Consent: Bowel Resection

This article is for educational purposes only. It should not be used as a template for consenting patients. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications. Always refer to your local or national guidelines, and the applicable and appropriate law in your jurisdiction governing patient consent.

Overview of Procedure

There are several variations of bowel resection, which in the elective setting is most commonly done for cancer treatment.

  • Right hemicolectomy involves removal of the ascending colon and caecum
  • Left hemicolectomy involves removal of the splenic flexure and the descending colon
  • Sigmoid colectomy involves removal of the sigmoid colon; anterior resection involves removal of the sigmoid colon and rectum
  • Abdominal-perineal resection (APR) involves removal of the sigmoid colon, entire rectum, and anus with formation of an end colostomy
  • Hartmann’s procedure typically involves removal of the sigmoid colon +/- rectum with end colostomy formation in the acute setting (usually for perforated diverticular disease or an obstructing cancer)

The above procedures all begin with a laparotomy or laparoscopy, which will also include an assessment of each organ in turn, including inspecting the entire length of the bowel, palpating the liver and spleen, inspecting the gallbladder, and (in the female) assessing the uterus and ovaries.

The appropriate segment of bowel is then resected by dividing and securing the blood supply, then transection of the bowel followed by reanastomosis or stoma formation. This can be done by hand or using a stapler device.

Figure 1 – A Hartmann’s Procedure

Complications

Intra-Operative

Complication Description of Complication Potential Ways to Reduce Risk
Haemorrhage Damage to any of the surrounding structures, particularly veins in the pelvis, can cause significant haemorrhage.
Injury to spleen and ureter The spleen can be damaged during mobilisation of the splenic flexure (particularly if it is located high up) and could necessitate splenectomy.  The ureter is also at risk, particularly in left-sided resections.
Resection of another organ If the cancer is advanced, it may be necessary to remove parts of other organs (e.g. spleen, bladder, uterus).
Stoma Formation A stoma or colostomy may be required in cases where a primary anastomosis is unlikely to heal, such as due to contamination or in a malnourished patient. Optimise your patient pre-operatively and avoid peritoneal contamination (these are often unmodifiable by the time of consent).
Anaesthetic Risks Includes damage to the teeth, throat and larynx, reaction to medications, nausea and vomiting, cardiovascular and respiratory complications. Forms a part of the anaesthetist assessment before the operation

Early

Complication Description of Complication Potential Ways to Reduce Risk
Pain The patient will most likely have an epidural or patient controlled analgesia to minimise this.
Bleeding There is a small chance of bleeding and bruising in the abdomen post-operatively.
Infection Superficial wound infection is common (10%), however collections in the pelvis or paracolic gutters can also occur. Chest infection is common following laparotomy, due to reduced lung expansion secondary to pain Peri-operative antibiotics will reduce the risk of wound infections.  Early mobilisation, optimal analgesia, and encouraging breathing exercises reduces the risk of lower respiratory tract infections
Scarring A midline or transverse incision will result in a scar, which may develop as a keloid scar, particular in high-risk ethnicities Laparoscopic surgery will minimise this risk
Seroma A swelling of lymphatic fluid may occur in the abdomen due to disruption of the lymph nodes and channels.
Blood Clots DVTs and PEs are a possibility in any operation. The risk is increased in patients with a raised BMI, on the pill, recent flights, previous DVT, pregnancy, smokers, cancer and prolonged bed rest. The patient will be given anti-embolism stocking and low molecular weight heparin peri-operatively to minimise this risk as deemed appropriate.
Anastomotic leak (5-10%) The anastomotic site or stoma may have insufficient blood supply due to ligation of the corresponding arteries. These may break down requiring further surgery.
Stroke, MI, Kidney Failure, Death Although small, this is always a risk in any major surgery
Reintervention There is always a potential for further surgery due to anastomotic leaks, reversal of stoma’s, further washout etc depending on the underlying pathology.

Late

Complication Description of Complication Potential Ways to Reduce Risk
Hernia Any laparotomy incision has the potential to cause a hernia in future. Avoid heavy life for 6 weeks post-surgery.
Adhesions Abdominal surgery may cause adhesions as a reaction to the procedure, which in turn can cause adhesional bowel obstruction

 

Note: This article is for educational purposes only. It should not be used as a template for consenting patients. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications. Always refer to your local or national guidelines.

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