Gastrointestinal and Urinary Tract Surgery Procedures

This assignment delves into a range of surgical procedures performed on the gastrointestinal and urinary tracts. It includes descriptions of proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, Hartmann's procedure, panprotocolectomy, lower anterior resection with ileostomy, radical cystectomy, simple and partial cystectomy, Indiana Pouch continent urinary reservoir, and more. The document provides insights into the techniques, potential complications, and applications of each procedure.

Running head: Nursing-surgical care
NURSING-SURGICAL CARE
Name of the Student
Name of the University
Author Note

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1A. Surgical Procedures that result in a stoma:
1a (i): 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. In the 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.

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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).
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:

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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).

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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).
1 B. Indications for the surgery:
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

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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).

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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).
I C: Specific Risks:
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).

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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

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(less than 5%) and more significant among women older than 65 years of age (Diver, Rauh-
Hain & del Carmen, 2018).
ID: Type of Stoma/Diversion-
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 opening 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

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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).
2. How Restorative Proctolectomy differs from Proctolectomy:
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. Immediate post operative and long term characteristics of the output-
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

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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. How Loop stoma and end stoma are made and why:
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. Continent Urinary Diversions:
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).
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).

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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. Indiana Pouch
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

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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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