GROUP PRESENTATION ON GENERAL SURGERY

TOPIC: INTESTINAL PROCEDURES

BY

GROUP 9

OKOH EVELYN

OKPARA CHARITY

EMEKA EZEH ESTHER

POST BASIC PERIOPERATIVE NURSING SCHOOL

UNIVERSITY OF NIGERIA TEACHING HOSPITAL

ITUKU OZALLA, ENUGU

JULY, 2024
Intestinal Procedures

Diagram of the intestine

Anatomically, the intestines are divided into the small (upper) and large (lower) intestines, and

there are subdivisions of each.

The small intestine extends from the pylorus to the ileocecal valve. The three sections include the

duodenum (proximal portion), the jejunum (middle section), and the ileum (distal portion that

joins the large intestine). The ileocecal valve, a sphincter

muscle, lessens the backflow of material that has been discharged to the large intestine. The

blood supply to the small bowel is divided into arcades with several [Link] large

intestine, or colon, extends from the ileum to the rectum and is generally divided into the

ascending, transverse,

descending, and sigmoid colon. The cecum is the pouch formed where the large intestine joins

the small intestine.

The blood supply to the large bowel is united on the mesenteric border by the marginal artery of

Drummond with widely dispersed arcades of

[Link] mesentery, a peritoneal fold, attaches the small and large intestines to the posterior

abdominal wall and contains the arteries, veins, and lymph nodes that supply the intestines.
Inflammation, intestinal obstruction, and disruption in absorption and motility are disorders that

may lead to surgical intervention. Etiologic factors determine the surgical procedure. Segments

of bowel can be removed, and the continuity can be reestablished by anastomosis.

Resection of the Small Intestine

Tumors, as well as strangulation from adhesions, volvulus, obstruction, and regional ileitis,

usually are treated by resection of the involved segment. An abdominal incision is made over the

suspected or known site of disease. After exposure, clamps are placed above and below the

diseased segment of the bowel and mesentery to avoid spillage. The involved area is resected,

and an

end-to-end, end-to-side, or side-to-side anastomosis is performed to restore continuity.

Variations of this technique are used for other related problems of the small intestine, such as

extensive perforation. Bowel strangulation and obstruction necessitate an immediate surgical

procedure to prevent necrosis, peritonitis, and death.

Hemicolectomy, Transverse Colectomy, Anterior

Resection, and Total Colectomy

Colitis, diverticulitis (or diverticulosis), obstruction, and neoplasms are the most common

reasons for surgical intervention to remove a diseased segment of the colon. Most surgical

procedures involve opening the abdomen, walling off the peritoneal cavity, incising and

clamping at the points where resection is to be carried out, and, finally, reestablishing continuity

by anastomosis.

In select patients, a laparoscopic approach may be used to mobilize the segment of the large or

small bowel to be resected. The resected bowel is removed through a small minimal-access inci
sion in the abdominal wall. Stomas also can be created with the laparoscopic [Link]

perioperative plan of care includes preoperative administration of intestinal antibiotics, bowel-

cleansing methods, and diet restrictions (e.g., a clear liquid diet). Bowel cleansing can

cause depletion of electrolytes and is performed only as [Link], contaminated

instrument technique should be used during the procedure. Instruments used on the interior

aspect of the bowel should not be used on other tissues and should be isolated after use.

An NG tube may be inserted before the surgical procedure begins and may remain in place until

partial healing of the anastomosis occurs and effective peristalsis returns. Fluid and electro

lyte balance is [Link] Stomas

An intestinal ostomy is a surgically created opening, or stoma, that extends from a portion of the

bowel to the exterior via theabdominal wall. This procedure may be performed to divert intes

tinal contents so inflamed bowel can heal, to decompress pressure caused by an obstructive

lesion, or to bypass an obstruction such

as a benign or malignant tumor. A stoma can be created from the large or small bowel. Some

intestinal stomas are temporary; others

are [Link] type and level of the lesion determine whether an ileostomy, cecostomy, or

colostomy is indicated. Preoperatively, the patient’s abdomen will be assessed for stoma

placement based on the type of stoma, body size, and belt line. The stoma site is marked so the

patient’s clothing will not interfere with the collection appliance. Most facilities have stoma

nurses available to assist with stoma planning and teaching. An ileostomy will be positioned on

the right side of the lower abdomen. The output will be more frequent and liquid. A colostomy is

usually positioned on the left side of the abdomen. The output will be more [Link] patients

with a temporary stoma, intestinal continuity is reestablished after healing, through closure of the
opening in the bowel and anastomosis of the previously separated ends. If the stoma will be

permanent, the patient will wear a collection appliance at all [Link] patient’s acceptance of

these procedures is as varied as an individual’s emotional reactions. Each patient requires a

rehabilitation plan based on personal needs. These plans should include care of the collection

appliance, maintenance of skin integrity,

proper diet, odor control, and comfortable clothing. Patient participation is an integral part of the

preparation for self-care and enhances self-confidence.

Ileostomy

An ileostomy is performed for conditions such as chronic ulcerative colitis or after removal of

the colon (colectomy). In this procedure the proximal end of the transected ileum is exteriorized

through the abdominal wall. The usual stoma site is the midportion of the right rectus sheath,

approximately 3 cm below the level of the umbilicus. First, a disk of epithelium the size of the

planned stoma is excised. The anterior and posterior sheaths are then incised, and the rectus

sheath is divided with a muscle-splitting incision. The proximal end of the ileum is brought out

through peritoneum and muscle. Here the edges are everted and sutured to the skin. Liquid or

semisolid discharge is collected in an ileostomy bag placed over the stoma. The surrounding skin

requires special care to prevent excoriation and [Link] entire cecum and colon, as well as

the rectal mucosa (mucosal proctectomy), are resected in an endorectal-ileoanal pull through

procedure. The ileum is anastomosed to the anus with a circular stapler. The rectal and anal

muscles are preserved for anal continence.

In a multistage procedure, a pouch can be constructed for use as a fecal reservoir using loops of

the terminal ileum. This procedure can be performed as an open surgery or laparoscopically.
Pouch configurations can resemble a J, W, or S. Studies have shown that the J pouch is the

preferred method overall. A 20-cm J pouch is fashioned of the ileum with a linear stapler. The

lower curve of the J is anastomosed to the rectal stump with a circular stapler side to the end.

During the healing period, a temporary ileostomy may be in place. Fecal material will pass

through the ileostomy, pouch, and the rectum. The anal anastomosis is closely monitored during

this time for integrity. Once it is confirmed that the pouch is healed and the anastomosis is

secure, the ileostomy will be closed as a final step in the [Link] not without

complications, these procedures offer acceptable alternatives to a permanent ileostomy stoma,

especially in children and young adults.

Cecostomy

With a cecostomy, an opening is created in the cecum, and a tube is inserted for decompression

of the massive distention caused by colonic obstruction. The tube is placed into the cecum

through the lower right side of the abdomen. Less severe distention maybe relieved by suction

and irrigation through a colonoscope and the insertion of an intestinal tube through the anus to

the cecum. Cecostomy or colonoscopic decompression may precede subsequent colon resection.

Colostomy

An opening anywhere along the length of the colon to the exterior skin surface creates an

artificial anus. The section of colon to be exteriorized depends on the location of the lesion to be

resected or treated. For example, a low anterior bowel resection necessitates a sigmoid

colostomy. A permanent colostomy in the sigmoid colon forms an artificial anus after a

combined abdominoperineal resection for rectal carcinoma. The rectum is removed. A collection

device for fecal material is not needed after a patient’s bowel evacuation becomes regulated.

Most patients wear a stoma cap even when they are in the process of [Link] a double-
barreled or a loop colostomy may be performed as a temporary measure. In a double-barreled

colostomy , the transverse colon is divided and both ends are brought out to the margins of the

skin incision. The proximal stoma serves as an outlet for feces, and the distal opening leads to

the nonfunctioning bowel. In a loop colostomy , a loop of colon is brought out onto the

abdominal wall. A plastic rod or ostomy bridge is placed under the loop to hold it out on the

exterior abdominal wall. The peritoneum is closed, and the wound around the colostomy is

sutured.

Appendectomy

Appendicitis can occur at any age but is seen most often in adolescents and young adults. It may

imitate other conditions such as a ruptured ovarian cyst or ureteral calculus. Some appendices are

retrocecal, which makes diagnosis and excision more difficult . Classic symptoms of early

appendicitis include pain in the right lower quadrant at McBurney’s point, rebound tender

ness, nausea, and moderate elevations in temperature and white blood cell count.

An emergency appendectomy is necessary to prevent a progression to gangrene and the

perforation of friable tissue, with subse

quent peritonitis. Most appendectomies can be performed via laparoscopy. The open abdominal

approach involves a muscle splitting incision in the right lower quadrant, over McBurney’s

point. The blood supply to the appendix is ligated and severed. A crushing clamp is applied to

the appendiceal base, which is then ligated and severed from the cecum. After amputation, the

sur

geon may elect to cauterize the stump with phenol and alcohol or wipe it with a sponge soaked

with an iodophor (povidoneiodine [Betadine]) to reduce contamination. The stump is then

inverted
into the cecum as a purse string suture is tightened around the stump. Instruments used in the

appendectomy are isolated as contaminated and not used on other [Link] is indicated in

the presence of an abscess, appendix rupture, or any gross contamination of the wound. An

appendectomy is usually an uncomplicated procedure with rapid convalescence unless

lifethreatening peritonitis results.

Laparoscopic Appendectomy

After creation of a peritoneal working space with carbon dioxide, trocars are placed, the

laparoscope is inserted through theinfraumbilical incision, and the patient is placed in

Trendelenburg’s position. If a single-lumen approach is not used, secondary trocars are inserted

in the suprapubic area and left lower quadrant for placement of graspers and dissectors. The

appendix is located and hemostatically dissected from the mesoappendix with endoscopic clips

or staples. Endoloop ligatures are placed at the base of the appendix, and endoscopic scissors are

used to transect it. Grasping forceps are used to place the appendix into an Endopouch collection

reservoir to prevent the extrusion of contents during evacuation through the infraumbilical trocar.