MODULE 14 Gastrointestinal Surgery RPN2023.pdf

MODULE 14: Gastrointestinal Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 11 ORNAC Standards 2023 Learning Outcomes Explain relevant anatomy and basic procedural considerations...

MODULE 14: Gastrointestinal Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 11 ORNAC Standards 2023 Learning Outcomes Explain relevant anatomy and basic procedural considerations for gastrointestinal surgery, including bowel technique. Differentiate between the various surgical staplers and their implications for open procedures and minimally invasive surgeries. Indicate isolation technique for bowel and GI procedures, as appropriate. Surgery of the Gastrointestinal (GI) system may be indicated to establish a diagnosis, to prevent or cure disease, to relieve symptoms or restore function, or to afford palliative measures that provide comfort or nutrition. GI surgery is a subspecialty within the domain of general surgery related to the surgical management of the esophagus, stomach, small intestine, large intestine, and rectum. Anatomy Module 14: GI  Blood supply The superior mesenteric artery shown (left) arises from the anterior surface of the aorta, just inferior to the origin of the celiac trunk, and supplies the intestine from the duodenum and pancreas to the left colic flexure. The inferior mesenteric artery supplies the large intestine from the left colic (or splenic) flexure to the upper part of the rectum. Perioperative Nursing Considerations Nursing Assessment The risk for injury or failure to achieve the expected outcome are equally present in GI surgery as in any surgical or invasive procedure. No procedure is routine and unexpected outcomes can occur even when planning and preventive measures have been employed under the most optimal circumstances. The patient’s skin is assessed for bony prominences and high-risk areas for skin breakdown. The patient’s pain tolerance is assessed to determine her/his need for necessary teaching or tools for managing postoperative pain. Patients undergoing Bariatric surgery need special consideration as Module 14: GI they often have associated comorbidities that place them at a heightened risk during the procedure. Blood Replacement - Patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, Surgicel, etc to anticipate any critical surgical needs. Patient Positioning Typically, a patient undergoing a GI surgery will be placed in the supine position or modified lithotomy. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Other positioning devices, such as bean bags and bolsters, may be used for lateral decubitus position. The patient position and the associated positioning devices may vary depending on the surgeon’s preferences and available institutional resources and policies. It is recommended that the perioperative nurse collaborates with the surgical team to ensure that the patient is positioned safely before, during, and after surgery. The perioperative nurse ensures that the patient return electrode pad is applied and the safety strap secured. Instrumentation and Counting Basic laparotomy instrument set Specialty instruments used as per surgical preference Abdominal self-retaining retractors Long instruments eg. scissors, lowers, mixtures, and forceps with long hemoclips appliers and various size clips depending on the vessels being approximated. Special gastric soft clamp instruments are used when clamping the stomach Drains are often used A major count is conducted at the beginning of all cases, and a small or minor count for final count Initial Count (major) → Closing Count (major) → Final Count (minor) Equipment Forced-Air Warming Blankets – The large amount of skin exposure required for either a laparotomy or a laparoscopic approach presents a risk for hypothermia. There must be a continuous assessment of patient’s temperatures to ensure normothermia intraoperatively. Operating Room Table – If bariatric surgery is being performed an OR Table that will support Module 14: GI excessive with must be used to ensure patient safely. Procedural Considerations Bowel / Isolation Technique – Prevents cross-contamination of the wound or abdomen with bowel organisms. This technique is the same used in cancer surgeries to prevent mechanical metastasis of malignant cells, as discussed with breast surgeries. Bowel technique begins as soon as the GI tract is clamped and opened, and proceeds through irrigation, before the wound closure. Bowel instruments are separated from the “clean instruments” for this part of the surgery. Often these instruments will be passed off to the circulating nurse with the specimen. Extra draping may also be placed around the incisional area for the closure. The surgical team with change gloves once the anastomosis is completed as well as gowns if appropriate. Stapling Devices Stapler Type Dispos- Reload- Cuts Staples Comments able able GIA Yes Yes Yes Yes Used for side-to-side anastomoses Gastro- intestional GIA comes in an Anastomosis endoscopic form - more in gynecology notes. GIA comes in a no- knife version, where it only staples - this is quite rare TA Yes Yes No Yes Staples tissues together – Manual cutting Thoraco- required eg. scissors abdominal Stapler Module 14: GI  EEA Yes No Yes Yes Used for end-to-end AND end-to-side End to end Can anastomoses Anastomosis only OR be Cuts and staples in a Intraluminal fired circular fashion stapler (ILS) once EEA technology has reduced the number of permanent colostomies needed Can be used for esophagectomies Anastomoses There are three types of Anastomoses in the GI tract: End-to-End, Side-to-Side (often called a functional end-to-end), and End-to-Side (often called a Roux-en-Y) Side-to-Side Anastomoses (GIA Stapler) – This type of anastomosis is performed when the diseased portion between two segments of the bowel has been resected eg. Right Hemi colectomy or transverse colectomy. Steps After Resection (see images below): 1. One side of a bowel is positioned next to a side of another bowel 2. A GIA stapler is inserted – each jaw of the stapling device is in one segment of each bowel 3. The GIA is fired by the surgeon, which staples the two bowel segments together, while creating a small hole in the middle. This becomes the passage for bowel contents between segments. 4. The GIA is removed, leaving behind two small insertion sites in each segment of bowel. This can be manually sutured closed or stapled shut using a TA stapler. The advantage of this type of anastomosis is that you can join two different size lumens to one another eg. anastomosis of a small bowel to segment of large bowel. When this anastomosis has healed, the bowel will straighten out somewhat and functions much like an end-to-end anastomosis. That is why they call it a “functional end-to-end”. Module 14: GI  Insertion of the GIA Stapler Activation of stapler – creates side-to-side anastomosis Closure of entry sites using TA stapler Completed side-to-side anastomosis (Internal view) Mesenteric Repair – When bowel is removed, it’s corresponding mesenteries will also be dissected resulting in the need of a mesenteric defect repair. The surgeon will ensure the blood supply of the Superior and Inferior mesenteric arteries are intact so that the bowel left behind is not compromised of a blood supply. The Mesenteric defect is always repaired to prevent entrapment of bowel post-operative and obstruction occurring. An absorbable suture would be used for this repair. Internal and External Serosa - Although staplers are used to anastomose bowel, manually suturing of the internal serosa and external serosa may be indicated. Absorbable suture is always used for the internal serosa eg. 2/0 or 3/0 vicryl/ polysorb on a taper needle. Permanent suture is always used for the external serosa eg. 2/0 or 3/0 silk on a taper Module 14: GI  needle. Laparoscopic Nissen Fundoplication This procedure has been developed for GERD (Gastro Esophageal Reflux Disease) management, also known as anti-reflex surgery preventing the reflux of gastric juices into the esophagus. GERD occurs due to the mechanical dysfunction of the lower esophageal sphincter (LES). Nissen Fundoplication is also used to reduce the hernia, to eliminate the hernia sac, and to repair the large defect in the diaphragm hiatus. The Nissen fundoplication can be performed with an open or laparoscopic approach. Open Nissen Fundoplication Supine position A dilator is passed orally into the stomach, providing a stent to prevent the surgeon from accidentally suturing the esophagus shut. Upper part of stomach is tucked or wrapped around lower esophagus with 3-4 permanent sutures to anchor it there. The cardiac sphincter (the GE junction) then will stay in abdomen - it does not migrate north into the esophagus any more. The stomach wrapped around the base of the esophagus would hold it there securely forever and prevent GERD Nissen’s are also done on babies who have reflux problems Laparoscopic Nissen Full Fundal Wrap Lithotomy position NG Tube and urinary catheter is inserted. Bougie dilators may be used as esophageal stent A crurorrhaphy and a fundoplication is complete Main challenge is getting the right amount of suturing tension on the Fundal wrap around the esophagus. If you get it too tight, food will not go down; if you get it too loose, GERD persists. An endostitch instrument may be used Gastric Surgeries Gastrostomy - Percutaneous endoscopic gastrostomy (PEG) is now the most popular method of gastrostomy tube approach and is performed under local anesthetic or moderate sedation. PEG uses a flexible gastroscope for placement of the gastrostomy tube through the abdominal wall. Gastrotomy – A surgical opening into the stomach to explore, biopsy, or retrieve a foreign body. Pyloromyotomy – The opening of pyloric sphincter to increase diameter. Used for pediatric surgery for pyloric stenosis. Module 14: GI Gastrectomy - The removal of all or part of the stomach. The reference will depend on the location of the gastric lesion. This may be a total or a partial gastrectomy. Total Gastrectomy – The complete removal of the stomach. Reestablishment of the GI continuity is with a Roux-en Y anastomosis between the jejunum and esophagus (Esophagojejunostomy). Partial Gastrectomy Billroth 1- Distal gastrectomy with GI reconstruction to connect stomach to duodenum (Gastrodudenostomy). Billroth 2 - Distal gastrectomy with anastomosis to connect Stomach-jejunal (Gastrojejunostomy). Bariatric Surgery Bariatric surgery is referred to as weight loss or weight reduction surgery is a surgical treatment for obesity. Most bariatric surgeries are performed laparoscopically and are malabsorptive and/or restrictive. Roux- En- Y Gastric Bypass (Restrictive and malabsorptive surgery) - The stomach is reduced in size and connected directly to the middle portion of the small intestine (jejunum), allowing food to bypass part of the small intestine (duodenum). Bypassing part of the intestine results in fewer calories being absorbed, and will also provide the sense of feeling full more quickly compared to when the stomach was its original size. Sleeve Gastrectomy (restrictive surgery) - Generated by restricting the amount of food (and therefore calories) that can be eaten by removing 85% or more of the stomach without bypassing the intestines or causing any gastrointestinal malabsorption. Module 14: GI Adjustable Laparoscopic Band (restrictive surgery) – The placement of an adjustable LAP- BAND is placed around the top of the stomach. The constriction created by the saline inflated band restricts the amount of ingested food that can enter the stomach, preventing overeating. Colon Surgery Colorectal Cancer – Occurs commonly in the rectosigmoid area. It is very common in western, industrialized societies, and is usually diagnosed in patients 50+ age group. The initial sign of colorectal cancer are Polyps. The tumors are very slow growing, and therefore have a high rate of curing if discovered in the early stages. Diagnosis is confirmed with a colonoscopy. Surgical Interventions Include: 1. Right Hemicolectomy 2. Left Hemicolectomy 3. Transverse Colectomy 4. Anterior resection (Left Hemicolectomy) 5. Sigmoid Colectomy 6. Abdominal Peroneal Resection of HINT: Learn the areas of resection for surgery and the stapling devices required and which Mesenteric Artery is involved with removal of bowel segments (Superior or Inferior mesenteric Artery). Staplers required 1. Right Hemicolectomy: Stapler: GIA, TA soft bowel clamps Doyen’s 2. Left Hemicolectomy: Stapler: GIA, TA soft bowel clamps Doyen’s 3. Transverse Colectomy: Stapler: GIA, TA soft bowel clamps Doyen’s 4. Sigmoid Colectomy (Anterior Resection: Stapler: GIA, EEA soft bowel clamps Doyen’s 5. Abdominal Peroneal Resection of Colon: Stapler: GIA, TA, soft bowel clamps Doyen’s. A colostomy will be required done here. Identify the following bowel resections, blood supplies, and stapling devices: 1. Module 14: GI 2. 3. Module 14: GI 4. 5. 1) Right Hemicolectomy; 2) Left Hemicolectomy; 3) Transverse Colectomy; 4) Sigmoid Colectomy (Anterior Resection); 5) Abdominoperineal Resection Colostomy / Ileostomy Creation Temporary o Allows the bowel to rest due to inflammatory disease or let an anastomosis heal o Decompress the bowel that is about to perforate; can be done in babies Permanent o Rosebud colostomy after bowel resection for cancer - e.g. Abdominoperineal resection (described below). Abdominoperineal Resection– This procedure is required when a rectal tumour is too close or too large to the anus, requiring a permanent colostomy. Dissection is done around the anus and structures in the hollow of the sacrum are freed. The bowel is brought out distally and a purse- Module 14: GI string suture is used to close anus. The proximal section of bowel is brought out through the skin as a permanent rosebud colostomy. Closure of Colostomy / Ileostomy Hartmann Colostomy - A colostomy done in emergency/urgent situations in the event that bowel is about to perforate or perhaps contamination is already occurring in the bowel. The surgeon knows that he/she will not be able to get a primary anastomosis that night once the bad part has been removed eg. cancer has caused a near obstruction and the proximal bowel is hugely distended. The proximal part of the bowel is brought out to skin (to be used for normal fecal drainage) and the distal stump is closed inside. This is known as a closed mucous fistula. Closure of Hartmann Colostomy – This is done several weeks after the Hartmann procedure, if the patient is infection-free and healthy. The surgeon puts the aforementioned bowel back together, by finding the blind closed mucous fistula and anastomoses it with the proximal colostomy portion, then puts it all back inside. This can be performed laparoscopically. Ileal Anal Pull Through – A procedure for patients with ulcerative colitis and familial polyposis. All large bowel is removed as well as 2/3 of the rectum. A pouch is made using small bowel and doing a side to side anastomosis. This is pulled down to the remaining rectum and attached to the anus. The anal sphincter remains intact and this eliminates the need for an ileostomy. This is done partially open and partially laparoscopically. Module 14: GI