Site General English

8/9/2019 Site General English

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service in

GENERAL SURGERY

I) ADVANCED MINIMALLY INVASIVELAPAROSCOPIC SURGERY

Laparoscopic Approach

why laparoscopy instead of the classical open approach of the abdomen

less pain minimal use of analgesicsno narcotics fewer complications better postoperative lung function full mobilization on the day of surgery faster oral intake shorter hospitalization faster recovery faster return to work better cosmesisno scars

to treat (link)

heartburngastroesophageal reflux, hiatal herniaoesophageal achalasia

morbid obesity (gastric banding, sleeve gastrectomy, gastric bypass)

benign large bowel disease (diverticulitis, inert colon-constipation, rectal prolapse)

malignant large bowel disease (colon cancer, rectal cancer)

gynaecological disease (ovarian pathology, womb pathology)

spleen pathology

Classical Open Approach of the Abdomen

when absolutely indicated

Diseases of the Anusdifficulties in opening the bowels (defaecatory problems)

constipation

obstructed defaecation

rectocele

enterocele

internal rectal prolapse

prolapse of mucosa

haemorrhoidspiles

three to six 5-12mm holes on the abdominal wall

closure of the holes with glueperfect cosmetic result


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link to laparoscopygynaecological disease

GENERAL CONSIDERATIONS

Laparoscopic Approach

why laparoscopy instead of the classical open approach of the abdomen

less pain minimal use of analgesicsno narcotics fewer complications better postoperative lung function full mobilization on the day of surgery faster oral intake shorter hospitalization faster recovery faster return to work better cosmesisno scars

Laparoscopy necessitatesgeneral anaesthesia. Complementary, and in case of a large operation such as

splenectomy, colectomy, or gastrectomy, epidural anaesthesia may be added. The abdomen is blown upwithgas (carbon dioxide) , to achieve internal visualization.Duration of surgery varies from minutes to

few (no more than 31/2) hours depending on the sort of the operation. In general, duration of the

laparoscopic approach tends to be longer than the open one for the same operation. However, with

increased experience in the laparoscopic approach, differences in duration between the approaches are

not significant. Irrespective of the operation inside the abdomen, the patient who has a laparoscopic

approach can bemobilized in the afternoon of the day of the operation; he/she gets off the bed and takes

a few steps. In not contraindicated by the sort of the operation, the patient takes a lightdiet by mouth on

the next day of surgery. Also, the patient passes flatus or even opens the bowels on the next day of

surgery. Provided that there are no postoperative complications, the patient is discharged on the next to

4-5 days after surgery (more information about postoperative course see relative diseases at links).

three to six 5-12mm holes on the abdominal wall

closure of the holes with glueperfect cosmetic result


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link to heartburngastroesophageal reflux, hiatal hernia

heartburngastroesophageal reflux, hiatal hernia

general informationGastroesophageal Reflux Disease (GOR) is the pathological condition at which juice of the stomach

that contains acidand possibly bile and pancreatic juice refluxes up into the oesophagus. Gastric juice

into the oesophageal lumen, if in excess and for long time, irritates the mucosa and produces heartburn

or even chest pain. Trivial reflux times and occasional heartburn is experienced in normal life by a

substantial proportion of the population. However, the disease of GOR is evident, if reflux occurs often

and in large amounts and medical advice is needed. Reflux may cause severe inflammation of the

oesophagus termed oesophagitis. If severe reflux persists for a substantial period of time, oesophageal

mucosa transforms to bowel mucosa in an effort to resist to injury by the refluxing material. This

transformation is termed Barrett oesophagus, a condition which may lead to oesophageal carcinoma.

When the refluxing material reaches high to the upper part of the oesophagus (regurgitation), there is a

risk of aspiration of the content into the larynx, trachea or even lungs, particularly when the patient is in

the supine position. This consequence causes the so called respiratory complications. Inflammation of

the larynx, trachea and bronchi is manifested with chronic cough, hoarseness, shortness of breath,symptoms similar to those of asthma. Aspiration of gastric juice into the lungs is the most severe chest

complication and produces infection.

oesophagitis heart burn

chest pain

Barrett oesophagus heart burn settled

cancer of the oesophagus difficulty in swallowing

regurgitation acid or bitter sensation in mouth

gastric juice in mouth

aspiration chronic coughrespiratory complications hoarseness

laryngitis saliva hypersecretiontracheitis shortness of breath

chest infectionpneumonitis high temperature

shortness of breath


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GOR assumes a very severe form when associated with major abnormalities, such as severe impairment

of the lower oesophageal sphincter (LOS) function and hiatal hernia. When LOS is impaired shows a

lesser tone and allows gastric juice to reflux much more easily to the esophagus. Hiatal hernia is the result

of attenuation, loosening and dilation of the pillars of the diaphragm (hiatus), through which the

oesophagus crosses to join the stomach in the abdomen. The result of this anatomical disorder is the

protrusion of the upper stomach into the chest (hiatal hernia). Loss of LOS tone and hiatal hernia are

translated to excessive, in amount and duration, reflux and more severe symptoms.

how to diagnose GOR diseaseIn young subjects who have mild occasional heartburn the diagnosis can be safely made by swallowing a

pill that reduces gastric acid production and treats the sympotm. This medicationis termed Proton Pump

Inhibitor PPI). When symptoms are more severe and constant upper alimentary endoscopy

oesophagogastroscopy is indicated. By this test, which is performed under sedation, the severity ofoesophagitis, the presence and severity of Barretts oesophagus and the size of hiatal hernia are

assessed. If Barretts oesophagus is seen, biopsies for histology are taken to assess any risk for the

development ofcarcinoma (presence ofdysplasia).


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Complementary tests are the oesophagogatrogram, the oesophageal manometry, the ambulatory

24hour oesophageal pH monitoring and the ambulatory 24h oesophageal impendence monitoring.

These tests are indicated when there are atypical symptoms and the diagnosis is in doubt, when symptoms

do not respond to medication and when surgery for treatment is planned.

conservative-medical treatmentApproximately, 80 percent of the patients with GOR disease fall in the category of mild to moderate

severity. In this case, one or two PPI-pills every day are enough to control the symptoms. The exact doseof medication is individualized according to the features of the disease. To maintain the good response,

additional measures, mostly concerning daily habits, are necessary: the subject should keep a normal

body weight, have small and frequent meals and avoid chocolate, pies, effervescent drinks (beer, gaseous

refreshments) and fatty meals. Also, in some cases use of two or cushions in bed are necessary to prevent

overnight reflux. Some novel endoscopic interventional techniques are currently available for the

control of symptoms in patients who otherwise would need indefinite treatment with PPS-pills. These

techniques aim to sharpen the joint oesophagus-stomach. At present, adequate data on the short and long

term efficacy of endoscopic intervention are not available.

surgical treatmentIn general, surgical treatment is indicated in the severe forms of the disease, in which medication fails to

control symptoms or indefinite medical treatment in increased doses is necessary to maintain good

response. Usually, presence of a large hiatal hernia, loss of LOS tone, frequent regurgitations, Barretts

oesophagus and persistent chest symptoms signify a disease of great severity. Also, surgery is indicated in

young patients who are otherwise obliged to follow medical measures for life, or when the patient fails

to comply with long-term medication and measures.

aim of surgerySurgery aims to correct the hiatal hernia, close the gap of the diaphragm and reinforce the LOS.

Reduction of the hiatal hernia is achieved by freeing the part of the stomach situated in the chest and by

pulling it back into the abdomen. The gap of the diaphragm is closed with stitches snuggly but loosely

around the LOS. Whoever these steps are not enough to abolish reflux and reinforcement of the LOS isnecessary. Several techniques have been described to achieve this goal, but only those that involve a wrap

of the upper part of the stomach around the LOS (fundoplication) are currently in use. The full 360o

floppy and short wrap (Nissen fundoplication) is the most popular, because it almost fully controls

reflux in long term. The efficacy of partial wraps [anterior partial fundoplication (Watson), posterior

partial fundoplication (Toupet)] in controlling reflux is not that sound, and may be indicated in specific

subsets of patients.

series of pictures:

reduction of hernia suturing of hiatus fundolication


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patient and surgeryAfter completion of the tests to fully assess the disease (recent endoscopy, oesophagogram, oesophageal

manometry, oesophageal pH monitoring metry), the patient is admitted in the hospital on the day prior to

surgery, or even on the day of surgery. The routine preoperative work includes full blood count,

assessment of blood clotting mechanisms, basic biochemical tests concerning liver and function, a chest

x-ray, an electrocardiogram and assessment by the anaesthetist. An overnight fast is necessary before

taking the patient to the operating theatre.

The operation is performed under general anaesthesia. The duration of surgery alone ranges between 30

and 60min, depending of the size of the hiatal hernia and the effort spent to free the stomach. After fully

awakening, the patient returns to bed, bearing a venous drip and sometimes a tube through the nose, and

approximately 6 hours later is encouraged to get off the bed and take some steps. Fluids by mouth areallowed by the evening of the day of surgery. Non narcotic analgesics are usually given in the form of

suppositories, or by injection. With the exception of severe complication, the vast majority of the patients

is discharged the day after surgery. Instructions are given concerning oral diet and physical activity.


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postoperative complications

Bleeding is the most common early complication closely related to surgery. However, bleeding that does

not cease spontaneously and needs re-operation occurs in much less 0.5 percent. Perforation of

oesophagus or stomach is much more rarely reported. Chest infection (atelectasis most usually) is by far

the commonest general postoperative complication. It is more commonly seen in smokers and patients

with past history of chest problems. However, chest infection is much less common after laparoscopy

than after open surgery, as a result of faster mobilization of the patient and less pain after the former

procedure. For the same reason urinary retention or infection and venous thrombosis of the legs are notseen. Cardiac complications are only seen in patients with a history of heart problems, and can be

prevents by a thorough preoperative work out and treatment.

course after discharge

The commonest complains after a Nissen fundoplication are dysphagia (difficulty in swallowing)and sensation of fullness even after small amounts of food. Following dietary instructions, both

symptoms settle within a few weeks after surgery, because gullet and stomach adapt to the changes

induced by surgery. Persistence of those symptoms occurs in less than 1-3% and in this case they

are most usually the result of technical errors during surgery. In general, these complaints are much

less common after laparoscopy than open surgery.

Recurrence of reflux symptoms are almost always attributed to technical errors at surgery. They areseen very rarely after Nissen fundoplication even in the long term, but they reoccur in up to 20% ofthe cases after partial fundoplication, few years after surgery. Heartburn, regurgitation and

aspiration should disappear after a well designed and executed antireflux surgery, and antireflux

medication should not be necessary. This is achieved by enough experience of the medical team

in correctly selecting the patient suitable for operation and by performing a technically

adequate antireflux surgery. Chest symptoms of the form of upper respiratory airways irritation,

such as chronic cough, hoarseness and shortness of breath may not disappear in up to 20% of the

cases, despite an operation that successfully controls reflux otherwise. In this case, chronic

inflammation with permanent changes of the upper airways is an obvious explanation. According to

current evidence, Barretts oesophagus without dysplasia tends to remain stable and not to develop

to malignancy.

Other symptoms, such as abdominal bloating or diarrhoea, are not common and never troublesome.Return to daily activities is feasible within few days after laparoscopic antireflux surgery. Heavy physical

activity is allowed at least 8 weeks later.

Gastroesophageal reflux (GOR) is a common disease, usually treated with drugs that reducegastric secretion and settle heartburn.

In the subset of patients with severe form of the disease (long standing daily symptoms requiringindefinite medical treatment, presence of large hiatal hernia, loss of the tone of LOS) surgery is

indicated.

Before surgery, investigation with specific tests is necessary to assess severity of the disease andaccurately design surgery.

Nissen fundoplication is the most commonly performed antireflux operation. All types of antireflux surgery should be approached laparoscopy, after which recovery is

spectacularly fast, and the patient is discharged the next day of the operation.

Return to normal physical activities and at work are possible within few days after surgery. A technically perfect antireflux operation abolishes reflux symptoms in the long term in the vast

majority of the patient.


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link to oesophageal achalasia

general informationOesophageal achalasia (OA) is a non-common disease of the oesophagus (one case/100000

population/year), with no specific age distribution, manifested with difficulty in swallowing, regurgitation

of non ingested food and saliva, and respiratory symptoms because of aspiration of the regurgitating

material into the respiratory airways. The cause of the disease is the destruction of the normal nerve

plexus of the oesophagus that results to a) loss of normal peristalsis and inability to propulse the foodbolus from the pharynx to the stomach and b) inability of the lower oesophageal sphincter (LOS) to relax

its increased tone and allow the bolus to pass into the stomach. As food and saliva stagnate in the

oesophagus, the body of the organ dilates and loses the normal configuration, while emptying of limited

amount of its content in the stomach is the result of gravity. Severity of the disease is graded according to

the appearance of the oesophagus at the oesophagogram: stage I: oesophageal diametre 60mm; stage IV) loss of normal

configuration and assumption of an S-shape.


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symptomsDifficulty in swallowing (dysphagia) is occasional and not that severe at the early stages of the disease,

but aggravates by time in severity and incidence. At first, difficulty in swallowing may be present only in

fluids, but later appears after ingestion of solid food. Dysphagia is more commonly seen after swallowing

bread, pie, spaghetti or meat. However, loss of weight is rather uncommon. Also, at the first stages of the

disease the patient may complain ofchest-substernal pain not related to food intake, mimicking a heart

attack, and possibly relieved by drinking water or nifedipine. Chronis food and saliva stagnation in the

lumen of oesophagus may irritate the oesophageal mucosa and causeoesophagitis. As a late complication

of oesophagitis, a small percentage of patients with non-treated achalasia may develop squamous cell

oesophageal carcinoma. At the supine position in bed, stagnated material regurgitates up to the mouth.Patients usually complain of sticky foamy fluid or non ingested food in the mouth that wet the pillows.

When the regurgitating material is aspirated into the respiratory airways, respiratory complications

ensue: irritation of the upper airways (laryngitis, tracheitis, bronchitis) is manifested with hoarsness,

chronic cough or shortness of breath, and irritation of the lung causespneumonia.

diagnosisSymptoms of achalasia, dysphagia in particular, are very specific, but the disease must be differentiated

from carcinoma of the oesophagus, at which loss of weight is very common. The barium

oesophagogram and oesophageal manometry confirm the diagnosis. The oesophgogram also stages the

disease and excludes any other pathology. At oesophageal manometry, no oesophageal peristalsis isdetected and the LOS does not relax at swallow. Some unusual forms of the disease may be also detected

by manometry (vigorous achalasia etc). Oesophagoscopy is also mandatory to assess oesophageal

mucosa and exclude other pathology, carcinoma in particular.

There is no aetiological therapy of the disease, in the sense to reestablish nerve plexus

integrity of oesophagus. So all sorts of treatment are symptomatic, and practically

aim to reduce the tone of the LOS.

conservative treatmentConcervative treatment includes medication, injection of Botox to LOS and pneumatic dilation of the

LOS.

The most commonly medication in use are the calcium channel blockers. Nifedipine is the main

representative of this group of drugs. Nifedipine is given in the form of a pill under the tongue, and acts

within few minutes. Because of the short duration of action and the side-effects (headache, hypotension)

the drug is not given as a permanent treatment, but reserved for temporary relief prior to a more definite

treatment or to relieve substernal pain.

Botox injection to LOS is achieved with endoscopy and mild sedation on an outpatient basis. The

injection paralyses the LOS and swallowed food passes in the stomach if ingested at the upright position.

However, the duration of LOS relaxation usually does not exceed three months and dysphagia gradually

reoccurs. This sort of treatment id reserved for patients unfit to undergo any other more definite

treatment.Pneumatic dilatation of the LOS is to standard treatment of achalasia. The treatment is undertaken by

endoscopy and with the patient under sedation, intravenous analgesics and fluoroscopic control. A wire

that bears a plastic balloon at its tip is introduced to the oesophagus, with the balloon situated along the


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LOS. The balloon is inflated dilated forcefully with air at a specific pressure and diametre and for certain

duration. This maneuver aims to relief dysphagia and allow food to pass into the stomach by disrupting

the muscle fibres of the LOS and so reducing its tone to levels well below normal. The treatment relieves

dysphagia in approximately 60% of the cases. There is no solid evidence that repeat pneumatic dilation

improves this figure. The most severe complication of the procedure is rupture of the oesophagus that

necessitates hospitalization. Development of gastroesophageal reflux can also occur. The treatment is

ineffective in young patients (age


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surgeon. Return to daily activities is feasible within few days after surgery. Heavy physical activity is

allowed at least 8 weeks later.

course after dischargeThe commonest complains after a myotomy is persistent of dysphagia (difficulty in swallowing). This

may be the result of an inadequate myotomy, oedema-swelling at the area of operation, ingestion of solid

food in large boluses or the advanced stage of the disease. If myotomy is inadequate re-operation is

mandatory. However, in experienced hands this rather unusual. Dysphagia due to oedema is temporaryand settles by time and after dietary restrictions. Sensation of fullness even after small amounts of food is

the result of the fundoplication and also settles within a few weeks after surgery.

The outcome of a technically adequate operation is considered successful when, after swallowing ofa well chewed bolus, the oesophagus empties in the stomach within 5min. Success depends on the

preoperative stage of the disease. Success rate is well over 90% in stages I and II, 80-85% in stage III and

less than 50% in

Development ofreflux symptoms appears in less than 10% of the cases when anterior fundoplication is

added to myotomy. If not, the rate of reflux symptoms is over 20%. When heartburn is reported, an

ambulatory oesophageal pH monitoring will differentiate whether it is due to food stagnation and lactic

acid production or the true reflux of gastric contents into the oesophagus. In the latter case antisecretory

drugs (PPIs) are given.follow-upBecause oesophagus may degenerate and dilate by time, as result of disease process and despite an

adequate myotomy and satisfactory good response, food stagnation in the oesophagus and dysphagia may

reoccur. For this reason, every year the patient should contact the surgeon and report on any changes in

symptoms. Also, an oesophagogram should be performed yearly and every time compared to the previous

ones. In general and according to current evidence, an initial good result is maintained for at least 10-15

years after laparoscopic myotomy. Further information will accumulate in the next years, but the

prospects are rather encouraging.


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link to morbid obesity (gastric banding, sleeve gastrectomy, gastric bypass)


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link to benign large bowel disease (diverticulitis, inert colon-constipation, rectal prolapse)

benign large bowel diseaseThere are benign diseases that at some time of their course may require surgery for treatment. The

commonest diseases of this sort are thediverticular disease, the inflammatory bowel diseases (ulcerative

colitis, Crohns disease), the rectal prolapse, and the slow transit constipation. Surgery involves

resection of a segment or of the total length of the large bowel, and can be performed by the laparoscopic

approach, thus exploiting the advantages of few complications and fast recovery.

diverticular diseasegeneral information

A diverticulum is the protrusion of the mucosa through a weak point of the large bowel wall. They can be

found in more than 50% of the population of the western world aged more than 50 years, are numerous

and located at the left site of the bowel. Subjects with diverticular disease are usually without symptoms,

but diverticula may be aetiologically associated with chronic constipation. Occasionally, the diverticula

may bleed, and sometimes bleeding can be massive, requiring hospitalization. Rupture of a diverticulum

and leak of faecal material outside the bowel causes inflammation termed diverticulitis. The

inflammation may settle spontaneously, develop to local abscess formation, or spread in the abdomen

leading to peritonitis. In any case, hospitalization is necessary and assessment of the severity of thedisease is achieved with an emergency C/T scan.

Inflammation and small abscesses may resolve after antibiotic treatment and without any further

intervention, and this is the most usual outcome of diverticulitis. Larger abscesses can be drained with

tubes inserted under the guidance of ultrasound or C/T scanning and under local anaesthesia, without

operation. In case of peritonitis or lack of response to antibiotics, emergency surgical intervention is

mandatory. Occasionally, an abscess may drain spontaneously to nearby loop of small bowel (diarrhea),

or the urinary bladder (faces and air bubbles in the urine, urinary tract infection), or even the anterior

abdominal wall (discharge of faeces or air), resulting to a fistula (communication) formation. This

complication requires elective surgery. An attack of diverticulitis, initially treated successfully without

operation, mayreoccur once or more.


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elective surgical treatment

Elective surgery for diverticular disease (absence of active inflammation) is indicated in case of

recurrent attacks of diverticulitis initially managed conservatively, residual mass on C/T after

successful conservative treatment, presence or imminent internal or external fistula, particularly in male

subjects in whom development of a fistula between the bowel and bladder is more common than in

female ones.The operation can be performed by the laparoscopic approach. An additional small suprapubic incision

may be required in case of a fistula to the bladder, in order to fix the opening. Basically, the operation

involves resection of the lower descending colon, the sigmoid colon and the upper rectum, parts that bear

the diverticula, and reestablishment of the continuity of the bowel by fashioning an anastomosis (joining

the two cut edges of the bowel with a use of stapling device). In the absence of inflammation, creation of

a colostomy or diverting ileostomy is not necessary.

After laparoscopic large bowel resection for diverticular disease, recovery is very fast. On the next day,

the patient is mobilized, bowels open, and oral diet is resumed. In the absence of severe complications,

the patient is discharged on the 4th

-5th

postoperative day. Complications are seen in much less than

10% of the cases. General complications include chest infection (atelectasis most usually), urinary

retention, urinary tract infection or deep venous thrombosis are really rare as result of the lack of severe

pain, fast recovery and mobilization of the patient after laparoscopy. Bleeding from the site of operation

is not usual and is managed conservatively in most of the cases. Anastomotic leak (disruption of the

anastomosis and leak of faecal material) clinically manifested occurs in approximately 5-8% of the cases.

This complication is managed conservatively by drainage of the collection under C/T scanning guidance.

If needed, a diverting temporary ileostomy is fashioned, until spontaneous seal of the leak.

inflammatory bowel diseasesCrohns disease is an inflammatory process most commonly of the terminal part of the small (ileum) and

the large bowel. The inflammation is of unknown aetiology and involves the full thickness of the

intestinal wall, the mesentery that suspends the bowel and surrounding structures in the abdomen. The

inflammatory process may also involve other organs than the bowel, leading to extra-intestinal

manifestations. The clinical picture of the disease is characterized by exacerbations and remissions.

Inflammation of the bowel wall may cause strictures manifested with signs of bowel obstruction, or

penetrate the wall resulting to phlegmon or abscess formation between the bowel loops. The abscess, if

not resolved, may spontaneously drain to adjacent loops of bowel, urinary bladder or abdominal wall so

to form fistulae.Abdominal surgery may be necessary for the resection of a severely diseased small part of the small or

the whole of the large bowel. Depending on the presence of other complications, resection may be

associated with refashioning of a stricture of the bowel (stricture-plasty) to relieve obstruction, drainage

picture of

surgery


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of an abscess, resection of adjacent structure to remove an internal or external fistula . Because multiple

surgical interventions may be necessary in Crohns disease and because the suffering subjects are young

and very much interested in their body image, laparoscopy is the approach of choice to undertake all

the above operations. The laparoscopic approach is associated with faster recovery after surgery, less

postoperative complications, shorter hospital stay and greater satisfaction of the subject with the cosmetic

result as compared to open surgery.

Ulcerative colitis is an inflammatory disease of the large bowel manifested with diarrhea, blood per

rectum and occasionally general symptoms including high temperature, loss of weight and bad generalcondition. The treatment is medical at first with drugs including steroids and immunosuppressants and, if

necessary, support with parenteral nutrition.

Surgery is necessary in case of i) lack of response of an acute or even fulminant attack to intensive

medical treatment, ii) need of long term medical treatment to maintain the disease in remission iii) some

extracolonic manifestations of the disease that only respond to removal of the large bowel and iv)

development of dysplasia (precancerous condition) or even cancer. The operation of choice is removal of

the entire large bowel (total colectomy) with preservation of the anus and anastomosis of the terminal part

of the small bowel to the anus, after fashioning a pouch. (ileal-pouch anal anastomosis). This operation

achieves removal of the whole of the disease large bowel but also preservation of the normal passage of

faeces through the anus. In long term, subjects with this operation experience 4-8 semi-solid bowel

motions per day, with good control of the sphincters and minimal or no soiling at all. The procedure canbe performed in one or two stages: in one stage (removal and anastomosis) in elective cases with a patient

in a stable condition and in two stages (first removal and some weeks later anastomosis) in the acute

phase of the disease.

This procedure can be performed by the laparoscopic approach. As the patients are young they are

highly motivated to undergo this approach. Laparoscopic total colectomy with ileo-anal anastomosis is anextremely technically demanding and laborious procedure of 3-5 hours duration. However with acquired

experience and improvement of laparoscopic instrumentation, nowadays the operation is attempted

laparoscopically more often. According to current evidence, the laparoscopic approach is associated with

faster recovery, less complications, shorter hospital stay and better cosmetic result as compared to open

surgery, with similar long term outcomes. Irrespective of the approach laparoscopic or open- the

anastomosis is usually protected with a temporary ileostomy, which is reversed 6-8 later.

also link to difficulties in opening the bowels (defaecatory problems)

constipation

obstructed defaecation

rectoceleenterocele

internal rectal prolapse

prolapse of mucosa


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rectal prolapseRectal prolapse is the folding and protrusion of the upper and middle part of the rectum into the distal one

and finally through the anus to the outside. The protrusion that reaches the anus but does not protrude

outside is termed internal prolapse or intussusception. If the rectum protrudes outside and becomes

obvious is term total or overt rectal prolapse. The aetiology and pathophysiology of the condition is not

fully understood, but it seems to be associated with severe chronic constipation and excessive straining at

stool as seen for example in aged multiparous women. It is not known whether internal prolapsedeteriorated and develops to total prolapse in the same subject who remains severely constipated.

Intussusception is manifested with symptoms of obstructed defaecation, namely chronic straining,

incomplete evacuation of the rectum from faeces, interrupted defaecation, passage of small pellet stools,

vaginal or anal digitation to facilitate defaecation, deep vague perineal discomfort or pain, and passage of

blood per rectum in case development of a solitary rectal ulcer. The investigation to confirm the diagnosis

includes the defaecogram, anorectal manometry, anorectal physiological tests and anal ultrasound. At the

defaecogram, a mixture of 150ml of mashed potatoes with barium sulfate, simulating faeces, is

introduced into the rectum and the vagina is coated with radioopaque paste, while the loops of the small

bowel are also opacified after ingestion of 500ml of barium sulfate. Then the subject sits on a commode

and is asked at first to squeeze the perineum and then to strain in order to empty the rectum, while the

whole procedure is filmed. The investigation demonstrates the intussusception and also depicts some

coexisting abnormalities which should also be taken into account when planning the treatment. These

abnormalities include the rectocele, the perineal descent, the enterocele or the sigmoidocele.

Treatment should be individualized and is at first conservative. Softening of stools, usually with high

fibre diet, and retraining-reeducation of the patient in the process of straining and bowel opening are

measures with good response rate in the majority of the cases. Conservative treatment usually fails in case

of a large intussusception associated with an enlarged anterior rectocele that entraps stools at straining. In

this case surgery can be applied. Currently, the procedure mostly in use to correct intussusception is theStapled Trans Anal Rectal ResectionSTARR. The procedure is performed under general anaesthesia,

with the patient in the gynaecological position, so to gain access to the anus. Excision of the protruding

rectum and joining up of the cut edges of the rectum is achieved with specific stapling devices, introduced


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through the anus. At surgery, caution should be taken not to include the posterior vaginal wall to the

resection-staple line. Any bleeders at the suture line are easily stitched. The duration of the procedure is

less than 30min. Pain after surgery is minimal. Recovery is fast and the patient is usually discharged on

the next day. It is common the patient to experience perineal discomfort, urge to defaecate or several

small bowel motions per day for the first 4-6 first postoperative weeks. These symptoms are the result of

oedema at the site of resection, which is perceived as a rectum full with faeces. The condition settles by

time and after following specific dietary and defaecatory measures. Symptoms of obstructed defaecation

disappear or significantly improve in most of the patients. Persistent symptoms may respond to additionaltraining in the defaecatory process in the form ofbiofeedback.

If the defaecogram shows that rectal intussusception is associated with enterocele or sigmoidocele,

STARR procedure is not expected to relieve symptoms. In this case, surgery through the abdomen that

permanently reduces intussusception and enterocele is mandatory. Currently, the most popular operation

applied to treat this condition is Ventral Rectopexy. The procedure is performed by laparoscopy and

involves unfolding and fixation of the rectum with prosthetic material, placed between rectum and

posterior vaginal wall, to prevent refolding and to obliterate the space occupied by the prolapsing loops of

small bowel. The patient is discharged on the next day of the operation. Initial reports on the symptomaticoutcomes are very encouraging.

Total rectal prolapse shares the same pathophysiology with rectal intussusception. The condition seems

to be associated with severe chronic constipation and excessive straining at stool as seen for example in

multiparous aged women. It can be also seen in younger patients, in whom congenital anatomical

abnormalities, such as impaired fixation of the rectum, are implicated. The patient with total rectal

prolapse complains of protrusion of the bowel during straining at defaecation or increased abdominal

pressure, mucous discharge form the anus, soiling, irritation of the skin around the anus, chronicconstipation, or even symptoms of obstructed defaecation. Blood discharge is not unusual, as a result of

mechanical injury of the protruding bowel or development of a solitary rectal ulcer. In approximately two

thirds of the patients, true faecal incontinence coexists.

The investigation, not only to confirm the diagnosis but also to assess the extent of the disorder and

identify additional abnormalities, includes the defaecogram, anorectal manometry, anorectal

physiological tests and endo-anal ultrasound. At the defaecogram, a mixture of 150ml of mashed potatoes

with barium sulfate, simulating faeces, is introduced into the rectum and the vagina is coated with

radioopaque paste, while the loops of the small bowel are also opacified after ingestion of 500ml of

barium sulfate. Then the subject sits on a commode and is asked at first to squeeze the perineum and then

to strain in order to empty the rectum, while the whole procedure is filmed. The investigation

demonstrates the intussusception and also depicts some coexisting abnormalities which should also be

taken into account when planning the treatment. These abnormalities include the rectocele, the perineal

descent, the enterocele or the sigmoidocele. Anorectal manometry and endo-anal ultrasound provide

information about the degree of anatomical and physiological integrity of the perineal-anal sphincters.

Also, colonic transit studies and barium enema are considered necessary to design the therapeutic

approach and choose the appropriate procedure.

STARR operation

operation of ventral

rectopexy


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The condition and resultant symptomatology can be treated only by surgery. There are several procedures

designed and applied to correct the abnormality, the choice of the optimum one depending on the

particular case. In, general they are divided into categories: the trans-anal and the trans-abdominalones. The trans-anal procedures are indicated in rather debilitated patients, unfit to undergo general

anaesthesia or any big trans-abdominal procedure. The most popular of them are the rectal mucosectomy

with muscular placation ( Delormes procedure) and the resection of rectosigmoid (Altemeirs

procedure) that protrudes with colo-anal anastomosis, fashioned trans-anally with stitches or a circular

stapling device. Both procedures can be completed in an hour or so and are associated with a rather fast

recovery and hospital stay of few days, depending on the general condition of the patient.

Of the trans-abdominal procedures, prosthesis-or-suture anterior-or-posterior rectopexies are indicated

in patients with prolapse associated with diarrhoea and non-redundant sigmoid colon on the barium

enema. These procedures implicate mobilization and fixation of the rectum upon the sacrum either with

stitches or with the use of a prosthetic material that covers the rectum either anteriorly or posteriorly.

Resection rectopexy is indicated in patients with rectal prolapse associated with constipation, redundantsigmoid colon, slow transit of the bowel or presence of diverticulae at the sigmoid colon. The procedure

involves mobilization of the rectum, resection of the redundant sigmoid colon, anastomosis of the

descending colon to the rectum with the use of a circular stapling device and fixation of the rectum to the

sacrum with stitches. Ventral prosthesis rectopexy is a modification of the prosthesis anterior rectopexy,

indicated in patients with prolapse and associated large rectocele or enterocele. At this novel technique,

the rectum is completely mobilized anteriorly and behind the posterior wall of the vagina and deep down

to the level of anal sphincters. The deep, redundant peritoneal sac (Douglas pouch) is excised, a strip of

the prosthetic material-mesh is sutured along the anterior aspect of the mobilized rectum and the posterior

vaginal wall and the mesh is pulled upwards and fixed on the sacral promontory, so to reduce the

prolapse, suspend the rectum and obliterate the space occupied by the enterocele (small bowel loops). All

trans- abdominal procedures are approached laparoscopically. If resection and anastomosis of thebowel is not included in the procedure, the patient is discharged within one or two days after surgery. In

case of resection of the bowel, the patient recovers fast, is mobilized on the day of surgery, resumes oral

feeding the day next to surgery and is usually discharged on the 4th

-5th

postoperative day.

OPERATIONS TO CORRECT RECTAL PROLAPSE

transabdominal operationsanterior prosthesis rectopexy (Ripstein)posterior prosthesis rectopexy (Wells)

posterior suture rectopexy

resectionsuture rectopexy

ventral prosthesis rectopexyresection of abundant rectosigmoid

transanal proceduresThiersch loop

resection of rectosigmoid (Altemeir)

rectal mucosectomymuscular plication (Delorme)

Stapled Trans-Anal Resection of Rectum (STARR)


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long-term results

Trans-anal procedures, Delormes procedure in particular, are associated with significant rate of prolapse

recurrence. Furthermore, Altemeirs and Delormes procedures are usually associated with rather poor

functional results, possibly because the capacity of rectum as a reservoir of faeces is abolished. This istranslated in urgency to defaecate, small and frequent motions and soiling. Also, faecal incontinence may

deteriorate, if pre-existing, or appear de novo, as a result of dilatation of the anus during the procedures.

Prosthesis-or-suture anterior-or-posterior rectopexies are associated with recurrent prolapse in rates

around 10%, much less than after the trans-anal procedures. Long term results, concerning defaecatory

habits vary and are unpredicted. A substantial proportion of the patients complain of urgency to defaecate,

unproductive straining or frequent and small stools, because the rectum becomes stiff and incompliant as

a result of irritation or inflammation by the prosthetic material.

Resection rectopexy is associated with the best long-term results. Recurrence of prolapse is seen in less

than 5% of the cases. Bowel habits become normal within few weeks after surgery. Preexisting

constipation is treated in the majority of the cases, while faecal incontinence is cured in approximately

two thirds of them. Results of ventral prosthesis rectopexy are promising, particularly in correctingenterocele, but current evidence is limited at present.

slow transit constipationSlow transit constipation or colonic inertia is a hereditary condition manifested with very severe

constipation in young female. Although hereditary, the condition is manifested at puberty, or at a young

age after a stressful situation (appendicitis, severe infection, etc). Constipation deteriorates by time and,

soon after onset, bowels are open after use of cathartics. Months or years later, cathartics fail to work and

only enemas may be of some relief. Abdominal distention, discomfort and pain are also reported. The

diagnosis is confirmed by assessing the colonic transit of radio-opaque markers or the polyethylene

glucole test. Both tests are easy to perform and give reliable results.

The condition is treated by surgery. Segmental resections of the colon, based on the observation of faecal

stagnation at a specific part of the large bowel, do not correct constipation and are not indicated. Theoperation is the subtotal colectomy with anastomosis of the terminal ileum to the rectum which is not

resected. The operation is performed by laparoscopy and, therefore, recovery, mobilization and food

resumption are expected to be fast, complication are few and insignificant and hospital stay is short. At

schematic and laparoscopic representation of all procedures.


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long term, constipation is cured in more than 90% of the cases. Usually the patient experiences 2-4 semi-

solid bowel motions every day. In few patients bowel motions are more frequent exceeding 10-12 per

day, impairing quality of life. Persistent constipation is accounted in less than 8% of the patients after

surgery, but in any case less severe than before with 1-2 bowel motions per week. A proportion of

patients that exceeds even 50%, particularly after the open approach, experiences attacks of bowel

obstruction. Although hospital admission may be necessary, these attacks settle after conservative

treatment, and in the end disappear. The vast majority of the patients are very satisfied with the outcomes

of the procedure.


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link to malignant large bowel disease (colon cancer, rectal cancer)

malignant large bowel disease (colon cancer, rectal cancer)

general considerationsIn the western world, cancer of the large bowel is the commonest cancer after that of the skin in both

sexes. As a general rule, the treatment of choice is surgical removal of the segment of the colon that bears

the cancer, with adequate proximal and distal margins and removal of the mesentery that corresponds tothe segment, so to achieve a so called oncologically correct resection. After removal of the segment of

the bowel an anastomosis is usually fashioned between proximal and distal stumps, so to reestablish

continuity of the bowel. If the operation is oncologically correct, good outcomes, in terms of local

recurrence of the disease and survival, are expected.

treatmentIn case of cancer located at the rectum (last 10-12cm of the colon-large bowel) which is locally advanced,

(assessment by an MRI of the pelvis) combined radiotherapy and chemotherapy (neo-adjuvant treatment)

is recommended prior to surgery in order to improve outcomes. At surgery, the part of the rectum that

bears the cancer, along with at least 20cm proximal and 2cm distal clearance, and the whole of themesentery of the rectum (total mesorectal excisionTME) are removed. An anastomosis between the

colon and the distal rectal stump or anus can be fashioned, provided that removal of anal sphincters is not

mandatory in order to achieve oncological clearance. This is usually the case in a tumour located at a

distance of no less than 3cm from the anal verge. If the distance is shorter and sphincters should be

removed, an anastomosis is not feasible. The operation that involves removal of rectum and sphincters is

termed Abdomino-Perineal Resection of RectumAPR.

laparoscopic colectomy for cancerAll colectomises (right, left, total, subtotal, low anterior resection of rectum with TMELARR-TME and

APR) are classically performed by the open approach, but recently can also be approached by

laparoscopy. The main contra-indications for the laparoscopic approach are i) large tumours (>8cm),

tumours located at the transverse colon (extremely technically demanding procedure, jeopardized

oncological adequacy) iii) tumours invading adjacent organ but a curative removal can be expected, iv)

lack of adequate training and experience with the particular approach and colorectal surgery and v) lack

of a high quality hardware incomplete instrumentation. Advanced age of the patient, impaired

cardiovascular and chest condition (category ASA III, IV), previous abdominal operations and obesity arenot contra-indications for laparoscopy.

For specific anatomical reasons and because extended surgery is required to cure a cancer, laparoscopic

colectomy is very technically demanding. LARR-TME is even for difficult to accomplish. It is usually

argued that for this reason the latter procedure should be attempted only by open, at present. However,

supporters of laparoscopy claim that the novel approach is superior to open, in particular in the obese

male patient, because of a better visualization deep in the pelvis. Understandably, good training and

overcome of the steep learning curve are prerequisites to operate of colonic cancer by laparoscopy. The

operation is achieved by creating 4-6 holes on the abdominal wall for the trocar insertion. By the end of

the operation, the wound at a trocar site (left loin or just above symphisis pubis) is elongated to

approximately 4cm, to remove the resected specimen in bag, to protect the abdominal wall from

contamination. In general duration, of the laparoscopy is long than by the open approach, but difference

diminishes as experience increase. For several local (tumour characteristics), general (poor cardiovascular

response at surgery), mechanical (hardware failure), operational (surgeons inability to cope with)

reasons, conversion of the laparoscopic approach to open may be necessary. The most common reason is

Schematic representation of rt and

left colectomy, LARR and APR


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the tumour characteristics that preclude laparoscopy, but have been missed at the preoperative staging

work out. If conversion is early, no addition impact on patient outcome is expected. However, if

conversion is decided after having spent hours in attempting to accomplish the operation by laparoscopy,

higher morbidity (complications) and mortality (deaths) are seen, as compared to a totally open or totally

laparoscopic approach.

short-term outcomesAccording to current evidence, laparoscopic colectomy is associated with all the advantages of the

approach over open surgery. The patient is mobilized on the day of the operation, oral feeding is resumed

and bowels usually open the first day after operation. Pain is minimal and non-narcotic analgesics may be

given for 2-3 days. In the uncomplicated cases, hospitalization is short and the patient is discharged on the

4-6 postoperative day. Local complications (bleeding, leak from the anastomosis, abdominal sepsis) are

seen in similar rates between the two approaches. Wound infection and hernia are much less common

after laparoscopy than after open. Similarly, pulmonary complications and deep venous thrombosis are

less common after laparoscopy than after open, apparently because of less pain and conceivably better

respiratory function and faster mobilization after the former approach.

long-term outcomes Local recurrence of cancer, survival, and quality of life are the parametres that characterize long-term

outcomes after colorectal surgery for cancer. Although current literature on this issue is still limited and

more is expected to appear soon, there is evidence that laparoscopy is associated with at least similar

rates of local recurrence and survival to the classical open approach. Quality of life is also favourably

compared between the two approaches. The fear of increased recurrence of cancer at the sites of

abdominal trocar-wounds, expressed the early days of the approach, is not substantiated by current

evidence, and, in fact, it may be less common than recurrence of cancer on the abdominal wound after the

open approach.

Video of all colectomies


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link to spleen pathology

general considerationsOccasionally, the spleen, which is situated below the left part of the diaphragm and on top and left of the

stomach, should be removed electively, because of some haematological diseases. These include

idiopathic thrombopenic purpura (ITP) sickle cell anaemia, or hairy cell leukaemia. Other pathology

necessitating elective removal of the spleen is rare. The classical open approach is achieved through a

large incision on the abdominal wall across the left subcostal margin. Because of this long wound,postoperative pain is severe, necessitates narcotic analgesics administration, impairs depth of breath

resulting in chest infection, and conceivably prolongs hospital stay.

laparoscopic approachTo tackle disability and slow recovery after open splenectomy, the laparoscopic approach is

recommended. The contraindications to attempt laparoscopic splenectomy are emergency condition

(acutely bleeding spleen) and enlarged spleen (greatest dimension 25cm). The operation is accomplished

through 3-4 trocars along the left subcostal margin and one 5th

at the umbilicous for the optique. The

spleen is freed from its attachments and the blood vessels (splenic artery and vein) are ligated and divided

with the use of specifically designed vascular stapling devices. Duration of the operation is less than

60min.

As usual after laparoscopy, pain is minimal as is use of analgesics. Patient is mobilized and fed on the

afternoon of the operation day. The patient is discharged on the 2nd

-4th

postoperative day, provided that no

respiratory complication develops. In any case respiratory complications, such as lung atelectasis,

pneumonia, or left pleural infusion, are much less common than after the open approach.

video of laparoscopic

splenectomy


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link to haemorrhoids piles

II)HAEMORRHOIS - PILESgeneral considerations

The haemorrhoidal cushions (haemorrhoids-piles) are anatomical elements consisted of clusters of smallveins and covered by mucosa of a trasitional type, situated at the lowermost part of the rectum and at the

proximal orifice of the anus. They contribute to continence and control of defaecation. Chronically

increased and sustained effort at defaecation and hard stools may lead to enlargement, bleeding and

protrusion of the piles outside through the anus. Protruding-prolapsing piles may also be strangulated,

resulting in thombosis (clot formation) manifested with swelling at the area and severe pain, or even

necrosis of the covering skin and ulceration.

Severity of haemorrhoidal disease is graded as follows: 1st

degree: enlargement of the cushions and

bleeding, no prolapse;2nd

degree: prolapsing piles at straining and spontaneous reduction after the end of

the defaecatory process;3rd

degree: prolapsing piles at straining and manual reduction after the end of the

defaecatory process;4th

degree: permanently prolapsing piles, impossible to reduce. Bleeding, irritation

of the skin and discomfort at the area may be present at any degree of the disease. In general, symptoms

severity parallels the severity of the disease.

treatment

Conservative treatment consists of simple measures that aim to soften the stools and relieve topicaldiscomfort (tepid baths, application of local anaesthetic ointments). If respond is poor, symptoms are

bothersome and bleeding significant, interventional therapy, including also surgery, is indicated. There

are numerous methods of varying degree of invasion designed to treat piles. The approach is not

schematic representation of

haemorrhoids at all degrees


26/29

unanimous between surgeons. However, it is generally accepted that treatment should be individualized,

primarily considering the severity of disease, as expressed by the degree of presentation.

1st

degree piles: Sclerosing injections or rubber banding of the piles is usually indicated. Treatment is

applied through a proctoscope at an outpatient basis. Injections are painless is properly performed. Re-

injections may be required if bleeding reoccurs. Rubber banding of piles is more effective in controlling

bleeding but is associated with some complications, if not properly applied. Usually one pile is treated at

a time. Complications include, pain, ulceration and bleeding of the strangulated by the band pile and local

sepsis. Some surgeons recommend the THD method for the treatment of 1st

degree piles, as it isassociated with superior results, less complications and much less pain than rubber banding.

2nd

degree piles: A novel technique is nowadays recommended for the treatment of 1st

and particularly 2nd

degree piles. According to the method, the branches of the haemorrhoidal arteries that supply the piles

with blood are identified just above their entrance into the piles with the aid of an ultrasound probe

mounted at the tip of a specific proctoscope. After identification, the arterial branches are ligated with

stitches introduced through the proctoscope. This method is termed as Transanal Haemorrhoidal

DearterializationTHD, according to company that provides the market with the instrumentation. The

method is applied on an outpatient basis and under mild sedation. As relative literature is limited at

present, there is no sound evidence on the results of the method. It seems that bleeding is controlled in

more than 80% of the cases. Similar are the rates of reduction of prolapse. THD is applied on an

outpatient basis, is practically painless and can be repeated if bleeding reoccurs. Some discomfort may bereported in some patients for the first few days after the procedure.

pictures of THD


27/29

3rd

degree piles: Another novel method is currently been advocated for the surgical treatment of 3rd

primarily, but also 2nd

degree, haemorrhoids. The method carries the term Procedure for Prolapsing

Haemorrhoids - PPH and has been introduced into practice by A. Longo. Through a specific anal

retractor, a threat is fashioned at the rectal mucosa above the haemorrhoidal cushions in a circular purse-

string manner. Then, a specifically designed circular stapler is introduced through the rectractor, the rectal

mucosa is pulled into the chamber of the stapled and the device is fired. As a result of this, a 2cm widering of rectal mucosa and submucosa above the piles is excised and the mucosal stumps are automatically

and at the same time approximated and anastomosed with staples. By this method, first the haemorrhoidal

arteries that supply the piles with blood are ligated and divided and secondly the prolapsing part of piles

is pulled and reduced above the anus. The procedure is performed under epidural, spinal or general

anaesthesia. The method is painless, if correctly applied. Bleeding from the staple-line is not that common

with the new generation of stapling devices and can easily be controlled with stitches. Some severe

complications, such as rectal perforation or pelvic sepsis, have appeared in the literature as case-reports.

If the surgeon is adequately trained and method is meticulously applied, complication rate is not

significant and is of very mild severity. The patient is usually discharged on the next day after surgery.

Postoperative discomfort may last for few days, but true pain is not usually a problem. Also, adequate

training and correct application of the method by the surgeon are the prerequisites for good functional

results. In general, bleeding is controlled and prolapse is reduced in more than 85% of the cases. There is

no substantial evidence that repeat PPH is indicated in case of relapsing piles. The method precludes anal

intercourse.


28/29


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4th degree piles: The classical surgical technique of Milligan Morgan is indicated in case of 4th

degree piles, or recurrence of piles treated with the PPH method. The method is performed under general,

epidural or spinal anaesthesia. The piles are dissected from outside and towards the base of the

haemorrhoidal cushions and ligated and transected. The only severe drawback of the procedure is the

severe postoperative pain and discomfort which lasts for at least 5-7 days after surgery. Pain can be eased

with warm baths and application of local analgesics. Also, injections with local anaesthetics may be of

help. If dissection and ligation is achieved with new sources of energy (ultrasound, bipolar diathermy)

postoperative pain is significantly reduced as opposed to the situation after the application of the classicalmonopolar diathermy and stitches. In any case, the classical method of Milligan Morgan is the one

associated with the best long term results. Recurrence of bleeding or prolapse of piles is well less than

5%.

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