Colectomy - Total - and Ileostomy Surgery in India
Q. What is it ?
The bowel is a tube of intestine which runs from the stomach to the back passage. It is much longer than the inside of your belly (tummy). It fits in by coiling up in loops. The upper part of the bowel is called the small bowel. It joins the lower part of the bowel (the colon) just to the right of the waistline.
This is where the appendix pouches out from the colon. The colon runs up to the right ribs and loops across the upper part of the belly. Then it passes down the left side to run backwards into the pelvis (the lower part of your abdomen) towards the back passage, where it is called the rectum. If most of the colon is diseased it can cause diarrhoea, bleeding or general illness which can potentially be life-threatening. It is better removed.
Sometimes the ends can be joined up inside your tummy. More often, the back passage is not healthy enough to make a safe join. Then the lowest part of the small bowel is brought out as a sort of spout (ileostomy) on the right side of the tummy. This looks like a big nipple of pink bowel stuck to the tummy skin. The bowel waste runs into a special bag stuck over the ileostomy.
The Operation
You will have a general anaesthetic, and will be asleep for the whole operation. A cut is made in the skin in the middle lower part of your abdomen and is about 25 cm (10 inches) long. The colon is freed inside your tummy. The diseased bowel is taken out. The lower end of remaining bowel is stitched shut. The upper end is made to open as an ileostomy. The wound in the tummy is stitched up. You should plan to leave hospital two weeks or so after the operation.
Q. Any alternatives ?
Leaving things as they are is risky. Bleeding or perforation (a hole in your bowel) will mean that an urgent operation is a must. General ill health will not get better by carrying on with drug treatment alone. A bigger operation to take out the back passage as well as the rest of the colon is not needed. There are three ways of dealing with the stoma. The simplest and most reliable is called a spout stoma. This means wearing a bag to collect the waste.
A second way is to make a pouch out of the bowel inside your tummy so that you can empty the pouch from time-to-time and there is no need to wear a bag. A third way is to make a pouch joined to the back passage so that the waste will pass out the normal way. The second and third operations are possible only in certain cases and can give rise to problems. Both the latter two operations can be done on a spout stoma at a later date.
Before the operation
Stop smoking and try to get your weight down if you are overweight. If you know that you have problems with your blood pressure, heart, or lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT).
Check you have a relative or friend who can come with you to the hospital, take you home, and look after you for the first week after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you. On the ward, you will be checked for past illnesses and will have special tests, to make sure that you are well prepared and that you can have the operation as safely as possible. .
Please tell the doctors and the nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Before you sign the consent form, make sure that you fully understand all the information that was given to you regarding your health problems, the possible and proposed treatments and any potential risks. Feel free to ask more questions if things are not entirely clear. Many hospitals now run special preadmission clinics, where you visit a week or so before the operation, where these checks will be made.
After - in hospital
You will have a fine thin plastic drip tube in an arm vein connected to a plastic bag on a stand containing a salt solution or blood. You may have a fine plastic tube coming out of your nose and connected to another plastic bag to drain your stomach. This is to decompress your stomach which, along with the bowel, may feel sluggish after an operation. Swallowing may be a little uncomfortable.
You will have a dressing on your wound and a drainage tube nearby, connected to yet another plastic bag. This drains any residual blood from the operation. You may have a fine rubber tube (catheter) passing into the bladder through the front passage. This lets the bladder stay empty and small during the operation and helps control your body fluids afterwards.
A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. The nurses will help you with everything you need until you can do things for yourself. Do not make important decisions during this time. You will be most likely able to get out of bed with the help of the nurses the day after the operation despite some discomfort.
You will not do the wound any harm, and the exercise is very helpful for you.The second day after operation you should be able to spend an hour or two out of bed. You may be given a blood-thinning injection in your skin once a day to prevent any blood clots in your legs. This can happen in the first few days after the operation until you can move around a bit more. Those clots can be very dangerous because they can 'travel north' through your blood stream to your heart and lungs and cause very serious problems and even death.
Many hospitals are now using what is called PCA (patient controlled analgesia). By pressing a button on a device you can inject painkillers into your blood stream through a very fine plastic tube that goes into one of the small blood vessels (veins) in your hand. A small computer controls the amount of painkiller that is released and prevents any accidental overdose. Alternatively, you may have a fine tube in your back through which pain relief can be given to help control the pain.
Ask for more if the pain is not controlled or if it gets worse. By the end of four days you should have little pain. The ileostomy may not work for a day or two. It is always runny. It does not smell. You will get special advice and help from the nurses. Because of the drainage tube (catheter) in the bladder, passing urine should not be a problem. Once you can walk about in reasonable comfort, the catheter will be taken out. You can take the dressing off after 48 hours. Usually there are stitches or clips in the skin. These will come out 7 to 10 days after the operation.
Sometimes, the wound may be held together underneath the skin. There may be some purple bruising around the wound which spreads downwards by gravity and fades to a yellow colour after two to three days. This is expected and you should not worry. There may be some swelling of the surrounding skin which should also improve in two to three days.
You can wash as soon as the dressing has been removed but try to keep the wound area dry until the stitches/clips come out or if there are stitches only inside the wound, for a week after the operation. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or bath as often as you want. You will be given an appointment to visit the outpatient department for a check-up about one month after you leave hospital. The stoma nurse will arrange to visit you at home. The nurses will advise about sick notes, certificates etc.
After - at home
You are likely to feel very tired and need to rest two or three times a day for a month or more. You will gradually improve so that by the time three months have passed you will be able to return completely to your usual level of activity. You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about three weeks. You can restart sexual relations within two or three weeks when the wound is comfortable enough. Sometimes the operation affects the sex nerves. This will be discussed with you. You should be able to return to a light job after about six weeks and any heavy job within 12 weeks.
Possible complications
As with any operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
Complications are relatively unusual but are rapidly recognised and dealt with by the surgical staff. If you think that all is not well, please let the doctors and the nurses know.
Chest infections may arise, particularly in smokers or obese patients. Do not smoke. Getting out of bed and being as mobile as possible after the operation and working together with the physiotherapists who will help you do a lot of breathing exercises will minimise the chances of getting a chest infection.
Occasionally the bowel is slow to start working again. This requires patience. Your food and water intake will continue through your vein tubing until the bowel works. Sometimes there is some discharge from the drain by the wound. This stops given time.
Wound infection is sometimes seen. This happens relatively more frequently in any bowel operation compared to other 'clean' operations such as taking out your gallbladder and the reason is that the bowel has many bugs that can cause an infection. The infection settles down with antibiotics in a week of two.
Other complications are a skin rash, infection or an abscess (a pool of pus) around the ileostomy, narrowing/stricture or necrosis (death of bowel tissue) of the bowel at or near the area of the ileostomy and also a hernia of the ileostomy, a situation where the bowel falls through the skin. These complications occur in 4 to 30% of cases depending on the original disease of the bowel that lead to the creation of the ileostomy.
Some inflammatory diseases of the bowel (the bowel gets swollen red and possibly infected) and cancer are diseases that are associated with higher chances of complications following the creation of an ileostomy. If you get such complications it is likely that you will need another operation to fix the problem.
Aches and twinges may be felt in the wound for up to six months. Occasionally there are numb patches in the skin around the wound which get better after two to three months. The stoma can sometimes swell, or shrink or irritate the skin. The stoma nurses will help you here.
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