Laparoscopic Intestinal Surgery

The introduction of laparoscopic removal of the gall bladder (Laparoscopic Cholecystectomy) in the late 1980s revolutionized the surgical management of many abdominal operations. It was obvious to both the patient and the surgeon that hospitalizations were much shorter, intestinal function returned much faster, patients had much less discomfort and they returned to work and normal physical activities much quicker. It was only the delay in the development of proper instruments that prevented Colon and Rectal Surgeons from performing laparoscopic intestinal surgery until 1991. With patients asleep under a general anesthetic, Carbon Dioxide gas is used to distend the abdominal (peritoneal) cavity. Several cylindrical “Ports” that are 1/2 inch in diameter are placed in the abdominal wall. Surgical instruments are then placed through the ports in order to detach the intestine from its supporting structures. One of the port sites is enlarged to remove the diseased intestine. Intestinal continuity is then restored using special surgical staplers. Drs. Launer, Worsey and Salganick have performed several hundred laparoscopic intestinal operations for the treatment of Diverticulosis , Inflammatory Bowel Disease (Ulcerative Colitis and Crohn’s Disease ), Rectal Prolapse and Cancer . Hospitalization for most laparoscopic operations is 2.5 days (as opposed to 5-10 days for conventional surgery) and most patients return to normal activities within two...

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Sphincter Preservation

The preservation of anal sphincter function and intestinal continuity and the avoidance of the need for permanent ileostomy or colostomy are of utmost importance. Very few operations require that the muscles of control be sacrificed. In many others, however, the preservation of continence is determined by the knowledge and skill of the surgeon. Drs. Launer, Worsey and Salganick are continuously refining their techniques of sphincter saving operations for cancer of the colon and rectum, Crohn’s Disease , Ulcerative Colitis . Repair of anal sphincters damaged by prior surgery and childbirth injuries is also an interest to us. Techniques are now available to assess sphincter function by Anal Manometry, Endoanal ultrasound , Fluoroscopic Defacography and nerve testing. These simple tests help define the cause and location of anal sphincter injuries so that reconstructive operations can be precisely...

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Surgical Management of Ulcerative Colitis

The surgical management of Ulcerative Colitis has evolved dramatically from the days when patients were subjected to removal of the colon and rectum and creation of a permanent ileostomy (Proctocolectomy and Brooke Ileostomy). The creation of an ileostomy, a surgically created connection between the small intestine and the skin, necessitated the lifelong need to wear an appliance or bag to collect waste from the intestines. For more than 25 years, innovative operations have been available that preserve continence and maintain intestinal continuity. These operations are usually performed by Board Certified Colon and Rectal Surgeons who have had specialized training that optimizes the results of surgery. The Restorative Proctocolectomy (also called J-Pouch, Parks Pouch, Ileoanal Pull-Through and Ileal Pouch Anal Anastamosis) is now the procedure of choice for patients needing surgery for the complications of Ulcerative Colitis. The operation involves removing the colon and most of the rectum, leaving the anal sphincter muscle intact. A reservoir is then constructed from normal small intestine and sewn or stapled to the anal muscles, thereby restoring intestinal continuity. Drs. Launer, Worsey and Salganick have performed more than 1000 Restorative Proctocolectomies and have had superior functional results. A majority of patients are able to have a single stage procedure. Patients who are very ill at the time of their operations, patients who are severely anemic or patients who take large doses of prednisone will frequently require two-stage operations. At the time of the first operation, after the colon and rectum are removed and the pouch is connected to sphincter muscles, a temporary ileostomy is constructed in order to divert waste from the pouch and allow it to heal in a stool-free environment. The ileostomy is closed in a second-stage operation performed approximately twelve weeks after the original surgery. Some elderly patients or those who have significant sphincter muscle dysfunction are not candidates for Restorative Proctocolectomy. Patients in this category can maintain their continence post operatively with the Koch Continent Ileostomy. This operation was devised by Dr. Nils Koch of Gotteborg, Sweden in 1969 in order to provide an alternative to the conventional ileostomy and wearing a bag. An internal reservoir is constructed that contains a specialized valve that prevents the flow of waste to the outside. The reservoir is emptied 2-4 times daily by inserting a tube through a small opening in the abdominal wall. Dr. Launer studied with Dr. Koch in Sweden in 1985. Since that time he has performed more than 500 Continent Ileostomies with remarkably good...

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Koch Pouch

In the late 1960’s, Dr. Nils Koch of Gotteborg, Sweden created the first Continent Ileostomy in an attempt to provide a better life style for patients whose large intestines had to be removed for treatment of colitis and other diseases. In the past, patients requiring Proctocolectomy for ulcerative colitis needed an ileostomy to deal with intestinal waste. Patients with ileostomies needed to wear an appliance or “bag” to collect the waste. As an alternative, Dr. Koch constructed a internal reservoir by refashioning the small intestine. A one way valve, also made from the small intestine, was added to the reservoir to prevent the flow of waste to the outside until a small tube was inserted by the patient to overcome the valve. The Koch Pouch was hailed as a major advance by patients and their physicians who realized that regaining control over intestinal function provided a much better life than the conventional ileostomy. However, the popularity of the Koch Pouch decreased when surgeons found that its construction was technically demanding and was sometimes associated with complications. The continued search for operations that preserved continence led to the development of the Restorative Proctocolectomy (J-Pouch) as the operation of choice for patients with Ulcerative Colitis. Dr. Launer studied with Dr. Koch in Sweden and both Drs. Launer and Worsey had extensive experience with the Koch Pouch at the Cleveland Clinic. Between them they have performed more than 350 Koch Pouches. The Koch Pouch remains an excellent alternative to the Restorative Proctocolectomy in patients over age 50, in patients with incontinence, and in patients who have not had good results from prior J-Pouch...

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Flexible Fiberoptic Sigmoidoscopy

Flexible fiberoptic sigmoidoscopy is a diagnostic examination which permits visualization of the last two feet of the intestinal tract. It is recommended as a screening examination for people over age 40. Approximately 75% of all colon and rectal cancers and polyps occur in the portion of the intestine visualized during sigmoidoscopy. Other common intestinal diseases such as diverticulosis , diverticulitis , colitis , and hemorrhoids can also be diagnosed during a sigmoidoscopic examination. The extent of those diseases can also be assessed. A flexible fiberoptic sigmoidoscopy is much more comfortable than in the past when more rigid scopes were used. Preparation for the examination is quite simple. One Fleet’s enema is taken two hours and one hour prior to the procedure. It is not necessary to alter your diet either the day before, or the day of, your examination. Similarly, it is important not to take additional laxatives in an attempt to better clean the colon. A flexible fiberoptic sigmoidoscopy is performed in the knee-chest position on a special tilt table which permits gravity to help with the passage of the scope. After digital examination with a well-lubricated, gloved finger, the scope is introduced into the anus. A small amount of air is insufflated into the colon in order to facilitate visualization of the intestinal lining. This occasionally causes some mild cramps and a feeling of urgency (similar to that sometimes experienced prior to a bowel movement). This examination is typically completed in less than five minutes and does not commonly cause pain. If an abnormality is found, a biopsy can sometimes be obtained through the sigmoidoscope. Since there are no pain fibers in the intestinal tract, there is no discomfort associated with a biopsy. The risks associated with flexible fiberoptic sigmoidoscopy are negligible. The instrument is sterilized between examinations, and there is virtually no chance of transmission of communicable diseases. A small potential for bleeding or perforation does exist, but in 20 years of practice, this has not...

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Colonoscopy

Colonoscopy represents a major advance for diagnosis and treatment of diseases of the colon and rectum. Colonoscopy enables the physician to visualize disease processes which cannot normally be diagnosed with certainty or which do not show on standard x-rays, lower GI series, or barium enemas. Frequently, this examination is done to locate and treat colon and rectal polyps (small benign or malignant growths of the large intestine). The examination is performed using a colonoscope , a long, flexible tube that permits the examiner to visualize the inside of the colon (large intestine). The ability to remove polyps through the colonoscope in the outpatient setting provides the patient with a relatively safe technique that avoids major surgery and costly hospitalization. Following colonoscopic polypectomy, patients can usually return to their normal activities within 24 hours. Colonoscopy is also frequently used as part of a diagnostic workup for rectal bleeding or inflammatory bowel disease . Finally, it is used as a surveillance technique in patients who have undergone removal of parts of their intestine for cancerous growths. Periodic examination permits early diagnosis of recurrent cancer and/or removal of pre-cancerous polyps before they become malignant. Proper preparation for colonoscopic examination is extremely important. The large intestine must be clean and empty for an adequate examination. Preparation for colonoscopy can be accomplished the day prior to the examination. Colonoscopy is performed in the Outpatient Department of Scripps Memorial Hospital or the La Jolla Endoscopy Center (Suite 980) in the Scripps Ximed Medical Building. An IV is started in order to administer medications. In order to reduce apprehension and discomfort during the examination, Fentanyl (a narcotic) and Versed (a sedative) are usually given intravenously at the beginning of the examination. These will cause sedation and may cause some light-headedness. Colonoscopy is performed on a comfortable examining table with the patient lying on the left side. A lubricant is applied around the anal opening and the instrument is inserted into the rectum. The scope is then manipulated so that the entire lining of the large intestine can be seen. In order to do this, the examiner must instill small amounts of air into the colon. This can cause a sensation of distention and fullness. The large intestine (colon) can be very redundant and can contain many turns and folds. As the scope passes around some of these turns, one may experience a cramping or tugging sensation. This sensation is usually relieved as the instrument and the colon are straightened. Colonoscopy usually takes 15 to 60 minutes. If polyps are present and removed, the length of the procedure will be longer. A nurse is always present to help the examiner and to monitor the patient during the...

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Enterostomal Therapy

Enterostomal Therapy is the treatment of patients with surgically constructed connections between the intestines and the skin (Colostomy, Ileostomy, Urostomy). In 1958, the first school of Enterstomal Therapy was created at The Cleveland Clinic by Dr. Rupert B. Turnbull and Mrs. Norma Gill. Since then, most advanced medical institutions have recognized the importance of Enterostomal Therapy and have trained enterostomal therapists on their staffs. The success of operations that require intestinal stomas is determined by the skill of the surgeon, the placement of the stoma and the pre- and post operative care and education provided by the enterostomal therapist. Dr. Launer is a graduate of the school of enterostomal therapy and Dr. Launer, Dr. Worsey and Dr. Salganick have extensive experience constructing and caring for patients with colostomies, ileostomies and urostomies. In addition, their team includes a stoma therapy nurse with many years of experience, and has special expertise managing some of the unique problems that arise in patient’s with the Koch continent ileostomy or...

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