Whilst laparoscopic colorectal surgery (LCR) shares many of the same risks as open bowel surgery, patients tolerate it far better, have less pain and enjoy a quicker recovery with a faster return to their normal life style/work.
What is the large bowel?
The small bowel absorbs nutrients. What can't be used (1 Litre/day) enters the large bowel where fluid is absorbed, gradually forming the waste into faeces. The rectum is usually empty, except when a pressure wave propels stool into the rectum. The latter is often stimulated by activity or eating, especially breakfast. Bowel frequency varies from individual to individual.
What is a large bowel resection?
A large bowel resection is an operation to remove all or part of diseased bowel. The bowel is like a hollow tube. The surgeon removes part of the bowel and sews or staples the ends together. The amount removed depends on the reasons for the operation.
Traditionally these operations are performed through large incisions running up and down the whole length of the abdomen (shown on the left - a surgeon divides the distal rectum with a staple gun). The abdominal wall is held appart with a metal retractor.
A drain or small tube is usually placed in the abdomen to draw away any oozing fluids around the operation site. The abdomen is closed in layers and the patient watched for any problems developing while waiting for the bowel to resume function so that they can eat and go home.
Whilst waiting for bowel function to return the patient is kept hydrated with a drip. Occasionally a nasogastric tube is required to drain the stomach (if it is not emptying properly or the small bowel becomes paralysed/ileus). Morphine is given for pain relief through a vein using a little button switch which you control or via an epidural. Your anaesthetist will explain how this system works before your operation.
Open operations leave the patient with a large wound (shown here); this patient had an elective (planned) right hemicolectomy and stayed in hospital for nine days!
What is a laparoscopic bowel resection?
Since the 1990s, an increasing number of surgeons experienced in colorectal and laparoscopic surgery have been removing bowel in a similar manner to the more familiar gallbladder surgery.
Instead of making an opening large enough to work with his hands the surgeon places three ports in the patient, through which a video camera and miniature versions of the usual surgical instruments are passed.
Most people who have an open operation need 6-8 weeks off work depending a little on what you do. Most people undergoing laparoscopic operations are home within 1-4 days of surgery and fully recovered in a fortnight.
Laparoscopic Anterior Resection: is designed to remove all or part of the rectum and its blood supply; removes the lymphatic drainage in cancer cases. The blood supply of the large bowel, from the inferior mesenteric artery, makes it necessary to also remove the sigmoid and descending colons. The mobilised splenic flexure is then anastomosed (re-joined) without any tension to the lower 2/3 of the rectum in a high anterior resection or in a TME resection to the lowest part of the rectum, just above the anal canal at the level of the pelvic floor.
This is an illustration of a rectal carcinoma invading the uterus and causing a large bowel obstruction. The TME specimen with attached uterus is removed through a small incision sited through the umbilicus.
A conventional "open" operation would require a FULL length midline incision (shown above); ouch!!
Typically the patient will be left with a 3cm incision through the umbilicus that is used to remove the specimen along with 5mm and 12mm incisions (operating ports) in the right iliac fossa (where the appendix is found).
In the majority of TME resections the large bowel and anastomosis or "join" will be defuctioned with a loop ileostomy or stoma untill the "join" has healed.
Bristol Laparoscopic Associates are now offering single port (SILS, LESS, E-NOTES) laparoscopic surgery with added benefits of an even quicker recovery and reduced pain. The picture on the left shows the final cosmetic appearance following a low anterior resection for rectal cancer; with the patient discharged home within 40hrs of extubation from the general anaesthetic.
BLA have the largest experienc eof this type of approach for colo-rectal resection in the world!
Laparoscopic right hemicolectomy: is designed to remove the right side of your colon along with its blood supply (ileo=colic artery and vein) and the final few inches of the small bowel. Typically the patient will be left with a 3cm incision through the umbilicus whic is used to remove the operative specimen and 5mm and 12mm suprapubic incisions. After removal of the diseased portion of the bowel the two free ends will be joined together. It is extremely unlikely that you would require a stoma after this operation.
Previous open surgery is nolonger a contraindication for laparoscopic surgery. This phots shows the cosmetic appearance following a right hemicolectomy in a patient who had undergone a previous partial gastrectomy and cholecystectomy. The possition of the scars is typical of a RHC. Previous surgery is not a contraindication for SILS/LESS.
NB. In all of these laparoscopic operations the surgeon performs exactly the same procedure as in open surgery but without opening the abdomen, other than enlarging one of the port sites to remove the diseased bowel.
Unless you are already hospitalised the majority of our patients come into hospital on the day of surgery. Unlike many surgeons we no longer consider it necessary that our patients have their bowel purged preoperatively and instead rely on a phosphate enema (sometimes two).
When we do use a mechanical bowel prep we prescribe two small bottles of Fleet. The first is taken at 12 noon following a light lunch. The second, 6 hours later. Drink as much water, tea or coffee as you like. But remember, no food or milk.
You can drink water up to one hour before surgery. For some time now we have been prescribing our patients a pre-operative drink (400mls) which contains lots of carbohydrate; it tastes of lemon sherbet and is quite welcomed after a period of overnight fast.
An anaesthetist will visit you and discuss your anaesthetic and various methods of postoperative pain relief (TAP block, liqid morphine which is taken orally and intravenous paracetamol or TAP and a spinal)
A stoma care nurse may visit you and mark the best place on your tummy for a stoma to be formed (i.e. where a bag would be positioned) in case this becomes necessary during the operation.
Whilst the risks of these operations are small and much less than the risk of doing nothing, this is a major operation. Specific risks to laparoscopic surgery include inadvertent or accidental damage to structures inside the tummy such as blood vessels and bowel. This is however, is very rare (approx 4/5,000 operations) but if it did happen you may require an open operation to put things right. Because of the nature of anterior resection surgery there is a small risk (about 5%) of injury to the bladder and the nerves that affect sexual function.
The most serious concern in performing bowel surgery is leakage from the anastomosis or join. This occurs in a small percentage of cases (3.8% audited figure for Bristol Laparoscopic Associates) and may require no treatment other than antibiotics or be life threatening and require another operation or even a colostomy.
Open Colorectal surgery is not trivial. The audited 30 day operative mortality for major colorectal resection in Bristol Laparoscopic Associate hands over the last 9 year period was 1.5%; 5.5% in patients older than 80years. The figure for laparoscopic surgery is 1.5% (all ages).
Eating and drinking?
Whilst we will encourage you to start eating within a few hours of surgery we realise that you may not have much of an appetite at first. If you feel sick medicines can help so ask your doctor. There are no hard and fast rules about what you should or should not eat. Eat what you like; little and often is best. Low residue food (low fibre) is usually best. Spicy meals, salad or fruit may upset you. It may be a case of 'try it and see'. Try to keep up your energy levels by having a good calorie intake. Drink 6-8 cups of fluid per day.
Getting back to normal?
An operation can be a stressful experience, physically and emotionally. In the first few weeks you may have times when you are low and this is normal. Some find that it takes months to adjust to the surgery. Be patient.
Are there any long-term effects of the operation?
To start with your bowels are likely to be loose, unpredictable and quite urgent. It can take months for this to settle into a predictable pattern. Your bowel function is unlikely to be the same as it was before your operation, so your expectation of what is normal may need to be adjusted. If a large portion of colon is removed then your stool may always be looser, as less water will be absorbed. It takes time for the bowel that remains to compensate for that which has been removed and it may never completely do so. Fortunately there are medicines which can firm things up, and some need to take these on a permanent basis.