3 Colorectal surgery

Anal fissure (botulinum toxin injection, lateral internal sphincterotomy, advancement flap) 81

Anal sphincter repair 83

Anorectal abscesses (incision and drainage) 85

Appendicectomy 87

Colectomy and rectal excision 90

Lower gastrointestinal endoscopy 96

Fistula-in-ano surgery 100

Haemorrhoids 102

Percutaneous caecostomy 105

Perianal skin tag excision 106

Pilonidal sinus 107

Rectal prolapse surgery 109

Rectocele repair 113

Restorative proctocolectomy (ileo-anal pouch) 115

Small bowel resection 117

Small bowel strictureplasty 119

Stoma (formation/reversal) 121

For any colorectal procedure it is important to mention the following general consent issues:

It should also be documented that should any unforeseen pathologies be identified then additional procedures (in particular hysterectomy and bilateral salpingo-oophorectomy (BSO) should they be involved in a malignant process) should be authorized if deemed in the best interest of the patient

Where appropriate, it is prudent to discuss the disposal of tissues

For laparoscopic procedures it is important to mention the following: perforation of bowel (following port-site insertion), port-site haematoma, port-site hernia and the potential for the operation to be converted to an open procedure

In 1981 the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system was introduced to classify the severity of a disease based on a number of different physiological parameters. There have since been two updated versions: APACHE II in 1985 and APACHE III in 1991. The APACHE system is used predominantly in the intensive care setting and calculates the mortality risk for a group of patients within a specific disease category

The Simplified Acute Physiological Score (SAPS) is a derivation of the APACHE system that uses fewer of the physiological parameters and is used to calculate the predicted hospital mortality

Operative

Operative parameters (if calculating risk preoperatively)

Intra-anal botulinum toxin: the toxin is injected in either three or four positions between the internal and external anal sphincter causing paralysis. This in turn prevents the anal spasm associated with the fissure, encouraging fissure healing

Anal advancement flap: the fissure is excised and adjacent healthy tissue is used as a flap to cover the excised area²

Therapeutic: relief of pain, allows painless defecation, and decrease constipation rates due to painful infrequent defecation cycles

Medical: topical glyceryl trinitrate (GTN) ointment, topical diltiazem (calcium channel blocker)

Lateral internal sphincterotomy: haematoma—2.5%, haemorrhage—2.5%, incontinence at 2 months—7.5%, incontinence at 3 years—5%, overall recurrence—7.5%

Intra-anal botulinum toxin injection: haematoma—2.5%, incontinence at 2 months—5%, incontinence at 3 years—0%, overall recurrence—55%

Anal advancement flap: the American Society of Colon and Rectal Surgeons’ guidelines have suggested this as an acceptable alternative to lateral internal sphincterotomy, however, there is a lack of prospective, randomized studies in the literature at the present time

Routine outpatient review if required

Obstetric anal sphincter injuries (OASIS), which are symptomatic (incontinence, perineal pain, and dyspareunia). These include only grade 3 and 4 perineal tears (classification based on the Royal College of Obstetricians and Gynaecologists guideline³)

Further trauma surgery—if other organs injured in the presence of traumatic sphincter injury

Sphincteroplasty:⁴

Overlapping sphincteroplasty: overall 16.5% complication rate (1.3% mortality, temporary difficulty in voiding, excessive bleeding, abscess formation, haematoma, faecal impaction⁵)

Continue conservative measures including dietary lifestyle change, use of bulk-forming agents, pelvic floor exercises, and biofeedback training

Some surgeons advocate immediate management, should a fistula-in-ano be found at the time of incision and drainage

Therapeutic: resolve sepsis, prevent fistula formation

Even with incision and drainage: up to 66% may develop a fistula-in-ano later in life and up to 35% present at the time of incision and drainage (there is some variation in the literature regarding the incidence of fistula-in-ano)⁴

Occasionally a course of oral or intravenous antibiotics will be given

Follow-up is necessary in cases where fistulas have been identified with subsequent examination under anaesthesia and fistula surgery

Laparoscopic:¹ in general, three or four small port incisions are be made in the abdominal wall, the ports and camera are inserted following the introduction of a pneumoperitoneum. The appendix is identified, ligated, and removed. The port sites are subsequently closed

Need for alternative procedure (i.e. right hemicolectomy, Meckel's diverticulectomy) if alternative diagnosis encountered

Excision of appendix despite macroscopically normal appearance

Therapeutic: remove a diseased appendix and source of sepsis

Open versus laparoscopic appendicectomy: wound infections are half as likely following open appendicectomy. Intra-abdominal abscess formation is three-fold higher following laparoscopic appendicectomy⁴

<1% risk of pulmonary complications, urinary tract complications, venous thrombosis/pulmonary embolism, post-procedure haemorrhage

Anterior resection of rectum: here the pathology is situated in the middle and upper thirds of the rectum. This involves the resection of a portion of the sigmoid colon and part of the rectum (Fig. 3.5). The remainder of the sigmoid colon is anastomosed to the rectal stump. A protective stoma can be performed to protect the anastomosis. In most cases this will be later reversed. With modern surgical techniques a low anterior resection will be possible in a proportion of patients with tumours in the lower third. Total mesorectal excision (TME) should be performed for tumours located in the middle to lower third of the rectum, either as part of an APER or low anterior resection to reduce the risk of local recurrence

Hartmann's procedure (Fig. 3.6): this is performed either in the emergency setting where gross contamination exists (for example secondary to a colonic perforation) thereby precluding primary anastomosis or as a palliative procedure. It involves resection of part of the distal colon with formation of a colostomy, which may be permanent. The rectal stump is closed

Left hemi-colectomy: involves the resection of part or the entire descending colon for pathology in the descending colon or splenic flexure. If it is extended, part of the transverse colon is also resected beyond the middle colic vessels. An anastomosis is made between the proximal colon and the distal colon. A defunctioning ileostomy or colostomy may be performed which the surgeon will decide in the postoperative period whether or not to reverse

Transverse colectomy: a rarely performed procedure for pathology in the transverse colon

Right hemi-colectomy: the caecum and ascending colon are resected. If it is extended, part of the transverse colon is also resected beyond the middle colic vessels. An anastomosis is made between the proximal segment of bowel and the transverse colon. It is performed for pathology in the caecum, ascending colon, or hepatic flexure

Total colectomy: this procedure involves resection of the entire colon with formation either of an ileorectal anastomosis or an end-ileostomy and mucous fistula. If the rectum is also excised it is termed a proctocolectomy. Indications include pancolitis refractory to medical therapy, patients with known HNPCC or FAP. An end-ileostomy may be fashioned. Alternatively, an ileoanal pouch or ileorectal anastomosis may be performed

Ileocaecal resection: for pathology in the terminal ileum and caecum. It is commonly performed for Crohn's disease or occasionally an appendiceal mass. Here, the terminal ileum and caecum are resected. The ileum is then anastomosed with the ascending colon

Excision of gynaecological or urological organs

Formation of defunctioning stoma

Therapeutic: to remove underlying pathology/disease process of bowel and restore function or reduce the risk of future complications

HNPCC/FAP: should the patient be in a high-risk category for future development of colonic carcinoma, alternatives to surgery include surveillance colonoscopies at regular intervals. It is important to inform the patient of the possibility of an interval cancer developing between consecutive colonoscopies. For most FAP patients with polyps total proctocolectomy is advised

Diverticular disease: dietary advice can be given for symptomatic disease. In acute diverticulitis perforates this may be treated initially with antibiotics or, alternatively if an abscess cavity develops, this may be radiologically drained. It is important to inform the patient that the disease process may persist or recur despite these measures at which point surgery may be the only option

Inflammatory bowel disease: medical therapy (steroids, immunosuppressants and 5-aminosalycilic acid (5-ASA) drugs) is generally advocated as first-line treatment for acute exacerbations. If unresponsive or there is risk of imminent perforation or indeed perforation of bowel, surgery would be advocated

Ischaemia: antibiotics, adequate oxygenation, intravenous fluids and bowel rest may resolve the acute event. If the bowel is non-viable and the patient is fit for surgery, resection of the affected bowel with stoma formation is advocated

Pelvic surgery: urinary and sexual dysfunction (impotence and retrograde ejaculation), faecal urgency, increased frequency of defecation³

Anastomotic leak: anterior resection (leak rate varies from 6% to 7.4%), other colonic anastomosis (leak rate varies from 2.6% to 4.1%). Anastomotic leak is associated with fivefold increased 30-day mortality⁴

Rigid sigmoidoscopy: visualization of the rectum (it is rare to directly visualize the sigmoid colon—up to 15–20cm of lower gastrointestinal tract). An enema or suppository is, in general, advised prior to commencing to aid in visualization of the mucosa. The patient is positioned on their left side. A digital examination is performed before the sigmoidoscope (Fig. 3.7) is inserted with the obturator lubricated. Once inside the rectum the obturator is removed and the bellows are used to insufflate air and dilate the rectum. The sigmoidoscope is advanced to approximately 15cm while negotiating the valves of Houston. Patients may experience discomfort and the sensation of the need to pass flatus

Flexible sigmoidoscopy: visualization of the rectum, sigmoid colon, and up to two-thirds of the transverse colon (in the majority of cases the descending colon is not seen). An enema will be administered prior to commencement. The patient is positioned on their left side with both knees brought forward. A digital examination is performed before the sigmoidoscope is inserted. The flexible sigmoidoscope is inserted into the rectum and advanced to the splenic flexure. Air will be insufflated during the procedure in order to view the mucosa adequately and aid advancement. The images are transmitted onto a screen, which the operator will observe. Should there be an abnormal area a biopsy can be taken which will be sent to pathology. The patient may experience an uncomfortable sensation and abdominal cramps as a result of the insufflated air. The procedure should last less than 10min

Colonoscopy: here the entire lower gastrointestinal tract can be visualized up to and including the caecum. Skilled endoscopists are able to cannulate the ileocaecal valve to visualize the terminal ileum. In the 2–3 days leading up to the procedure the patient is advised to maintain a low fibre, clear fluid-only diet. The day before, a laxative preparation is taken with large quantities of clear fluid. This will enable the colon to be free of solid matter. The patient is positioned on their left side with their left leg. A sedative can be administered to relax the patient. A digital examination is performed before the colonoscope (Fig. 3.8) is inserted. The colonoscope is inserted into the rectum and advanced to the terminal ileum. Air will be insufflated during the procedure in order to view the mucosa adequately and aid advancement. The images are transmitted onto a screen, which the operator will observe. Should there be an abnormal area a biopsy can be taken which will be sent to pathology. Should a tumour be noted, India ink can be injected at the site to aid location during surgery. The patient may experience an uncomfortable sensation and abdominal cramps as a result of the insufflated air. The procedure will last 15–20min

Therapeutic: permits biopsy of lesions, polypectomy, decompression of volvulus, injection of ink at tumour site (for intraoperative identification), colonic stenting for obstructing/potentially obstructing colonic tumours, argon laser coagulation for the management of colorectal disease (palliative therapy for obstructing or bleeding, malignancies, anastomotic strictures, ablation of colonic mucosal lesions, radiation proctitis), treatment of haemorrhoids (band ligation, injection of oily phenol), insertion of flatus tube, insertion of PEC for the management of recurrent sigmoid volvulus or acute colonic pseudo-obstruction

Surgical: open or laparoscopic surgical procedure for biopsy or tissue diagnosis or colostomy formation

Flexible sigmoidoscopy: UK multicentre randomized trial of 40 322 patients undergoing flexible sigmoidoscopy shows approximate risk of perforation at 1 in 40 000)

Caution is advised in neutropenic patients owing to the potential of bacteraemia. Antibiotics may be considered in this scenario and for patients with prosthetic heart valves

In a UK multicentre randomized trial of 2377 patients undergoing colonoscopy there were four perforations (approximate risk of 1 in 500), all following snare polypectomy. Nine patients were admitted with bleeding

For the insertion of colonic stents, a review of 27 studies performed between 2000 and 2006 concluded that the perforation rate was 2.5%, distal migration of stents 4.4%, rectal tenesmus 2.2%, occlusion 0.8% and recto-vaginal fistula 0.8%²

There are limited data available with reference to argon laser coagulation, however, perforation is a recognized complication³

With regard to PEC, the most common complications reported in the published literature are granular formation and infection. Other reported complications included pain, colonic leakage, and tube erosion.⁴ Unpublished data from a multicentre UK audit showed a 12% (13/105) infection rate following the procedure. Two deaths were also reported in patients with recurrent sigmoid volvulus due to late tube dislodgement. There were seven other cases of reported tube dislodgement following the procedure as well as four cases of migration (Simson, unpublished data, 2005)

Fistulectomy: the entire fistulous tract is excised. It is left open and allowed to heal through secondary intention, closed primarily with sutures, or closed with an advancement flap. The rectal side of the tract is closed internally

Seton suture: if the fistulous tract is high and involves a significant proportion of the sphincter complex, the surgeon may elect to pass a seton suture (which is essentially a thin Silastic tube or non-absorbable suture) through the tract and the two ends tied together outside the body. There are two types of seton available, the first being a cutting seton which is gradually tightened every 2 weeks (over an approximate 6–8-week period). This allows fibrosis to occur and the tract to gradually heal or becomes low enough to be ‘laid-open’. The second is a draining seton which is inserted in the presence of sepsis (if, for example a fistula is noted during incision and drainage of an anorectal abscess). This can be left indefinitely until the abscess has drained and then definitive treatment considered

Marsupialization fistulotomy: a conventional fistulotomy is performed and the wound edges are marsupialized to the fistulous tract with absorbable sutures

If the fistula is deemed to be ‘high’ (i.e. includes a substantial amount of the sphincter complex), fistulotomy is relatively contraindicated, given the high incidence of incontinence

Parks is the recognized classification system and defines four different types of fistula-in-ano: intersphincteric, trans-sphincteric, suprasphincteric and extrasphincteric (Fig. 3.9)¹

Packing of wound

Biopsies of fistula tract/rectal mucosa

Therapeutic: allow for fistula healing, reduce symptoms (pain/bleeding/mucopurulent discharge/incontinence)

It should be emphasized, however, that these treatments are associated with a high fistula recurrence rate

Conventional fistulotomy: recurrence rates range from 1.9% to 12.5% with an incontinence rate ranging from 4.2% to 12.8%

Fistulectomy: fewer studies are available to contrast fistulectomy, however, one study demonstrated a recurrence rate of 9.5% with an incontinence rate of 14.3%

Seton suture: regarding conventional seton suture placement, the recurrence rate is 6.2% with an incontinence rate of 12.5%

Marsupialization fistulotomy: recurrence rate of 4.5% with incontinence rate of 6%

Routine outpatient review with histopathology results and review of symptoms

Review in outpatient clinic if seton is of cutting type and has to be tightened

Those that have failed to respond to non-surgical measures

Significant external component

Extensive thrombosis (may best be managed conservatively)

Associated fissure-in-ano

Sclerotherapy: a solution of 5% oily phenol (in a solution of almond oil) is injected into the base of the haemorrhoid causing the blood supply to thrombose and in turn the haemorrhoid to shrink and disappear

Infra-red coagulation: infra-red light is directed at the haemorrhoid which causes the blood in the surrounding veins to coagulate, the haemorrhoid will shrink and eventually disappear

Cryotherapy: the haemorrhoid is frozen, causing it to shrink and eventually disappear

Stapled haemorrhoidopexy: a circular anal dilator is inserted and the prolapsed mucous membrane falls within the device. A purse-string suture anoscope is then inserted and rotated allowing a purse-string suture to be stitched into the anal circumference. A circular stapler is then introduced and traction applied to the purse-string. This pulls the prolapsed mucous membrane into the stapler and the device is fired excising a circumferential layer of mucosa. Meticulous haemostasis is then achieved

Rubber band ligation: overall success between 69% and 94%. Overall complication rate less than 2% (vasovagal syncope, anal pain, minor bleeding, chronic ulcer formation, priapism, difficulty in urination, thrombosis of external haemorrhoids)²

Haemorrhoidectomy:

Stapled haemorrhoidopexy: postoperative bleeding (1.5–9%), urinary retention (<5%), external haemorrhoidal thrombosis (1.2–4.7%), pelvic sepsis, rectovaginal fistula, rectal perforation, and anal stenosis are well-recognized complications of stapled haemorrhoidopexy and should be included in the consent process. Temporary faecal incontinence and faecal urgency have been documented, although these resolved in all cases by 3 months³

Patients must be discharged on laxatives and analgesia, and given appropriate advice regarding diet and toilet habits

Blind percutaneous caecostomy formation

Up to 45% patients experience minor complications including: pericatheter leak, superficial wound infection, tube occlusion, skin excoriation, premature tube dislodgement, colo-cutaneous fistula, ventral hernia¹

Complications with caecostomy may necessitate removal or replacement

Biopsy of anorectal mucosa

Therapeutic: symptomatic benefit for perianal skin tag (pruritis/bleeding/pain), interference with perianal hygiene, cosmesis

No outpatient follow-up necessary

V-Y advancement flap: in this technique a V incision is made, this is then approached to cover the defective as a Y shape

Bascom procedure: lateral (or off-line) incision to access the pilonidal cavity followed by curettage. The midline pits are then excised separately. The midline incisions are closed, the lateral incision is left open

Karydakis procedure: midline elliptical incision of the sinus down to the sacrum. A flap is then created by undercutting the midline side of the wound and advanced across the wound to the opposite side and sutured in place. The skin is then closed

Marsupialization: the sinus is incised, the borders are raised and stitched to form a pouch. This gradually closes and may need to be packed until this has happened

Laying open of sinus tract

Insertion of surgical drain

Therapeutic: to resolve a symptomatic or recurrent pilonidal sinus

Midline procedures: surgical site infection (12.4%), recurrence rate (9.4%), variable healing time (midline open wound is 41–91 days, midline closed wound is 10–27 days)

Off-midline procedures: surgical site infection (3.6–9.3%), recurrence rate (1.5–2.4%), variable healing time (off-midline open wound is 41–120 days, off-midline closed wound is 15–23 days)²

Delorme's procedure (Fig. 3.10): indicated in full thickness rectal prolapse. It is performed under regional or general anaesthesia, the patient is placed in the lithotomy or prone position. The basic principle is that only the mucosa (inner lining) of the prolapsed rectum is resected and the lining above is sutured back down to the anal canal. The outer wall of the rectum is plicated to strengthen the repair. The prolapse is then reduced, the stitches tied and a circular doughnut of tissue is left just inside the rectum

Trans-abdominal suture rectopexy: indicated in patients with rectal prolapse without constipation and a redundant sigmoid colon. Essentially the same as the Marlex rectopexy, with the exception that the rectum is sutured in place to the presacral fascia as opposed to the use of the mesh

Defunctioning colostomy/ileostomy when redundant bowel is resected and anastomosed

Perineal rectosigmoidectomy (Altemeier's procedure): 8.6% major complications, pelvic haematomas, anastomotic dehiscence, sigmoid perforation, pararectal abscess, late anal strictures, 14% minor complications, 18% recurrence rate at 41 months²

Delorme's procedure: urinary retention 12%, Clostridium difficile colitis 4%, myocardial infarction 1.3%, 4% suture line bleeding, 3% anastomotic disruption, 1.3% anastomotic stricture, 6.6% faecal incontinence postoperatively (includes patients who were continent and incontinent prior to procedure), 7% postoperative constipation, 14.5% recurrence rate at 60 months³

Trans-abdominal suture rectopexy: complication rates ranging from 9.4% to 20%, recurrence rate of 2–3.1%, postoperative incontinence of 16–26%, postoperative constipation of 31–71%⁴

Trans-abdominal Marlex rectopexy (Ripstein procedure): complication rates ranging from 2.3% to 28%, recurrence rate of 2–14%, post-operative incontinence of 28–50%, post-operative constipation of 17–43%⁵

Trans-abdominal rectopexy with sigmoid resection (Frykman–Goldberg operation): 6.3% full thickness recurrence, 8.5% mucosal prolapsed, 6.3% constipation (in patients who had not pre-operatively experienced this), 12.8% patients experienced diminished continence postoperatively, 8.5% developed significant diarrhoea⁶

Anterior resection: 15% morbidity, 7% recurrence at 5.5 years, 7.3% incisional hernia, 4.9% small bowel obstruction, 2.4% stroke⁷

Orr–Loygue rectopexy: prolapse recurrence 4.11% (mean follow-up 27.5 months) pelvic abscess 0%, 62.5% patients who were preoperatively incontinent of faeces were ‘totally cured’

Common: bleeding; swelling; pain; scar; prolonged wound healing, infection

Symptomatic review in outpatient clinic

Trans-perineal rectocele repair: this approach is also performed under general anaesthesia with the patient positioned either in the jack-knife position or supine. The recto-vaginal septum is repaired through an incision in the perineum and a decision whether or not to use a prosthetic mesh is made

Suprapubic catheter insertion

Pelvic floor reconstruction

Defunctioning colostomy/ileostomy

Biofeedback devices

Vaginal pessaries

Transvaginal/transcutaneous electrical stimulation to allow muscle contraction

Trans-perineal rectocoele repair: anatomical cure 89.2%, bleeding 3.6%, infection 4.8%, incomplete evacuation, faecal impaction, faecal incontinence, recto-vaginal fistula, dyspareunia, sexual dysfunction, failure of procedure, recurrence, if a mesh is used there is potential for mesh erosion and infection³

Symptomatic review in outpatient clinic

Failure to create pouch and alternative procedure performed (end-ileostomy, total colectomy with ileorectal anastomosis)

Regarding mucosectomy (excision of the rectal mucosa prior to ileo-anal anastomosis), one review article concluded that whereas performing mucosectomy results in both lower rates of inflammation and dysplasia in patients with ulcerative colitis and lower rates of cuff polyposis in FAP patients, it also leads to worse functional outcomes³

Symptomatic review in outpatient clinic

Patients will often require follow-up pouchoscopy with rigid/flexible sigmoidoscopy, especially if symptomatic to ensure no evidence of pouchitis or recurrence of pathology in pouch⁴

Crohn's disease resistant to medical treatment

Small bowel ischaemia (i.e. superior mesenteric artery infarction)

Radiation or Crohn's disease induced stricture

Therapeutic: remove diseased segment of small bowel

Surgical: for small bowel structuring disease in patients where length of bowel will need to be conserved, stricturoplasty can be considered as an alternative to small bowel resection

Finney: the operation is performed under general anaesthesia with the patient placed in the supine position. A midline laparotomy incision is made, the layers are divided and the abdomen entered. The small bowel is carefully examined to identify the previously imaged strictures and ensure none are missed. The segment of bowel containing the stricture is brought together in a side-to-side U-shaped configuration with stay sutures placed to maintain this (Fig. 3.13). The enterotomy over the stricture is closed, suturing the opposed surfaces of the bowel together.

Defunctioning small bowel stoma

Therapeutic: to relieve symptoms, signs and complications of small bowel obstruction

Surgical: small bowel resection

One long-term study of 314 patients undergoing Heineke–Mikulicz (88%) and Finney (11%) strictureplasties (1% not clearly defined) demonstrated the following: overall morbidity 18%, septic complications 5%, intra-abdominal abscess 2%, anastomotic leak or enterocutaneous fistula 2%, wound infection 1%, reoperation in postoperative period 1%, prolonged ileus 4%, mechanical small bowel obstruction 1%, luminal bleeding requiring transfusion 7%, at a mean period of 7.7 years 37% had undergone a reoperation (92% as a result of obstruction)²

Site: an ileostomy is commonly sited in the right iliac fossa (Fig. 3.14) with a colostomy commonly sited in the right iliac fossa (Fig. 3.15)

Single- versus double-barrelled

Possibility of a mucous fistula

Loop—formed in order to defunction either a distal obstructing colonic lesion or in order to protect a distal anastomosis

Loop—formed in order to defunction either a distal obstructing colonic lesion, a distal anastomosis or complex pelvic disease

Therapeutic: to relieve symptoms, signs and complications of small or large bowel obstruction

Reversal of stoma: Bleeding, infection (intra-abdominal abscess, urinary and wound infection), perforation of bowel, anastomotic leak, enterocutaneous fistula, ileus, stricture at the anastomotic site, reoperation