; , intestinal cleansing )

Emergency surgery

The acute onset of severe illness requiring emergency surgery typically means that preoperative conditions cannot be optimized (see above). This can considerably increase the risk for intraoperative and postoperative complications.

  • Measures to prevent complications: in a two-stage surgical procedure a temporary stoma is created in a first step to divert stool from diseased portions of the bowel, allowing rest, and is reversed in a second step after healing has occurred.

Stoma (enterostomy, artificial bowel outlet, artificial anus)

  • Indication: : allows removal of feces from the body
  • Procedure
    • The site of the stoma is selected and marked prior to surgery
    • The protruding bowel is secured by a support ring to prevent it from slipping back through the incision.
    • A skin barrier that allows for attaching the collection bag is fitted over and around the stoma.

Loop stoma

  • Indications
    • Protective loop stoma: Protects distally located parts of the intestine (e.g., inflamed parts, fresh anastomoses
    • Palliative loop stoma: fecal drainage (e.g., cases of distal bowel obstruction)
  • Technique
    • Entire loop of bowel is exteriorized
    • Usually, parts of the ileum are used (ileostoma).
    • Handling: the stoma continually drains bowel contents, requiring continuous use of a stoma bag.
    • A protective loop stoma is reversed a few weeks/months following surgery (after sufficient healing of the anastomosis).

End stoma

  • Technique
    • Exteriorization of the proximal end of the bowel. The distal end is sutured or stapled closed and remains as a blind pouch in the abdomen.
    • The bowel is pulled out 1–2 cm and then sutured to the skin.
    • Usually, parts of the colon (colostomy) are used.
  • Indications
  • Handling: in colostomy patients, irrigation is an option (controlled evacuation of the bowel to have a period free of output, restoring control)
  • Depending on the indications for the initial operation and the underlying condition, re-anastomosis with restoration of intestinal continuity may be possible 3–4 months following surgery.

References:[1][2][3][4]

Complications

Anastomosis insufficiency (anastomotic leak)

  • Causes
    • Emergent surgery or prolonged operative time
    • Decreased perfusion of the anastomosed bowel segments
    • Increased pressure within the anastomosis
  • Clinical features
    • Postoperative fever, tachycardia (usually 5–7 days following surgery)
    • Abdominal distention, pain, and peritoneal signs
    • Tender incision wound, purulent (or feculent) drainage
  • Diagnostics
    • Elevated inflammatory parameters
    • X-ray/CT scan: contrast medium leakage; in a barium meal or rectal filling; fluid collections and/or gas collections
  • Complications: : abscess formation, peritonitis, SIRS, sepsis
  • Treatment
    • Revision surgery
    • Treating complications (e.g., by giving broad-spectrum antibiotics in the case of infection)
    • Endoluminal vacuum-assisted closure therapy

Wound dehiscence

  • Definition: spontaneous wound rupture along an incision with fascial dehiscence and possible prolapse of underlying structures/organs; may occur following any type of surgery, but seen particularly often following laparotomy in abdominal surgery.
    • Partial wound dehiscence; : insufficiency of deep sutures while the superficial sutures remain intact
    • Complete wound dehiscence: insufficiency of all suture layers (e.g., visibly protruding intestine)
  • Causes
    • Postoperative inflammatory processes in the abdomen
    • Wound healing disorders
    • Insufficient surgical sutures or poor suturing technique
    • Increased pressure in the abdomen caused by coughing; or gas
    • Premature mobilization of the patient
  • Clinical features
    • Usually occurs 4–7 days postoperatively
    • Pink, watery wound drainage
    • Open wound and protuding intestine in case of complete wound dehiscence.
  • Diagnostics: : usually a clinical diagnosis
  • Treatment
    • Preoperatively
      • Use of adhesive tapes as adjunctive wound support and abdominal binders to prevent further wound dehiscence.
      • Mobilization of the patient with great care to avoid an increase in pressure.
    • Urgent revision surgery (multiple irrigations and debridement of the wound margins) to prevent evisceration or a hernia later on.
    • Usage of a support bandage and a negative-pressure (vacuum) wound dressing if wound heals inadequately.

Others

  • In malignancy: (locally) recurrent cancer
  • Fecal incontinence, increased stool frequency
  • Adhesions
  • Stomal complications
    • Stoma retraction (the stoma is drawn below skin level)
    • Prolapse
    • Skin maceration, necrosis

References:[4]

We list the most important complications. The selection is not exhaustive.