Intestinal Surgery

Intestinal surgery involves operations of the small intestine, the colon and the rectum. Both benign and malignant tumors (cancer), but also inflammation are treated. Bowel surgery is necessary if the disease can not be treated by medication or other procedures. However, if health is compromised or the quality of life of the patient is affected, a bowel surgery is the saving measure.

Most people only register the intestine when it behaves abnormally or when the digestion is disturbed. The intestine is the most important part of the digestive tract: it can reach a length of up to seven and a half meters in adults and has a surface area of ​​around 32 square meters. The gut is also home to an estimated 100 trillion bacteria, which together weigh as much as a pack of flour.

The intestine is divided into the small and large intestine as well as the rectum and anal canal, with each part fulfilling its own function. However, illness or an unhealthy lifestyle can disrupt the functions and lead to an imbalance in the intestine. Surgery is essential for some causes.

In general, the attending doctor recommends surgery if conservative therapy does not bring the desired improvement in the present disease or if the health of the person concerned is acutely endangered. This can be the case with inflammation as well as with benign and malignant diseases. Inflammation such as appendicitis or diverticulitis can justify surgery if a change in diet or antibiotics are no longer sufficient as a treatment. Benign tissue changes such as polyps or adenomas are usually surgically removed. Colon cancer is feared as a malignant bowel disease. If surgery is indicated, the patient can ask for a second opinion to check the diagnosis.

Surgery for small intestinal diseases

Small intestinal diseases rarely need to be treated surgically. Common small bowel operations include:

• adenoids
• adhesions
• diverticulum
• mesenterialinfarkte

Polyps are growths of the intestinal mucosa. They protrude into the intestine interior and can degenerate. If it comes to a degeneration, colon cancer is a possible consequence. For this reason, doctors suggest in this case a small bowel surgery and remove the polyps.

Adhesions, however, are adhesions that cause pain and indigestion.

Diverticula are evaginations of the intestinal mucosa. These can become inflamed, which leads to a so-called diverticulitis (diverticulitis). Again, the doctor removes complaints or risks to health.

Mesenteric infarction is another urgent need for small bowel surgery. In the process, a vessel closes in the intestine, whereupon it is not adequately supplied with blood and nutrients. The result is the death of the intestinal tract. For this reason, a mesenteric infarction represents an emergency requiring immediate surgical treatment.

Which colon surgeries are there?

The about 1.5 m long colon is located between the small intestine and anal canal. In this area, it is particularly common to diseases. Colon surgery therefore takes place more frequently than small bowel surgery. The following diseases of the large intestine usually require surgery:

• appendicitis (appendicitis)
• diverticulitis
• carcinomas
• adenomas
• adenoids

A carcinoma is a malignant tumor of the epithelial tissue, ie the covering layer of the mucous membrane. Carcinomas are common in the colon. The earlier the colon operation takes place, the higher the chance of recovery. Therefore, the appropriate procedure should be initiated quickly if a carcinoma is present.

Adenomas, on the other hand, are gland-like, benign tumors. They are often in the form of polyps. Adenomas and polyps are basically harmless, but can degenerate into malignant ulcers. Surgical removal is the sure way to prevent a serious condition.

Behind appendicitis is the inflammation of the appendix. He is at the end of the colon in the right lower abdomen. In a bacterial inflammation is either a simple appendicitis (appendicitis simplex) or a destructive appendicitis (appendicitis destructiva) before. The latter is characterized by particularly severe abdominal pain. In both cases, your doctor will recommend immediate removal by abdominal surgery. He does not remove the entire appendix, but only the inflamed appendix. The earlier the cecal surgery takes place, the lower the risk of complications.

Surgical Procedures

Right hemicolectomy

In the case of tumor localization in the right large intestine (caecum, ascending colon, right colonic flexure, right transverse colon), so-called hemicolectomy is performed on the right, i.e. right colon removal. The intestinal continuity is restored by sewing the small intestine to the transverse or descending colon. In addition to the small intestine, you have half the large intestine on the left side and the rectum. This should help you develop a shaped bowel movement again after you get used to it.

Left hemicolectomy

In the case of tumor localization in the left large intestine (left transverse colon, left colonic flexion, descending colon), the so-called left hemicolectomy is carried out, i.e. the left colon removal. The ascending or transverse colon is then sutured to the rectum. In addition to the small intestine, half of the large intestine, located on the right side, and the rectum remain.

Sigmoid

If the tumor is located in the sigmoid colon (sigmoid colon), i.e. between the descending colon and the rectum, the sigmoid resection is performed. The descending colon is sutured to the rectum to restore intestinal continuity. You have enough intestine for good stool quality.

Anterior rectal resection

Anterior or deep anterior rectal resection removes the sigma and the tumor-bearing rectum. During the operation, enough healthy rectum can be obtained towards the sphincter to restore intestinal continuity. After the tumor has been removed, the descending colon is sutured to the rectum. It is important for tumor removal that the circular fatty tissue, which is located around the rectum and contains the lymphatic drainage channels, is removed to a sufficient extent. We call this extremely important technique partial or total mesorectal excision. This surgical technique involves a surgical procedure in anatomically predetermined enveloping layers. This surgical technique protects important nerve fibers in the small pelvis, which are important for emptying the bladder and sexual function.

Since the reservoir function of the rectum is destroyed, various surgical techniques for reservoir restoration exist. We also call this pouch formation. Talk to your surgeon and let them explain various options. The aim of the reservoir formation is to achieve a reshaped and portioned bowel movement.

Depending on how close your new intestinal suture is in relation to the sphincter and whether you have had radiation before your operation, we will recommend that you create a temporary artificial intestinal exit in the small intestine. We know that intestinal sutures heal worse than others after pre-radiation or very close to the sphincter. For this reason, we protect the new intestinal suture in these cases with an artificial intestinal exit, which is covered after 2-3 months. This temporary artificial intestinal exit means that the bowel movement is not passed through the new intestinal connection, but is temporarily led outside via the abdominal wall. You must discuss with your surgeon whether an artificial intestinal exit is necessary or not.

Abdominoperineal rectum extirpation (Miles operation)

Abdominoperineal rectum extirpation, also known as Miles operation, includes the complete removal of the sigmoid, rectum and the sphincter apparatus with the anus. It is primarily the same as the anterior rectal resection described above, except that due to the proximity to the sphincter, no healthy rectum is reached below the tumor in order to make an intestinal connection. For this reason, complete removal of the sphincter, including parts of the pelvic floor and the sphincter, is mandatory for complete tumor removal. The defect in the pelvic floor is closed after the tumor has been completely removed and the descending colon is diverted as an artificial intestinal exit in the left lower abdomen. At first you probably cannot imagine life with an artificial intestinal exit, as you have never been confronted with it before. There is a wealth of experience and important studies that have shown that living with an artificial intestinal outlet enables a very good quality of life. You need to know that complete tumor removal should be a top priority for your prognosis and therefore does not allow for compromises. If you are about to have a complete rectum removal, consult your doctor, nursing staff and stomatotherapist before the operation. You should be trained so well after the surgery that you can do your daily activities. This includes sporting activities including swimming, but also intimate relationships with your partner.

Wedge or segment resection

This operation is usually performed laparoscopically, i.e. using the keyhole technique, and involves very limited intestinal removal in the form of a wedge or section (segment). The operation can be performed on all sections of the colon. We perform this operation on broad-based polyps (benign intestinal changes) that could not be removed by colonoscopy or were incompletely removed. The operation is carried out under colonoscopic supervision so that only the diseased section of the intestine is removed with a sufficient safety distance. This operation is usually only offered in specialized centers.

Transanal endoscopic mucosectomy (TEM)

For benign or early malignant changes in the rectum, so-called transanal endoscopic mucosectomy or full-wall resection is available as a smaller alternative to anterior rectal resection or abdominoperineal rectal amputation. This technique does not require an abdominal incision, but the entire operation is performed through the anus in the anal canal. With specially developed instruments, the benign or malignant change is cut out in the form of a block with a sufficient safety distance and then the defect is sutured in the rectum. The advantage of the operation is the quick recovery of the patient from the operation. The disadvantage is that no information about affected lymph nodes is obtained. This technique should therefore only be used for very early malignant changes to the rectum, since in these cases the likelihood of lymph node metastases is very low. If the rectal cancer is already larger, it must be done radically via an abdominal incision, i.e. with the lymphatic drainage pathways as described above. The operation should only be performed by specially trained surgeons.

Operations of the rectum

Also, the rectum can fall ill, so that an operation is necessary. A common example of a terminal disease is hemorrhoids (jammed vessels). If these are in a high grade, surgical removal will improve. Anal fistulas and anal abscesses are also inflammatory processes in the rectum that the colon surgeon removes surgically.

Laparoscopic bowel surgery

A laparoscopy is understood as a laparoscopy. A section only a few millimeters in size and a camera allow a view into the interior of the patient. In this way, surgical instruments are introduced and thus operated in the abdomen. Whether gallbladder, cecum, or parts of the colon are removed, surgery remains basically the same in the abdomen. Only access to the abdominal area is different.

Advantages of the minimally invasive approach include considerably less scarring. Furthermore, in the following years, fewer scar fractures develop after the procedure, which occurred relatively frequently, especially with large abdominal incisions. In addition, the patients tolerate the operation better, have less pain and can reactivate faster.

While the gallbladder is now being very successfully minimally invasively removed, making this procedure the standard, worldwide studies have shown that minimally invasive large-bowel removal is the most appropriate for appropriate diseases, but it is not yet widely available as a standard. In Germany, minimally invasive colon removal is mainly performed in recurrent diverticulitis, a common form of intestinal inflammation. Here, the affected colon section is removed and the two bowel ends are reconnected by means of a stapler. Ideally, the patient may be discharged from the fifth day after surgery.

What complications can occur?

Like any surgery, bowel surgery involves risks and potential complications. For example, during and after bowel surgery pathogenic (pathogenic) germs may get into the wounds, causing infection. Even bleeding into the abdominal cavity can not be ruled out.

If the ends of two intestinal sections are sewn together again, these sutures open in rare cases. This is also possible with the seam to a bowel outlet. The doctor then speaks of an anastomotic insufficiency. One possible consequence of this complication is that intestinal contents enter the abdominal cavity and cause inflammation there. If a patient complains of nausea, pain, or fever following bowel surgery, the doctor will examine him for these complications.

Diarrhea after bowel surgery often occurs when the doctor removes part of the left colon. These patients have to change their diet because the large intestine is no longer sufficiently thickening the porridge. Here a nutritionist helps.

The complications and risks associated with cecal surgery are rather low. If the appendix perforated, so perforated, the risk increases. Bacteria penetrate the bloodstream more easily. For this reason, the appropriate method in appendicitis is removal of the appendix.