Laparoscopic colectomy is a procedure whereby a portion of the colon or the rectum or the entire colon and rectum are removed surgically with minimal incisions on the skin and abdominal wall. There are many different operations that can be performed on the colon and rectum and these are done for a variety of reasons including colorectal cancer, diverticulitis, ulcerative colitis and Crohns disease. The operations include
Right hemicolectomy – the caecum and ascending colon is removed and the small intestine is joined to the transverse colon.
Extended right hemicolectomy – the caecum, ascending colon and a proportion of the transverse colon is removed and the small intestine is joined to distal transverse colon.
Left hemicolectomy – the descending colon and sigmoid is removed and the transverse colon is joined to the rectosigmoid area.
Sigmoid colectomy – the sigmoid colon is removed and the descending colon is joined to the rectum.
Anterior resection – this is where the sigmoid and a proportion of the rectum are removed and the descending colon is joined to the rectum below. An anterior resection may be:
Subtotal colectomy – the caecum, ascending colon, transverse and descending colons are removed and the small intestine is joined to the sigmoid.
Total colectomy – the entire colon is removed and the small intestine is joined to the rectum.
Proctocolectomy – the entire colon and rectum are removed. The small intestine can be brought out through the abdominal wall as an ileostomy (bag) or the small intestine can be made into a reservoir (pouch) and joined to the anus.
Colectomy is a major abdominal operation. It is important to maintain a healthy lifestyle preoperatively ie stop smoking, drinking excessively and keep exercising and have adequate nutrition. Sometimes nutritional supplements such as ensure, impact or sustagen are recommended attain adequate caloric intake. Bowel preparation is usually not needed for most colectomies except for low and ultra-low anterior resections.
Laparoscopic colectomies can take many hours to complete. It is performed under a general anaesthetic (completely asleep). Antibiotics are given to minimise the risk of wound infection. Measures such as calf compressors and anticoagulants like heparin are given to reduce the risk of deep vein thrombosis. A catheter is placed in the bladder to drain and measure urine output. A 1cm incision in the umbilicus (belly button) is made and the abdominal cavity entered. A port is placed through and carbon dioxide gas is insufflated and a space created in the abdominal cavity. A laparoscope (camera) is then used to view inside. Further 5-10mm incisions are made around the abdomen to place more ports to allow instruments in. The colectomy is then performed with the removal of the diseased colon. One of the incisions is lengthened a little to allow the specimen to be removed. A join (anastomosis) is then performed with either a stapling device or sutures (or both). Occasionally a drain is left in the abdominal cavity. The wounds are then closed with deep sutures and then superficial sutures (stitches) or clips.
All going well the hospital stay can be as short as 4-5 days but a longer stay may be necessary.
The pain after the procedure is usually well controlled by medications. For the first day, A PCA (patient controlled analgesia) pump is used. This contains morphine or a morphine type drug. In most cases, patients can be switched to oral analgesics reasonably quickly. Once discharged, analgesics are only required if pain persists. If needed Panadol (2 tablets every 4-6 hours) and/or ibuprofen (400mg 4-6hourly) can be used. Occasionally, stronger pain killers like endone are needed. Pain is always variable and can persist for a number of weeks at home. It should however slowly improve. If pain worsens, it is important to get reviewed by either your GP or surgeon.
Wounds are usually closed with stitches that are underneath the skin and are dissolvable. They do not require removing. Occasionally skin clips (staples) are used and these are removed on about the tenth post-operative day. The wounds will be covered by a waterproof dressing. You can shower and bathe with the dressing on. The dressings can be removed after 1 week. No dressings are then required and the wounds can be left open to the air. If there is still some discharge, replace the dressings.
Bowel function will inevitably change after colectomy. Some colectomies whereby only a small amount of colon is removed such as right hemicolectomy and left hemicolectomy do not lead to a major change in bowel function. Initially, it is normal to have slightly looser and more frequent motions but this usually settles over some weeks to months. Other colectomies such as total colectomy and anterior resections can lead to permanent and more significant changes in bowel function. The anterior resection syndrome is a constellation of symptoms that occur after an anterior resection. These symptoms can include frequent defaecation, urgency to defaecate, and possibly even incontinence (inability to always hold a motion in). The more rectum removed (especially after an ultralow anterior resection), the greater the chance of bowel dysfunction. Bowel function will improve over 1 – 2 years. Medications can be used to improve function if needed.
Diet and nutrition
In most cases fluids can be drunk on the first post- operative day and a solid diet started on the second post-operative day. In about 1 in 5 patients, return of bowel function is a bit sluggish (an ileus) and fasting (with intravenous fluids) is required until return of bowel function. Once home, a normal diet can be resumed. Initially, eat smaller meals more frequently and gradually build up over the course of some weeks. Return of normal appetite may take weeks to months to return. If dietary intake is insufficient, energy drinks such as ensure or sustagen can be valuable. If a large proportion of the colon is removed, foods that go slower through the bowel such as pasta, potatoes and rice can help to slow things down. A review by a dietician can be very helpful.
Recovery is variable and depends on the type of colectomy and reason for it. Usually by 2 -4 weeks most people feel generally ok but full recovery can take months. Post-operative fatigue is quite common. Don’t do any strenuous activities for 2 weeks. Don’t lift anything over 1-2kg during this time. Walking and normal activities around the house is encouraged if you feel comfortable enough. This helps recovery and minimises other risks like DVT. From 2 -4 weeks you can jog or swim if there is no discomfort. Don’t do any abdominal exercises for at least 4 weeks and then start slowly and continue if you don’t feel any discomfort.
One can return to work when comfortable and when the normal post-operative fatigue has lessened. Most people require between 2 – 4 weeks off work depending on the physical requirements of the job.
Colectomy is a major surgical procedure. Most people have no complications and if complications occur, they are usually minor. There is a 1-2% risk of a major life threatening complication. If recognised early and treated appropriately, these complications can be managed successfully. Major complications include major bleeding, anastomotic leak (leak from the new join), severe infections, heart and lung complications.
A general list of complications include
Bleeding – requiring blood transfusion and occasionally, return to theatre.
Allergic reactions – to medications or dressings.
Anastomotic leak – this is where the new join created leaks and bowel content spills into the abdominal cavity. This is usually managed by a return to theatre, washout of the abdomen and the formation of a stoma (bag). This is usually a temporary stoma that can be reversed at a later date (usually 3 – 6 months).
Wound infection or slow wound healing – redness, inflammation and discharge can be signs of a wound infection. This is usually treated by opening part of the wound to allow drainage and sometimes antibiotics.
Damage to other organs – Very uncommonly other intra-abdominal organs can be damaged during colectomy such as the duodenum, small intestine, spleen and ureter. Further surgery may be necessary if such damage occurs.
Deep vein thrombosis, pulmonary embolism, heart attack, stroke, pneumonia, urinary tract infection – these are all complications of major surgery. Many measures are undertaken to prevent these complications and the risk is very low.
Conversion to open surgery – Uncommonly, it is technically difficult or unsafe to proceed via the keyhole approach and a larger open incision is made to complete the operation.
Colostomy or ileostomy (stoma) – A stoma is when the bowel (either ileum or colon) is brought through the abdominal wall and sewn to the skin. Contents of the bowel pass through the stoma and are collected in a small plastic bag. Usually the need for a stoma is discussed before the surgery. It usually will be needed temporarily in patients undergoing low and ultra-low anterior resections. In any colectomy, however, due to unforeseen circumstances, a stoma may need to be created.
In low and ultra-low anterior resections, surgical dissection of the pelvis is undertaken. This risks damage to pelvic nerves that supply the bladder and sexual function. Sexual dysfunction such as impotence and difficulty emptying the bladder can result. This is usually temporary but can be permanent. There are a number of treatment options if it occurs.
Bowel obstruction – after any abdominal surgery adhesions (scar tissue) develops. This is essential for normal healing. Occasionally, a bowel can become blocked due to these adhesions and this may occur at any time after the surgery (from weeks to years). Keyhole surgery has the potential to form fewer adhesions and therefore reduce this risk.