Abdominoperineal Resection (APR)
Discus About The Simple Partial Cystectomy Urology Surgery?
Abdominoperineal resection (apr). In this surgical procedure, parts of the GI tract like the Anus, rectum and sections of sigmoid colon are removed via an incision in the abdomen. In this process, the end of the intestine is connected to the stoma called colostomy, or the opening in the abdomen, through which the bodily wastes are collected in a disposable bag, placed outside the body. Cancerous lymph nodes can be removed in this surgery (Cancer.gov, 2018).
Here the surgeon first divides the blood vessels supplied to the colon and rectum, after which the sigmoid colon and rectum is freed from the surrounding tissues, and then removed from the rest of the large intestine. After preparing the colon and rectum for removal, the perineal region (between the legs) is operated to remove the anus, after which the anus, along with the colon and rectum is removed from the body.
1a (ii): low anterior resection (lar). Low Anterior Resection (LAR) surgery is used in the treatment of rectal cancer. nursing procedure, the cancerous part of the rectum is surgically removed; the remaining portion of the rectum is connected back to the colon to enable normal movement of bowel. The surgery can be done by two different techniques, depending on the number and type of incisions made of the abdomen:
- Open Surgery: In this technique, a long incision is made on the abdomen (or belly), and the cancerous part of the rectum is removed through this incision.
- Minimally Invasive Surgery: Here many small incisions are made in the abdomen, through which surgical instruments and a video camera is inserted, to remove the cancerous part of the rectum. Robotic devices can be used in this procedure by the surgeons to help with the surgery.
After the removal of the cancerous part of the rectum, the remaining part of the rectum is connected back to the colon using stitches or metal staples. The region where the two ends of rectum and colon are connected is known as the anastomosis (Mskcc.org, 2018).
1a (iii): proctocolectomy. Total proctocolectomy with ileostomy is a surgical procedure in which the entire large intestine and rectum is removed (Medlineplus.gov, 2018).
The surgical procedure can either be an open surgery or laparoscopic surgery (also called keyhole procedure). The complete colon, rectum and anus are removed, and are also called a Pan-Proctolectomy. The blood and vessels and lymph nodes associated the part of the bowel are also removed. Along with the abdominal incisions, another incision is made near the bottom, to remove the anus. The rest of the bowel (consisting of the small intestine) is utilized to make an ilesotomy on the right side of the abdomen. The complete surgical procedure takes approximately three to four hours. (Birminghambowelclinic.co.uk, 2018).
1a (iv): hartmann’s procedure. In this surgical procedure, part of the sigmoid colon and/ or the rectum is removed. It is generally performed on patients suffering from bowel cancer or diverticular diseases (Birminghambowelclinic.co.uk, 2018).
Low Anterior Resection (LAR)
The surgery can be either done laproscopically or as open surgery. In the process, the bowel is made free from the surrounding attachments from the abdominal cavity, followed by the division of blood vessels. After this, the bowel is incised, and the segment that is diseased is then removed. The colon is the brought to the surface of the skin, and is stitched to it, to form a colostomy. The rectum is closed using stitches or staples and placed back in the pelvic region. This surgery can be reversed by another surgery later on (Sussexsurgical.co.uk, 2018).
1a (v) cystectomy. The procedure can be of different types, like:
radical cystectomy. Where the bladder and the fatty tissues around it is removed with a wide margin. The nearby pelvic organs (like prostrate in case of male patients, uterus and part of vaginal wall in case of female patients) are also removed. It is used for invasive or advanced cancer of the bladder (Kcurology.com, 2018).
After the removal of the bladder, urinary diversion is done to restore the continuity of urinary tract. The urinary diversion can be of three types: Neobladder (connecting a new bladder to existing urethra), Continent Diversion (ureters connected to pouch with catherizable stoma) and ileal Conduit (short segment of small intestine connecting ureters to skin)
Partial Cystectomy. Here a part of the bladder is removed, while preserving the rest of the bladder. It is utilized in case of benign lesions on the wall of bladder (Kcurology.com, 2018).
Simple Cystectomy. Here the entire bladder is removed, but the adjacent fatty tissue and pelvic organs are preserved (Kcurology.com, 2018). Thus, the prostrate, seminal vesicles and urethra in male and urethra, uterus and anterior wall of vagina in female is left intact. This also keeps potency conserved (Urology.ucla.edu, 2018).
1a (vi) pelvic Excenteration. Anterior Pelvic Excentration. In this surgery, organs from the urinary and gynecologic system are removed, in order to treat cancer in the cervix or other organs in the urinary or gynecologic system (Mskcc.org, 2018). This procedure can be performed if irradiation therapy has failed (atlasofpelvicsurgery.com, 2018). The bladder and urethra is removed and hence a new place is needed for the elimination of urine. Urinary diversion is created for collecting the urine, and can be either is in the form of ileal conduit or urinary pouch. The ovaries, fallopian tubes and uterus are also removed (mskcc.org, 2018).
Posterior Pelvic Excentration In this surgery, organs from the gastrointestinal and gynecological systems are removed to treat cancer of cervix or other organs in the gastrointestinal or gynecologic system. Part of the large intestine along with the rectum and anus are removed, and the remaining of the large intestine is brought to the surface of the abdomen to create a colostomy, attached with a pouch to collect stool, and the ovaries, fallopian tube and uterus are also removed (Mskcc.org, 2018).
Total Pelvic Excentration. This surgery involves bloc resection of pelvic organs including reproductive organs, urinary bladder and the recto sigmoid. It is used to treat advanced primary or locally concurrent forms of cancer (Diver, Rauh-Hain & Carmen, 2018).
1b (i) abdominoperineal resection. This surgery is commonly used to treat cancer located low in the rectum or in the anus, or cases of distal tumors or poor sphincter function (Perry & Connaughton, 2007). This surgery can also be used in case of severe traumatic injury to the rectum (Augusta.edu, 2018).
1b (ii) low anterior resection (lar). This surgery is used to treat stage 1, 2 and 3 cancers in the upper part of the rectum (that connects to the colon). The American Society of Colon and Rectal Surgeons (ASCRS) have outlined the parameters of the usage of colectomy to treat different conditions/indications (Emedicine.medscape.com, 2018). The different indications for colon resection are: Colorectal Cancer, Colonic Diverticular Disease, Trauma, Inflammatory Bowel Disease, Bowel infarction, Slow-transit constipation and Polyposis syndromes.
1b (iii): proctocolectomy. This surgery removes the diseased part of the bowel, thereby significantly improving the quality of life of the patients. This procedure can be used to cure ulcerative colitis, (Cdhb.health.nz, 2018). This surgery is also used when all other forms of treatment fails to treat the problems with large intestine, and is common surgical procedure for patients suffering from inflammatory bowel diseases like ulcerative colitis and Crohn’s Disease. Additionally, this surgery can also be performed in case of colon or rectal cancer, familial polyposis, bleeding of intestine, birth defects that cause damage to the intestine or other forms of intestinal damage due to injury or accidents (Medlineplus.gov, 2018).
1b (iv): hartmann’s procedure. Hartman’s procedure was initially developed to treat distal colonic adenocarcinoma, however other indications that calls for this procedure have progressed with time, including: Complicated Diverticulitis (stage I, II, III and IV), Recto sigmoid Cancer, Ischemia, Volvulus, Iatrogenic Perforation of the colon, Lymphoma, Metastatic Cancer in the Pelvis, Crohn’s Disease, Trauma due to accident or injury, Anastomotic dehiscence, Pseudomembranous colitis, Rectal prolapsed, Leiomyosarcoma, Ulcerative Colitis, Radiation Injuries, Retroperitoneal bleeding, Pneumatosis cystoides and For colon resection for patients who are haemodynamically unstable, immune-compromised or malnourished (Emedicine.medscape.com, 2018).
1b (v:) cystectomy. 1b.5.1: simple and partial cystectomy. Upper tract diversion can be used for the treatment of benign lower tract pathology or upper tract obstruction. Other indications for simple cystectomy include: radiation cystitis, interstitial cystitis, cyclosphosphamide cystitis, severe incontinence, neurogenic bladder, severe trauma to urethra and upper urinary tract obstruction. It can also be done to treat attenuation of bladder diverticuli, genitourinary sarcomas, manage urachal carcinomas and palliation of severe local symptoms, as well as to manage colovesical or vesicovaginal fistula and localized endometriosis of the bladder (urologysurgery.wordpress.com, 2018).
1b.5.2: radical cystectomy. Indications for radical cystectomy include: invasive bladder cancer, resectable locoregional metastases, superficial bladder tumors; Stage-pT1; grade-3 tumors that does not respond to BCG vaccine therapy; palliation for pain and primary adenocarcinoma (Emedicine.medscape.com, 2018).
1b (vi): pelvic Excenteration. Indications for pelvic Excenteration includes: Cervical Cancer, Uterine Cancer, Vulvar Cancer, Ovarian Cancer, Vaginal Cancer and Pallation (Diver, Rauh-Hain & del Carmen, 2018).
1c (i): abdominoperineal resection. Specific risks associated with Abdominoperineal Resection are: Intra abdominal or pelvic abscess, Nerve Injury, Urologic Injury, Perineal Wound and Ostomy, Risk of peroneal nerve injury, Brachial plexus injury, Damage to autonomic nerves, Injury to hypo gastric nerves, Sexual dysfunction in male, Bladder injuries and Perineal herniation (Perry & Connaughton, 2007; Murrell et al.,2005).
1c (ii): low anterior resection (lar). Risks of LAR includes: Anastomosis leakage, Postoperative ileus, Frequent Stools, Urinary and stool incontinence, Ventral hernia, Damage to autonomous nerves that can cause bladder paralysis, erectile and ejaculatory dysfunction and vaginal dryness. (Oncolex.org, 2018).
1c (iii): proctocolectomy. Possible complications arising from this surgical procedure include: Damage to adjacent organs and nerves to the pelvic region, Infection of lungs, urinary tract and abdomen, Formation of scar tissues blocking small intestine, Breaking of wound or poor healing., Reduced absorption of nutrients from food and Phantom rectum (medlineplus.gov, 2018).
The complications can include: infection and delayed healing of perineal wound, obstruction of small bowel, urinary retention, sexual dysfunction, stomal complications, pelvic infection as well as misdiagnosis. Additional physiological effects like dehydration, electrolyte abnormality, urinary and gall stone formation can also occur due to ileostomy (Dozois, 2004)
1c (iv): hartmann’s procedure. The common complications due to bowel surgery include bleeding (that can persist for few days), infection (inside the abdomen, lungs, bladder as well as in the surgical wound), Bowel Obstruction (due to internal scar tissues and causes a blockage of bowel movement and passing of wind, pain or cramps in abdomen and nausea/vomiting). Other complications include wound hernia (due to bowel obstruction), deep vein thrombosis (due to reduced mobility) (Cdhb.health.nz, 2018).
1c (v): cystectomy. The rate of urination can increase after cystectomy. Removal or bladder and surrounding organs can also change the normal function of the body. In men it can cause erectile dysfunctions, and menopause in women (cancercouncil.com.au, 2018). Other short term complications can include acidosis, leaking urine or stool, bowel obstruction and kidney infection, and long term conditions like obstruction to ureters or intestine, renal failure, complication with stoma, scar tissue formation in the intestine (webmd.com, 2018). Risks for urinary tract infection and urinary tract septicemia were also reported by van Hemelrijck et al., (2013).
1c (vi): pelvic excenteration. Common complications of this surgical procedure include sepsis, thrombo embolic disease, and cardiopulmonary failure. Other complications include loss of blood, fluid shift, urinary infection, wound infection, anastomotic leak, fistulae, small bowel obstruction and urethral obstruction. Death can also occur in rare cases (less than 5%) and more significant among women older than 65 years of age (Diver, Rauh-Hain & del Carmen, 2018).
1d (i): abdominoperineal resection. The type of stoma created in this surgical procedure is ‘End-Colostomy’, since it involves bringing the gastrointestinal tract to the surface of the abdomen, cuffing it back on itself and suturing it to the operating on the skin, and the colon and rectum is removed.
1d (ii): low anterior resection (lar). The type of stoma created in this surgical procedure is loop ileostomy, where a loop of the small intestine is bought to the surface of the skin in the form of the stoma, from which gas and waste from the intestine passes out, collected in pouch stuck to the skin at the opening of the stoma (uhn.ca, 2018).
1d (iii): proctocolectomy. The type of stoma created in this surgical procedure is an ‘end ileostomy’, since the complete colon and rectum is removed through the incision in the abdomen, and the end of the small intestine is brought to the surface of the skin through the incision, creating the opening or stoma through which the waste exits (nhs.uk, 2018).
1d (iv): hartmann’s procedure. In the Hartman’s procedure, ‘end colostomy’ type of stoma is created since in the procedure, parts of the large bowel or rectum is removed. It can be temporary or permanent.
1d (V): Cystectomy. Three types of diversions that can be made in a Cystectomy surgery are: Ileal Conduit (where a section of the intestine is removed, secured to skin through a small opening to create a stoma, and an ostomy bag is used to collect urine), Neobladder (creates a new bladder using a portion of small intestine, with the ureters connected at the top of the bladder and urethra at the bottom of it) and Continent Cutaneous Urinary Reservoir (where the urethra exits the abdominal skin through stoma, instead of being connected to the bladder) (Washington.edu, 2018).
1d (VI): Pelvic Excenteration. The type of diversion created in Pelvic Excenteration includes Urinary Diversion (also called wet colostomy, as the urine and feces are eliminated through a single stoma), Fecal Diversion (as a permanent end colostomy, as the anal sphincter is removed), Neovagina (reconstructing a part of the vagina), Pelvic Floor Coverage (Diver, Rauh-Hain & del Carmen, 2018).
In Restorative Proctolectomy, the entire large intestine is removed, and an internal pouch or reservoir is made using the small intestine, within which fecal discharge is stored, and is connected to the anus. This pouch is called the ‘J-Pouch or ileo anal pouch (Sofo, Caprino, Sacchetti & Bossola, 2016). This is different from Proctolectomy in which the entire large intestine and rectum is removed, and results in the formation of end ileostomy, through which the waste is discharged.
3.1: ileostomy. The stoma created by ileostomy would be pink, moist and slightly shiny. The output/ discharge from the stoma might be a thin or thick liquid, or even semi solid, but not solid like stool. The density of the exudates will depend upon the diet and medications. Some gas might also be discharged. The pouch should be emptied 5 to 8 times a day (Medlineplus.gov, 2018).
3.2: colostomy. If the rectum and anus are intact in the colostomy procedure, mucus is produced at the lining of the bowel to help the passage of stool. The longer the section of the bowel left, more is the discharge of mucous. The mucous can vary between clear, egg white to sticky glue like. This can occur every few week or several times daily (nhs.uk, 2018).
3.3: ileal conduit. Urine and some mucus are the main output. It will be in the form of continuous drainage. The mucous is formed by the segment of the intestine used to make the ileal conduit or urine pocket (Cancer.org, 2018).
4.1: end stoma. In end colostomy, the colon and rectum is removed, and the remaining portion of large intestine is brought near the surface of the abdomen to create the stoma. It can be temporary or permanent (Coloplast.com.au, 2018).
4.2: loop stoma. In loop colostomy, the intestine is lifted above the skin and fixed in place using stoma rod. Cut on the intestine loop is then rolled and sewn to the skin to form two stomas. In case of loop ilesotomy, a loop from small intestine is lifted above the skin, and fixed with a stoma rod. Cut on the loop is rolled up and sewn to the skin to form two stomas (Coloplast.com.au, 2018).
5a.1: indiana pouch. This is a continent catherizable urine pouch. The pouch is formed from the caecum, ascending colon, and ileum. The ileum is then sewn to the skin of the abdomen (on the right side) (columbiaurology.org, 2018).
Indications for the surgery
5a.2: the koch pouch. This is also called continent ileostomy. During the surgery, the small intestine is joined to an internal reservoir or pouch made from small intestine. A one way valve ensures the leakage of waste to the outside. The pouch is emptied using a catheter. The stoma is protected using stoma cap (Ouh.nhs.uk, 2018).
5a.3: mitrofanoff. This procedure is used to allow drainage of bladder, in situations where voiding or self catherization is not possible. The procedure creates a catheter channel into the bladder to empty it. This is done by forming a channel between the abdominal wall and the bladder to allow drainage. Mitrofanoff is made using the appendix or the fallopian tube. The continent mechanism is provided by tunneling one end of Mitrofanoff to the wall of the bladder to create a valve, and the other end passed through the skin of the abdomen to form stoma (mitrofanoffsupport.org.uk, 2018).
5b.1: immediate care. After surgery, tubes, drains and other equipments are used, and intravenous line is used for fluid and medicine. Abdominal drains such as stoma tube, suprapubic tube, stents, Jackson Pratt Drain, Foley Catheter, and NasoGastric Tube can be used. For pain control, medications will be used, to keep the pain limited to mild, and enable mobility. Walking is suggestible to speed recovery, and restoration of bowel function, and prevent blood clot or pneumonia. Drainage from the incisions might also occur, which would need cleaning and dressing (uwhealth.org, 2018).
5b.2: long term care. For long term care, the incision should be washed daily, gently with soap and water. Mucous buildup at the stoma should be wiped using plain warm water daily if required. Care should be taken cleaning near the stitches, and little bleeding might also occurs, which is normal. The stoma can be uncovered during bathing, once it has healed completely, but never should be scrubbed. After removal of tubes, a small gauze dressing can be used to cover the stoma. The tubes must also be cleaned daily with mild soap and water. It should be flushed 2-3 times every day to prevent plugging with mucous. The bags would also require changing or emptying of its contents. Self catherization will also be required on the long run, to be done by the patient. The diet should also be soft until the first visit after surgery, and 8-12 glasses of water should be drank every day (uwhealth.org, 2018).
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