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Colorectal - The Surgical Formula PowerPoint Presentation

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Description : Check out this medical presentation on Colon and Rectal Surgery, which is titled "Colorectal - The Surgical Formula", to know about the anatomy of the colon and blood supply, and paraphernalia indicating colorectal surgery.

Tags : Colon, Rectal Surgery, Colorectal, anatomy, paraphernalia indicating colorectal surgery

Published on : Jul 20, 2021 | Views : 2902 | Downloads : 10

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Slide 1-

Colorectal Dr Shiraz Jamshaid
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Anatomy Anatomy of the colon and blood supply
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Colon structure
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Blood supply Foregut Hindgut Midgut T12 L1 L3 COELIAC TRUNK SUPERIOR MESENTERIC ARTERY INFERIOR MESENTERIC ARTERY AORTA Left gastric Splenic Hepatic Ileocolic Right colic => ASCENDING Mid colic => TRANSVERSE Sigmoidal => SIGMOID Left colic => DESCENDING Sup. Rectal => UPPER RECTUM OOESOPHAGUS 1ST +2ND PART OF DUODENUM 3rd AND 4TH PART OF DUODENUM 2/3 OF THE WAY OF TRANSVERSE COLON REMAINING TRANSVERSE COLON UPPER ANAL CANAL REMEMBER THE NUMBER 3
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WE NOW KNOW WHAT SUPPLIES THE COLON AND WHAT BLOOD VESSELS CORRELATE TO WHICH PORTION OF THE COLON THUS IF THAT PORTION OF THE COLON IS REMOVED THE CORRESPONDING BLOOD VESSELS WILL NEED TO BE CAUTERISED/LIGATED
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Abdo exam- key signs
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General Inspection- signs Paraphernalia indicating colorectal surgery NG aspiration tube (not feeding)- to give bowel some rest IV fluids Parenteral nutrition Abdominal drain
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Closer Inspection- signs Abdominal SCARS STOMAS KEY PART OF EXAMINATION By looking at these two things alone, you should be able to work out the possible surgeries this patient has had  To do this we need to know the different types of colorectal surgeries!
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Extended Right Hemicolectomy (If Transverse colon involved) Right Hemicolectomy (If Ascending colon involved) Left Hemicolectomy (If Descending colon involved) REMOVED= CAECUM + ASCENDING COLON ANASTOMOSIS= YES STOMA= NO REMOVED= CAECUM + ASCENDING COLON + TRANSVERSE COLON ANASTOMOSIS= YES STOMA= NO REMOVED= DESCENDING COLON ANASTOMOSIS= YES STOMA= NO N.B Low pressure areas of the colon removed (i.e. not sigmoid). So anastomosis can occur as there is low risk of leak/perforation
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Abdomino-Perineal (AP) resection (If anal sphincters involved) Sigmoid colectomy/ Hartmann’s (EMERGENCY i.e. obstruction/ perforation) Anterior resection (If anal sphincters not involved) REMOVED= SIGMOID COLON ANASTOMOSIS= NO STOMA= END COLOSTOMY REMOVED= PART OF SIGMOID COLON + RECTUM + ANUS (patient’s anus closed) ANASTOMOSIS= NO STOMA= END COLOSTOMY REMOVED= PART OF SIGMOID COLON + RECTUM ANASTOMOSIS= YES STOMA= INITIAL LOOP (temporary) ILEOSTOMY N.B High pressure sigmoid removed. So can’t anastomose as risk of leak/perf. Thus stoma normally formed. EXCEPTION
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Pan-procto-colectomy (Entire colon until anus involved) Subtotal colectomy (Most of colon involved except sigmoid+ rectum) REMOVED= ALL COLON except some sigmoid + rectum ANASTOMOSIS= NO STOMA= END ILEOSOTOMY REMOVED= ALL COLON + RECTUM + ANUS ANASTOMOSIS= NO STOMA= END ILEOSTOMY N.B All colon removed, and as you can’t join the small intestine to any other part immediately, Ileostomy produced Now let’s look at the scars involved with these surgeries
Slide 12-

Midline laparotomy scar Laparoscopic port scars EMERGENCY SURGERY ELECTIVE SURGERY To differentiate further we look at the STOMA NO STOMA= R/L HEMICOLECTOMY END COLOSTOMY= HARTMANN’S END COLOSTOMY PLUS CLOSED ANUS= AP RESECTION LOOP ILEOSTOMY= ANTERIOR RESECTION END ILEOSTOMY= SUBTOTAL/ PAN-PROCTO COLECTOMY Difficult to distinguish as nearly always a stoma produced after resecting bowel – done by operating surgeon to give bowel time to rest Stoma reversed later on
Slide 13-

STOMA= Surgically created opening between a hollow viscous and the abdominal wall RIF SPOUTED (to prevent irritation of high enzyme content) WATERY CONTENTS drained LIF FLAT (flushed) FAECAL MATTER drained ILEOSTOMY COLOSTOMY END (permanent) ILEOSTOMY = SINGLE LUMEN LOOP (temporary) ILEOSTOMY = DOUBLE LUMEN END (permanent) COLOSTOMY = SINGLE LUMEN LOOP (temporary) COLOSTOMY = DOUBLE LUMEN SUB-TOTAL COLECTOMY PAN-PROCTOCOLECTOMY (ask if have closed anus to differentiate) ANTERIOR RESECTION HARTMANN’S (will have midline scar) AP RESECTION RARELY USED
Slide 14-

Stoma complications IMMEDIATE Infection Bleeding Necrosis (stoma too tight/ under tension) EARLY High Output Obstruction LATE Retraction (falls back in) Prolapse ( falls out) Stenosis (narrows)
Slide 15-

NOW WE CAN WORK OUT WHAT COLORECTAL SURGERY THE PATIENT HAS HAD BY LOOKING AT: SCARS STOMAS
Slide 16-

Palpation- signs None specific
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Percussion- signs None specific
Slide 18-

Auscultation- signs Absent bowel sounds = ILEUS (Stopping of peristalsis) Tinkling bowel sounds= OBSTRUCTION Both unlikely to present in your clinical exams= as patient’s wont be unwell
Slide 19-

Condition 1: Bowel Cancer Definition- Carcinoma of the bowel
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Causes Risk factors Genetic- FAP, HNPCC Diet- Low fibre Inflammatory bowel disease Adenoma - Rapidly dividing groups of cells Asymptomatic Can bleed Malignant potential Carcinoma Gene hits
Slide 21-

Features Altered bowel habit Anaemia + Wt loss 3) PR bleeding
Slide 22-

Complications Bowel obstruction (we shall see in next condition)
Slide 23-

IX 1) Bloods- Hb (anaemia) + CEA (cancer marker) 2) CT- STAGING 3) Endoscopy + Biopsy - GRADING
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MX Conservative (new guidelines) 2) Medical Chemotherapy +/- radiotherapy---------- normally if T4 staging 3) Surgical BOWEL RESECTION = ELECTIVE (Already seen all types)-------- T1/T2/T3 FAECAL IMMUNOCHEMICAL TEST (FIT) Ages : 60+ : 2 yearly test Looks for blood in faeces Endoscopy if +ve FLEXI SIG TEST Ages : 55-60 : once only Looks for polyps and biopsy taken to see risk of malignancy If +ve – full colonoscopy
Slide 25-

Condition 2: Bowel Obstruction Definition- Mechanical (physical) or functional (ileus) obstruction in the bowel
Slide 26-

Causes IN THE LUMEN IN THE WALL OUTSIDE WALL Faecal impaction Intussuception Gallstone Ileus Bowel cancer Diverticular disease Obstructed hernia Volvulus Adhesions MOST COMMON IN LARGE BOWEL MOST COMMON IN SMALL BOWEL
Slide 27-

Features 1) Abdominal distension 2) Abdominal pain 3) Absolute constipation- No flatus or faeces
Slide 28-

Complications 1) Ischaemia (strangulation of bowel) 2) Perforation= PERITONISM 3) Urinary retention What is this?
Slide 29-

IX Abdominal X-ray (with gastrogaffin) Erect Chest X-ray- To look for air under diaphragm if ? perforation 3) CT scan- to localise site and cause Large bowel obstruction Small bowel obstruction Volvulus Dilated bowel loops in periphery HAUSTRA vsible >6cm distance across= Abnormal >9cm across caecum= Abnormal Dilated loops in centre VALVULAE CONNIVENTES visible SIGMOID = Coffee bean sign CAECAL = Embryo sign
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MX 1) Immediate 2) Small bowel 3) Large bowel NBM NGT + Fluids= DRIP + SUCK Prophylactic Antibiotics Analgesia Conservative Mx Resection if perforation EMERGENCY SURGERY – with appropriate stoma If volvulus is the cause- Rectal tube insertion
Slide 37-

Condition 3: Diverticular disease
Slide 38-

Diverticulum = Outpouching of mucosa through muscle layer CAUSE= Increased intraluminal pressure e.g. constipation Diverticulosis = Presence of diverticulum Diverticular disease = Symptomatic diverticulosis Diverticulitis = Inflammation of diverticula
Slide 39-

Features Diverticular disease Diverticulitis Altered bowel habit Left sided colicky pain Relieved by defaecation Fever Abdo pain LIF constant Tenderness
Slide 40-

Complications 1) Abscess 2) Perforation = PERITONITIC SIGNS 3) Haemorrhage
Slide 41-

IX 1) CT- localise site 2) Gastrogaffin enema/ swallow 3) Endoscopy – colonoscopy
Slide 42-

MX Diverticular disease Diverticulitis Conservative Mild Very unwell Obstruction/ perforation Fibre Fluid Lose weight Bowel rest at home= Fluids only NBM NGT + IV fluids = drip and suck ABX= cef and met Analgesia Surgery Hartmann’s resection
Slide 43-

Condition 4: Acute Appendicitis Definition- Infection and inflammation of the appendix
Slide 44-

Features 1) Abdominal pain Tenderness over “McBurney’s point” 2) Rovsing’s sign 3) General signs i.e. Vomiting, pyrexia 2/3rd of the way between Umbilicus and ASIS Palpation in LIF= RIF pain
Slide 45-

Complications 1) Perforation 2) Perforation 3) Perforation Emergency- need to resect asap Patient has PERITONITIC signs
Slide 46-

IX 1) Bloods = High WCC + High CRP (inflammatory markers) 2) Pregnancy test= rule out ectopic 3) Erect CXR - rule out perforation
Slide 47-

MX 1) Immediate Abx  Metronidazole 2) Appendicectomy = open/ laprascopic 3) +/- Abdominal lavage If perforation LANZ = FLAT LAND Open appendicectomy scars
Slide 48-

Condition 4: Hernias- Inguinal Definition of hernia= Protrusion of a viscous through a defect in the wall of the cavity containing it. Inguinal hernia – Hernia involving the inguinal canal
Slide 49-

INGUINAL CANAL CONTENTS MEN= Spermatic cord WOMEN= Round ligament of the uterus BOTH= Nerve, Arteries (testicular/ ovarian), Veins
Slide 50-

SKIN CAMPERS FASCIA SCARPA’S FASCIA EXTERNAL OBLIQUE – MUSCLE INTERNAL OBLIQUE – MUSCLE TRANSVERSUS ABDOMINIS-MUSCLE TRANSVERSALIS FASCIA PERITONEUM INGUINAL CANAL ANT ANT – APONEUROSIS INT + EXT OBLIQUE ROOF- TRANSVERSUS ABDOMINIS POSTERIOR- TRANSVERSALIS FASCIA FLOOR- INGUINAL LIGAMENT
Slide 51-

Inguinal hernia- types Indirect = Hernia passes through deep ring and then out of superficial ring 2) Direct = Hernia pushes its way through an abdominal wall weakening (Hasselbach’s triangle) into the canal and out of superficial ring
Slide 52-

Complications 1) Irreducible (incarcerated) 2) Obstruction 3) Strangulation
Slide 53-

IX Clinical exam To distinguish indirect/ direct= Block deep ring (mid point of inguinal ligament) When patient coughs If hernia appears= DIRECT If doesn’t appear= INDIRECT 2) USS
Slide 54-

MX conservative- Weight loss Medical - none Surgical – indicated if incarcerated Open mesh repair = “Lichenstein” Open suture repair = “Shouldice” Laproscopic = Totally extra peritoneal (TEP) / Trans abdominal pre peritoneal (TAPP)
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Condition 5: Hernias- Femoral Definition of hernia= Protrusion of a viscous through a defect in the wall of the cavity containing it. Femoral– Hernia involving the femoral canal
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How to distinguish from inguinal Inguinal hernia = superior + medial to pubic tubercle Femoral hernia= inferior + lateral to pubic tubercle
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Complications 1) Irreducible (incarcerated) 2) Obstruction Strangulation NARROW CANAL = MORE RISK OF STRANGULATION THAN INGUINAL
Slide 59-

IX 1) Clinical = superior + medial to pubic tubercle 2) USS
Slide 60-

MX ALWAYS SURGERY ( as risk of strangulation) Herniotomy = Ligation and excision of sac (+/- Herniorrhaphy= repair of the abdominal wall defect)
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Condition 6: Fistula in ano Definition- Abnormal connection between a hollow viscus (bowel) and the surface of the body
Slide 62-

Types INTERNAL SPHINCTER = Involuntary control of anus EXTERNAL SPHINCTER = Voluntary control of anus 3 1 2 1 = SUPERFICIAL FISTULA 2 = INTERSPHINCTERIC FISTULA 3= TRANSPHINCTERIC FISTULA DOESN’T INVOLVE SPHINCTERS GOES THROUGH INTERNAL SPHINCTER GOES THROUGH INTERNAL + EXTERNAL SPHINCTERS
Slide 63-

Features 1) Discharge 2) External opening around anus 3) Previous perianal infection
Slide 64-

IX NONE – VISUAL and CLINICAL diagnosis MRI if not sure
Slide 65-

MX 1 = SUPERFICIAL FISTULA Fistula laid open https://www.youtube.com/watch?v=scxKioX_hDA 2 = INTERSPHINCTERIC FISTULA CUTTING SETON suture- progressively tightened 3= TRANSPHINCTERIC FISTULA FIBRIN glue- Plugs the fistula Seton suture not used as increased risk of incontinence
Slide 66-

Condition 8: Haemorrhoids Definition- Disrupted and dilated anal cushions caused by severe constipation
Slide 67-

Classification
Slide 68-

Features 1) Painless PR bleeding 2) Pruritis ani 3) Tenesmus
Slide 69-

IX 1) PR exam 2) Proctoscopy 3) CT – to look for any cause of constipation
Slide 70-

MX 1) Conservative 2) Medical 3) Surgical Topicals e.g. Anusol (hydrocortisone) Laxatives Fibre Rubber band ligation Injection sclerotherapy (fibrosis of artery) Haemorrhoidectomy (excision of piles)
Slide 71-

QUIZ
Slide 72-

QUESTION 1 Patient with fluctuant abdominal swelling, worse on coughing. Superior and medial to pubic tubercle. 1st line management is: Weight loss Laxatives Herniotomy Herniorrhaphy
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QUESTION 2 Patient with flushed stoma in LIF. Anus no longer patent. No scar. Most likely bowel surgery procedure: Hartmann’s AP resection Anterior resection Subtotal colectomy
Slide 74-

QUESTION 3 Patient presents with LIF constant pain, abdo tenderness, erect CXR shows no signs of perforation. Known chronic constipation patient. Patient not tolerating fluids. How should this patient be managed? Increased fibre in diet NBM, NGT +IV fluids Fluid only diet at home Hartmann’s resection
Slide 75-

QUESTION 4 Patient with the following AXR: How should he be managed? Conservatively Immediate NBM, NGT + IV fluids Hartmann’s Rectal tube insertion
Slide 76-

ANSWERS
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QUESTION 1 Patient with fluctuant abdominal swelling, worse on coughing. Superior and medial to pubic tubercle. 1st line management Weight loss Laxatives Herniotomy Herniorrhaphy
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QUESTION 2 Patient with flushed stoma in LIF. Anus no longer patent. No scar. Most likely bowel surgery procedure: Hartmann’s AP resection Anterior resection Subtotal colectomy
Slide 79-

QUESTION 3 Patient presents with LIF constant pain pyrexia, abdo tenderness. Erect CXR shows no signs of perforation. Known chronic constipation patient. Patient not tolerating fluids. How should this patient be managed? Increased fibre in diet NBM, NGT +IV fluids = management of unwell diverticulitis Fluid only diet at home Hartmann’s resection
Slide 80-

QUESTION 4 Patient with the following AXR: How should he be managed? Conservatively Immediate NBM, NGT + IV fluids Hartmann’s= Riglers sign present Rectal tube insertion
Slide 81-

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