Keyhole Surgery for the Colon

Laparoscopic or Keyhole Surgery of the Colon

Patient Information Leaflet

What is keyhole surgery?

Laparoscopic or “keyhole” surgery is a method of carrying out an operation without having to make a large incision in the tummy. Many different types of operation can now be carried out using keyhole surgery. Typically this reduces the length of time you need to stay in hospital, leaves less scarring and post-operative pain is reduced. Keyhole surgery is now performed for a number of conditions affecting the colon such as cancer or large polyps, diverticulitis, and inflammatory diseases such as Crohn’s disease or ulcerative colitis.

What are the advantages of keyhole surgery?

Removal of part of the colon is a major operation. When performed by conventional surgery, a long incision and up to a week in hospital is necessary. Keyhole techniques are used to perform the same operation through a number of tiny incisions. The benefits are:

 A shortened hospital stay (in some cases as little as two days)  Significantly less pain from the abdominal incision  An earlier return to normal activity  Less scarring

Another advantage of keyhole surgery is the reduced risk of a post-operative incisional hernia, and also the reduced risk of adhesions.

How long does a keyhole operation take?

The operation may take longer than conventional surgery – the length of time you spend away from the ward may be between one and a half to six hours.

What happens before the operation?

You will receive information about how to prepare for the operation in the admission information sent out before you come in to hospital. It is important to follow these instructions – otherwise your operation may need to be delayed or even cancelled.

Your surgeon will go through the details of your operation. This and the consent might have happened already before your admission but you can always ask further questions and get clarification.

An anaesthetist will also see you to explain your anaesthetic in more detail. You will be asked if you have any medical problems, such as allergies – it is important that you let the doctor know. You may be given an enema or other forms of bowel preparation prior to surgery and you will have an injection into the skin of your tummy. This is to reduce the risk of a blood clot occurring in the leg by thinning the blood. These injections will continue every day while you are in hospital.

The nurse will tell you when to stop food and water, as this will depend on what time your operation is scheduled for. You may be given some carbohydrate drinks on the day of admission and also further carbohydrate drinks up to 4 hours prior to your operation. What does the operation involve?

A laparoscopic colectomy is performed by inflating the abdomen with gas that creates a space between the thick wall of the abdomen and the organs inside. Using short incisions in the skin, thin tubes are inserted through the abdominal wall so that long, narrow instruments can be passed through them to perform the manoeuvres necessary for the operation. Surgery is observed directly on a video camera attached to the laparoscope. After removal of the diseased portion of bowel the two free ends will be joined together. This is what doctors call an anastomosis. Occasionally, if the surgeon is worried about the join healing, you may need to have a stoma to divert the bowel contents through a small hole in your tummy in to a bag. The bowel will then work in a normal manner. It may be that your bag will only stay for a short period of time.

Again your surgeon will discuss in much more detail the specifics of your own surgery.

What happens after the operation?

After the operation, you will return to the ward to recover. You may experience some shoulder pain. You may also feel some crackling under the skin around the site of the incision. This is because sometimes the gas escapes into the tissue just under the skin. These side effects are usually short lived and do not require any specialised care.

You can expect to have one or several of the following:  Dressings covering small wounds on your tummy.  A needle in to a vein (a drip) to give you fluids and medicines.  A catheter – a small tube to measure the amount of urine you produce.

You may have:  A fine tube in your neck to help measure the amount of fluid being put in to your body accurately.  A drain, a small tube to clear away any oozing fluids around the operation site. This helps to prevent infection.  A stoma appliance (a bag) on your tummy.  An epidural (a fine tube in your back) or a pump (a line in your arm) giving you pain relieving medicines.

You will: ● Sit up in bed on the evening of the operation, and the staff will help you to sit out of bed in the chair for a few hours on the first day after the operation. This is to help your lungs to function and reduces the chance of a chest infection, and also of blood clots.

● Be able to start drinking as much as you can manage on the day of the operation, and depending on how you are feeling will be able to progress to eating within 1-2 days.

After several days you may feel that you want to pass wind or have your bowels opened. Even if you have a stoma this is entirely normal and you may pass a little old blood or mucus. Please keep the nurses informed.

Are there any risks?

Risks of this operation are small and much less than the risk of doing nothing. But, as with all major surgery, there is always a risk. A very small percentage of people do not survive major surgery for a wide number of reasons. Also, all operations carry a risk from anaesthetics but this minimal due to modern techniques. More specific risks which relate to you your surgeon will discuss with you before surgery. There is always a chance that keyhole surgery will not be possible and your surgeon will carry out the operation using a larger incision instead. Your surgeon will explain the risks to you when you sign your consent form.

After you go home:

Your health will be regularly monitored over the coming weeks to ensure that all remains well. Should any post-operative complications arise they can be indentified and treated promptly.

Post Operative Activity

It is fairly common to feel weak and tired immediately after discharge from the hospital. The body needs time to recover from the stress of a major operation, but it is important to resume normal activity as soon as you can.

Walking – Walking is encouraged beginning the day after surgery. At home, start short, daily walks and gradually increase the distance.

Climbing – Going up and down stairs is permitted but it is wise to have someone there to give you confidence.

Lifting – You may lift light objects (less than 10lbs) after your discharge. This may be increased gradually. If lifting an object causes discomfort, stop.

Showers – You can take a shower two days after surgery. Gently wash over your incision with soap and water. Be sure to rinse well and pat the incision dry.

Driving – Driving is not allowed for two weeks after surgery or until your first follow up visit with your surgeon. If you are taking prescription pain medication do not drive.

Return to work – People with sedentary jobs have returned to work as early as three weeks post operatively. A physically demanding job may require 4-6 weeks before returning to work. Some people have residual fatigue several weeks after surgery, so do not take on too much.

There are generally no dietary restrictions following surgery but it is recommended that you avoid foods that cause any digestive discomfort. You will eventually be able to resume your normal diet. If solid food upsets you a dietary supplement or drink can be used.

Wound care

Stitches or staples – Stitches are placed just beneath the surface of the incision. They are absorbed by your body in about six weeks and do not need to be removed. Occasionally, you will note a small white string or suture at your incision site. This string can be cut at the surface of the skin using a clean pair of scissors (wipe them with a sterilent such as clinical alcohol prior to cutting). If non dissolvable stitches or clips have been used these will need to be removed either by the district nurse or the nurse in your GP surgery.

Steri-strips are small pieces of tape used to hold incisions together. They may be removed as they being to lift off the wound. If they have not done so, they may be completely removed 10 days after surgery. Moisten the strips with a small amount of hydrogen peroxide if they are stuck to the incision. Medication

Pain – Your doctor will prescribe pain relief medication after surgery. As the pain levels after laparoscopic surgery are generally only mild to moderate, you may be prescribed familiar painkillers such as those containing paracetamol or Ibuprofen. As the pain decreases, you may use over the counter painkillers.

Constipation – some prescription medications can cause constipation. If you are not back to normal bowel routine in two weeks, take a stool softener or gentle laxative.

When to contact your surgeon

If any of the following occur, contact your surgeon:

- Persistent nausea or vomiting - Persistent blood from the rectum - Temperature higher than 101.5F or 37.5C - Pus or increasing redness around the incision - Increasing pain - Increasing diarrhoea

Glossary of terms

Anastomosis – a connection made between adjacent parts of the intestine.

Colectomy – surgical removal of all or part of the colon.

Colon – the main part of the large intestine.

Colonoscopy – a procedure where a flexible fibre-optic instrument is inserted through the anus to examine the colon.

Crohn’s disease – chronic inflammatory disease of the intestine.

Diverticulitis – inflammation of a diverticulum, especially in the colon.

Diverticulum – an abnormal sac or pouch formed at a weak point in the alimentary tract.

Hernia – a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it.

Laparoscope – a fibre optic instrument which is inserted through the abdominal wall.

Stoma – an artificial opening made in to a hollow organ.

Adhesions – these are formed after an operation when the loops of bowel become stuck to each other. They can result in abdominal pain or bowel obstruction.

Authors

Mark Coleman MD FRCS, Consultant Colorectal Surgeon Clinical Lead for National Training Programme in Laparoscopic Colorectal Surgery Plymouth Hospitals NHS Trust Simone Slawik MD FRCS, Consultant Colorectal Surgeon Aintree University Hospitals NHS Foundation Trust

Deborah Clements MB Mch MPhil FRCS, Fellow Plymouth Hospitals NHS Trust

For further information go to:

NHS National Institute for Health and Clinical Excellence http://guidance.nice.org.uk/TA105

Produced by:

Lapco Unit N7, Scott Building Tamar Science Park 18 Davy Road Derriford Plymouth PL6 8BY Tel: 01752 439845

Copies of this leaflet are available to download at: www.lapco.nhs.uk