GI RPN ppt Student Copy 2023 PDF

Gastrointestinal Surgery.;// ' 'I.,..._----" Stomach Pancreas.'- - '- - Splenic flexure '-'"'--!....,;.. Transv€rse...

Gastrointestinal Surgery.;// ' 'I.,..._----" Stomach Pancreas.'- - '- - Splenic flexure '-'"'--!....,;.. Transv€rse colon ' r - ' -- Descending colon Jejunum 1 Learning Objectives Identify the anatomic components of the GI tract and explain their function. Explain procedural considerations for GI surgery. Differentiate between the types of instrumentation used for GI procedures. Understand Isolation Bowel Technique and the reasoning. Differentiate between endoscopic procedures performed on the upper and lower GI tract. Differentiate between surgical staplers and implications for open and minimally invasive surgeries.  Overview Subspecialty of general surgery Management of diseases of the esophagus, stomach, small intestine, large intestine, and rectum Specializations include: – Laparoscopic surgery – Bariatric surgery – Surgical oncology – Colorectal surgery Surgical Anatomy 5  Surgical Anatomy GI tract: tubelike structure extending entire length of the trunk Alimentary tract: mouth, pharynx, esophagus, small intestine, large intestine, rectum, anus Basic functions: ingestion, secretion, mixing and propulsion, digestion, absorption, and defecation  Surgical Anatomy: Upper Tract Esophagus – Extends from pharynx to cardia of the stomach – 25 cm (10 inches) long – Transports food/fluids by peristalsis  Surgical Anatomy: Upper Tract Stomach – Fundus – Body – Antrum Accepts and stores food and fluid Chemical and mechanical digestion Absorption of vitamin B12 Greater and Lesser Omentum 8  Surgical Anatomy: Upper Tract (Cont.) Small intestine – Begins at pylorus; ends at the ileocecal valve – 3 meters long Duodenum Jejunum Ileum Absorbs essential nutrients Provides protective barrier Duodenal Blood Supply 3 Branches from Celiac Artery 1. ___________ 2. ___________ 3. ___________  Surgical Anatomy: Lower Tract Large intestine – Ascending colon – Transverse colon – Descending colon – Sigmoid colon – Rectum – Anus Reabsorbs water and electrolytes Forms solid waste Synthesizes vitamin K and B complex vitamins Propels and eliminates solid waste Superior & Inferior Mesenteric Artery SMA -supplies most of the small intestine, ascending & 2/3rd of transverse colon vs IMA –supplies transverse colon (splenic flexure) down to the rectum 12 13 Mesenteries 14  Adhesions Fibrous bands of filamentous protein tissue Defect in normal tissue healing May cause infertility, small bowel obstruction, chronic pain 15 Perioperative Nursing Considerations 25  Diagnostic Testing Endoscopy/endoscopic imaging Radiologic studies Ultrasound CT MRI PET Wireless video capsule endoscopy 17  Implementation/Risk Reduction Antimicrobial prophylaxis - antibiotics Positioning concerns Laparoscopic safety Major count 18  Implementation/Instrumentation Laparotomy or Laparoscopy basic set Selected self-retaining retractors GI instruments – clamp/clamp/cut/tie Suction and irrigation – poole Pack offs, pushers, staplers, bowel clamps Long instruments Additional laparoscopic instruments (endo GIA) 19 Opening the Abdomen GI Instrument Sequence: Clamp Clamp Cut Tie i.e. – Kelly, Kelly, Metzenbaum, Tie with silk or Polysorb tie Isolation (Bowel) Technique – Wound edges and surrounding areas protected with extra drapes – Instruments used on bowel isolated after use – Gowns, gloves, drapes changed before closure Gastrointestinal Endoscopy 22  Endoscopic Procedures Direct or video visualization of the GI tract Interventional discipline Local anesthetic + IV moderate sedation Bowel preparation High-level disinfection used for scopes Endoscopy and Colonoscopy 23 Surgical Interventions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 24 Surgery of the Esophagus & Stomach 25  Diseases of the Esophagus Cancer – Distal Esophagectomy : – High mortality rate – Tumors discovered at late stage (stage III or later) – Gastroscopy – more tumors are now being found Hiatus Hernia – is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. GERD (acid reflux) – Barretts Esophagus – thinning of the esophageal lining 26  Hiatus Hernia GERD is a condition that causes food or stomach acid to come back up from your stomach into your esophagus. Two Types of Hiatus Hernia 1. Sliding 2. Rolling 27 Hiatus Hernia 28  Hiatus Hernia Repairs Known as ‘Fundoplication’ Goal: To prevent reflux The repair has 2 parts: 1. Plication: Fold a piece of the stomach tissue around the organ itself to shorten it 2. Crurorrhaphy: permanent suture repair  Surgery of the Esophagus Laparoscopic Nissen fundoplication – Management of GERD – Hernia reduction – Hernia sac elimination – Diaphragmatic hiatus defect repair 30  Laparoscopic Nissen Fundoplication The gastric fundus (upper part) of the stomach is wrapped (plicated) around the lower end of the ______________. It is then stitched in place to reinforce the closing function of the lower esophageal sphincter.  Laparoscopic Nissen Fundoplication Lithotomy position to accomodate camera operator Laparoscopic needle drivers Silk sutures measured in length Endo clip applier 32  Nissen Fundoplication https://www.youtube.com/watch?v=X840-6PyO4c  Surgery of the Stomach Purpose: Diseases of the stomach Types: 1. Partial Gastrectomy a) Billroth I b) Billroth II 2. Total Gastrectomy 3. Gastric Bypass Surgery Gastrectomy Surgery 35  Surgery of the Stomach Total gastrectomy – Complete removal of the stomach – Esophageal-jejunal Anastomosis called: _________________ – Curative or palliative 36  Open Gastrectomy Procedure Upper midline incision – supine with arms extended on arm boards Thoracoabdominal – right lateral TEDS stockings N/G tube (anesthesia) Jackson Pratt Drain Blood products available Staplers, atraumatic bowel clamps 37  Surgery of the Stomach Partial Gastrectomy 1. Billroth I Pyloric resection Stomach-duodenal anastomosis called: ___________________ 37  Surgery of the Stomach Partial Gastrectomy 2. Billroth II Distal resection Stomach-jejunal anastomosis called: ___________________ 38  Gastric Bypass Surgery Also called Bariatric Surgery (weight loss) BMI of 40 or higher Laparoscopic is the preferred method  Roux-en-Y Reduces stomach size and connected to jejunum Allows food to bypass the duodenum (lies dormant) = fewer calories absorbed = feeling “full” quickly Anastomosis: Esophagojejunostomy Staplers: GIA and EEA Gastric https://www.youtube.com/watch?v=FLYHI Bypass CUIYDE Surgery Gastric Lap Band Surgery Adjustable gastric band placed around top of stomach Reduces the stomach capacity and restricts the amount of food that can be consumed at one time 40 Gastric Sleeve Surgery Bowel Resections  Staplers GIA Gastrointestinal Anastomosis 2 double rows of titanium staples Cut, staple, and divide tissue simultaneously Staple lengths: – 60mm – 80mm – 100mm https://www.youtube.com/watch?v=8- w9mBUR6CY 47  TA EEA Thoraco-Abdominal End to End Anastomosis Anastomosis 48  Types of Anastomosis End-to-end (EEA) Connects the two open ends of the intestines together Side-to-side (SSA) Connects the sides of each part of the bowel together rather than the two ends End-to-side (ESA) Connects the end of the intestine that’s smaller with the side of the larger one  Anatomical side to side anastomosis (functional end to end) Step 1: Bowel Resection with GIA™ Stapler 50 Step 2: insertion of GIA stapler 51 Step 3: Creation of the Side-to-Side Anastomosis 52 Step 4: Closure of the GIA™ Entry Site with the TA™ Stapler 53 Step 5: Completed Anastomosis 23 Right Hemicolectomy Which staplers are used and how many fires? End to end Anastomosis 24  Video of Low Anterior Bowel Resection with EEA Stapler https://www.youtube.com/watch?v=KfJJWjAKFYk Surgery of the Small Bowel 58  Small Bowel Surgeries 1. Appendectomy 2. Small Bowel Resections 3. Perforated Duodenal Ulcers 4. Ileostomy Surgery of the Colon & Rectum 60  Intestinal Surgery 1. Right Hemicolectomy 2. Left Hemicolectomy 3. Transverse Colectomy 4. Low Anterior Bowel Resection (Sigmoid) 5. Abdomino Perineal Resection 6. Creating or Closing a Colostomy Large Bowel 62 Colostomy / ileostomy 63  Right Hemi Colectomy Resection of the right half of the colon: Cecum, Ascending, part of Transverse, SMA Anastomosis: Illeum and Transverse colon Tumors, bleeding, inflammation, trauma 64 Right Hemi Colectomy Right half of colon – cecum, ascending, portion of transverse and segment of the illeum is removed 65  Hartmanns Procedure Surgical resection of the rectosigmoid colon with closure of the rectal stump Colostomy creation Emergency situations – bowel obstruction or perforation The distal stump is left inside abdomen as a closed mucous fistula Patient returns 3 months later to be reversed 66 Hartmanns Procedure 67  Low Anterior Bowel Resection What is being resected?? Diverticulitis and Cancer Lithotomy position Ureters are identified and protected End to End anastomosis with EEA Change gown and gloves (WHY?) 68 Sigmoid Colectomy (Low Anterior Resection) 69  Abdomino Perineal resection Resection of lower sigmoid, rectum, and anus Abdominal and perineal incisions Lithotomy position Permanent colostomy 2 team Procedure – 2 scrub nurses, 2 count sheets 2 surgical set ups 70 Abdominoperineal Resection 71 Isolation Bowel Technique Bowel Contamination Protocol - Isolate instruments/staplers that ENTER the bowel in a K-basin on table - Change gown and gloves before starting closure - Use “clean” instruments for closure  Other Minor Surgeries Excision of pilonidal cyst and sinus – Excision of cyst and sinus tracts – Primary or secondary closure 73 Atraumatic Instruments 65 Atraumatic Instruments 75 Retractors 76 Bookwalter Retractor 77 Scissors 78  Summary GI surgery is a broad field encompassing surgery of the esophagus, stomach, large and small intestines, and the rectum. Many GI procedures have been adapted to minimally invasive approaches. Understanding of surgical anatomy is essential to planning care.  References Rothrock, J. (2022). Alexander’s care of the Patient in Surgery (17th ed.) Mosby Elsevier. Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.) Mosby. ORNAC Standards 2023 71