Understanding your bowel surgery Abdomino Perineal Excision of Rectum (APER) Hartmann s Procedure Pan Proctocolectomy Total Colectomy Subtotal Colectomy Information for patients, relatives and carers
This booklet is intended to provide you with help and further information about your treatment, which may include surgery. There is often a great deal of information provided in a short space of time when you see your doctor and you may feel quite uncertain, confused or even overwhelmed by this. Your doctor or nurse may have explained your operation or treatments to you, but you may not have understood or taken all the information on board at the time. We hope that this booklet will help you understand and feel reassured. What does the large bowel do? The large bowel is the last part of the digestive system and is made up of the colon and rectum (back passage). See diagram below: Transverse colon Stomach Descending colon Ascending colon Sigmoid Small bowel (ileum) Rectum
Once food has been swallowed, it passes into the stomach where digestion begins. It then moves through the small bowel where essential nutrients are taken into the body. The digested food then passes into the colon where water is absorbed. The remaining waste matter, known as stools or faeces, is held in the rectum until it is ready to be passed through the anus as a bowel motion. What does surgery involve? Your surgeon will have discussed the most appropriate type of operation with you. The surgery you have will depend upon the type, size and area of bowel affected. What about keyhole surgery? Your surgeon may offer you keyhole, or laparoscopic, surgery. However, not everyone is suitable for this type of operation. Laparoscopic surgery involves the surgeon making a few small cuts on your abdomen (tummy) to remove the bowel using a telescope and other specialised instruments. This type of surgery usually takes slightly longer than the traditional open operation. Advantages Shorter stay in hospital most patients are home within four to seven days Quicker recovery time most patients are fully recovered within three to four weeks You will probably begin to eat again more quickly Scarring is less visible than the scars from traditional open surgery.
Disadvantages Not everyone is suitable for laparoscopic surgery Not all surgeons can perform this type of operation. Enhanced Recovery Programme The Enhanced Recovery Programme is different to traditional care and can improve your recovery considerably. If you are suitable for this Programme you will be provided with additional information to explain the steps of your inpatient care and recovery. Will I need to have a stoma? Due to the type of operation you require it will be necessary to form a stoma. Your surgeon and nurse specialist will explain in more detail the type of stoma you will require and discuss whether this will be permanent or temporary. A permanent stoma would be required when the surgeon is unable to rejoin the bowel. A temporary stoma may be performed if it is possible to allow the joined ends of your bowel time to heal properly. You will be given the opportunity to meet the stoma nurse before your surgery to discuss a stoma and its management. The stoma nurse will need to mark an area on your abdomen in the most appropriate place with you before your operation. The stoma nurses will continue to provide support, information and assistance before, during and after your operation. A permanent stoma is formed by bringing an end of the small bowel or large bowel out onto the surface of your abdomen. This is called either an ileostomy (small bowel) or colostomy (large bowel). A temporary stoma is formed by bringing a loop of bowel out onto the surface of your abdomen. This would usually be a loop ileostomy. Your bowel motions (faeces) empty into a pouch that is worn over the stoma.
If your stoma is temporary, the doctors will discuss the possibility of an operation to reverse your stoma in more detail. What are the different types of operation and what do they involve? Abdomino perineal excision of rectum (APER) This is an operation to remove an abnormal area in the lower part of the rectum or anus. The surgeon will need to make two incisions (cuts). One incision is made down the centre of your abdomen (tummy) and one incision is made in the perineal area. This is the area between your buttocks, around your anus (bottom). During the operation part of the sigmoid colon, the rectum and anus are removed. The remaining end of the large bowel is then brought out onto the surface of your abdomen as a permanent colostomy. Permanent colostomy Abdomino perineal excision of rectum (APER)
Hartmann s procedure This is an operation to remove an abnormal area in the rectum or sigmoid colon. During the operation, an incision (cut) is made down the centre of your abdomen (tummy) and part of the sigmoid colon and rectum are removed. The end of the large bowel is then brought out onto the surface or your abdomen as a colostomy. This type of stoma may not be permanent and your surgeon will discuss this with you in more detail. Colostomy Hartmann s procedure
Pan proctocolectomy This is an operation to remove an abnormal area or areas in the colon and rectum. The surgeon will need to make two incisions (cuts). One incision is made down the centre of your abdomen (tummy) and one incision is made in the perineal area. This is the area between your buttocks, around your anus (bottom). During the operation the whole length of the colon, the rectum and anus are removed. The remaining end of the small bowel is then brought out onto the surface of your abdomen as an ileostomy. End ileostomy Pan proctocolectomy
Total colectomy This is an operation to remove an abnormal area or areas in the colon and rectum. During the operation, an incision (cut) is made down the centre of your abdomen (tummy) and the whole length of the colon and part of the rectum are removed. The remaining end of the rectum is stitched closed and left inside. This can be called a rectal stump. The end of the small bowel is then brought out onto the surface or your abdomen as an ileostomy. This type of stoma may not be permanent and your surgeon will discuss this with you in more detail. Ileostomy Total colectomy
Subtotal colectomy This is an operation to remove an abnormal area or areas in the colon and rectum. During the operation, an incision (cut) is made down the centre of your abdomen (tummy) and part or parts of the colon are removed. The remaining ends of the bowel are then joined together. It may be necessary for the surgeon to bring out a loop of small bowel onto the surface or your abdomen as an ileostomy. This type of stoma may be required to allow the joined ends of bowel to heal properly and may not be permanent. Your surgeon will discuss this with you in more detail. Subtotal colectomy
Are there any risks associated with bowel surgery? Yes. These operations are classed as major surgery and as with any operation, it carries risks (including risk to life). Your surgeon will discuss individual risks with you in more detail. All operations carry a risk from anaesthetic, but this is minimised due to modern techniques. The anaesthetist will meet with you before you have your operation and explain in the detail the type of anaesthetic you will have, as well as any risks specific to you. Fortunately, most people have no complications at all, although problems can occur with any operation. Listed below are the minor and major risks due to surgery and hospitalisation. Minor risks Urine infection Chest infection Wound infection Nausea and vomiting Paralytic ileus - this is when the bowel temporarily stops working and is unable to absorb fluids or food. Major risks Deep vein thrombosis (DVT) blood clot in the leg Pulmonary embolism (PE) blood clot in the lung Post-operative haemorrhage bleeding in the abdomen (tummy) Leak at the anastomosis where the bowel fails to heal at the join Injury to the pelvic nerves that supply sexual function and bladder function
Most people will not experience any serious complications from their surgery. The risks increase for the elderly or overweight or people who already have other medical problems. However, any problems that do arise can be quickly assessed and appropriate action taken. The risks along with the potential benefits of the operation will need to be considered. Please speak to your doctor or specialist nurse about your operation to make sure you understand exactly what is going to happen. Pre-operative assessment You will be asked to come for a pre-operative assessment appointment before your admission. This will involve the nurse or doctor completing a health questionnaire and assessment. Some routine investigations may also be carried out at this appointment, such as, blood tests, ECG and obtaining a simple nasal swab to check for MRSA infection. You will be provided with more information regarding your surgery, admission and any bowel preparation you may require. Is there anything I should do to prepare for my operation? Before you come into hospital for your operation, try to organise things ready for when you come home. If you have a freezer, stock it with easy-to-prepare food. Arrange for relatives and friends to do your heavy work (such as changing your bedsheets, vacuuming and gardening) and to look after your children if necessary. If you live alone, or think you will need help at home with cooking, shopping and so on after your operation, please tell the nurses on the ward when you are first admitted. They will then be able to help you organise this.
What happens on the day of my operation? The surgeon and anaesthetist will visit and ask you to sign your consent forms, if this has not already been completed. This is to make sure that you understand the risks and benefits of having the operation and the anaesthetic. We will ask you to have a shower or bath before going to the operating theatre. All make-up, nail varnish, jewellery (except wedding rings, which can be taped into place), body piercings and dentures must be removed. One of the nurses will then come and prepare you for the operating theatre. What happens after the operation? You will wake up in the recovery room before we take you back to the ward. We will encourage you to start moving around as soon as possible after surgery. The nurses and physiotherapists will assist you with deep breathing and leg exercises to help prevent chest infections and blood clots, even if you are still in bed. We will have discussed pain control with you before your operation. There are different types of pain relieving drugs that are effective. If you are in pain, it is important that you tell a doctor or nurse as soon as possible, so that they can find the right type and dose of painkiller for you. Your specialist team will do everything they can to make your recovery as pain free as possible. You may have various tubes and drains to assist with your recovery after surgery. These may include: Intravenous infusion (drip) to replace fluids until you are eating and drinking again
Catheter a small tube in your bladder to monitor your urine Nasogastric tube a fine tube passing down your nose into your stomach to help reduce sickness Abdominal drain a tube in your abdomen (tummy) near your wound to drain any fluid. You may not be able to eat or drink for a few days until your bowel has started working normally again. Your specialist team will let you know when you can start eating and drinking, usually starting with sips of water. The amount you have will gradually increase until you are able to eat a light diet. This may take a couple of days, but may be longer, depending on the type of operation you have had. When can I go home? You will be in hospital for approximately seven to ten days, but this will depend upon your recovery. If you have had keyhole surgery or are on an Enhanced Recovery Programme, you may be ready to go home within five to seven days. We will discuss this with you before the operation and again while you are recovering. If possible, please arrange for someone to collect you by car on the day of your discharge home, as you will not be able to drive yourself or travel on public transport alone.
Follow up appointment You would usually be asked to return to hospital within 4 to 6 weeks to see a member of the surgical team. This is to check how you are recovering from your operation. The section of bowel that was removed during the operation will have been sent to the laboratory for testing. When the results are available, you may be asked to return to the hospital to discuss them with your surgeon. Notes:
Please do not hesitate to contact your nurse specialist or the ward where you had your operation if you have any queries or concerns: Colorectal Clinical Nurse Specialists:- Marion Rogers, Nichola Richards Tel: 01256 314807 Or bleep 1216 via the hospital switch board (01256 473202) Mon - Fri, 09.00-17.00 (excl. Bank Holidays)
Useful contact details Pelican Cancer Foundation Macmillan Cancer Support Cancerline: 0808 808 2020 Cancer Research UK Citizens Advice Bureau Samaritans Helpline: 08457 90 90 90 www.pelicancancer.org www.macmillan.org.uk www.cancerresearchuk.org www.citizensadvice.org.uk www.samaritans.org Basingstoke and North Hampshire Hospital Aldermaston Road Basingstoke Hampshire RG24 9NA 01256 473202 www.northhampshire.nhs.uk Printed with the support of: July 2011 Review July, 2012 Colorectal Team, BNHFT