Practice. Source picture: Uniek van UMC Utrecht

 

What should you take with you to the hospital?

What should you actually take with you when you go to the hospital? Naturally it varies from person to person, but here are a few examples which people on the Dutch forum gave in answer to this question:

• Your punch card
• Proof of your health insurance (e.g. your card)
• Toiletries
• Medicine (preferably in original packaging)
• Ostomy supplies (if you already have a stoma)
• Pyjamas
• Slippers and robe
• Underwear and socks
• clothing for when you can return home
  (Joggers are very good after a stoma operation)
• Your own pillow
• Nice pillowcases
• Something nice to spray on your pillow
• An eye mask for night time
• Earplugs
• Reading/puzzle books and newspapers
• Pen en paper
• Diary for your guests
• Digital camera
• MP3 Player (with ear phones that you can use for the TV as well)
• Mobile phone / book with telephone numbers
• Pictures of people and animals close to you
• Laptop and some DVD’s
• TV guide
• Food such as lemon drops / peppermints, biscuits, drinks etc.

 

Nowadays it is possible to internet in ever more hospitals, so ask about it.

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The preparation

Normally there are investigations done at the clinics first: blood tests, heart checks (ECG), a general physical examination and sometimes an x-ray of the lungs. It is also usual to have an interview with the anaesthetist, surgeon and/ or stoma nurse. These interviews and the preparatory investigation can be done on the ward, if you are taken in the day before the operation. If you are going to have the operation on a Monday, you are often admitted on the Friday beforehand and the investigations are done then. It depends on the situation, but sometimes you can go home again and only have to return on Sunday evening to the ward. Nowadays an increasing number of hospitals have a pre-operative consultation. If you are planned in to have an operation, you attend the consultation. During this consultation the anaesthetist can inform you about the anaesthesia, will go over your medical history, medicine use, allergies etc with you through a list which you have filled in and will organise any necessary additional investigations, estimate the risks of the operation and may request another consultation or treatment with another specialist.

In order to be sure that your stoma bag will be in a good place after the operation and sits comfortably when you stand, sit or move, the surgeon and stoma nurse will carefully try to find the best place to site the stoma. The place can depend on the shape and folds of your stomach. It is very important that the stoma is formed in the “correct” place otherwise you can have problems with leaks. They take into account your bone structure such as the hips and ileum and also the navel, scars and the contours of your body. The stoma is often placed at the top of the “fatty roll” level with the navel. For people in a wheel chair the site must be measured sitting down. They also take into account the sort of clothing you wear, primarily where the waist band is. Finally it is also very important that you can see the stoma yourself and can easily move and bend with it. It remains only an indication because obviously the surgeon has to depend on the situation within the stomach. It is very difficult to determine placement with an emergency operation.

It is wise to walk around with a bag taped to your stomach prior to the operation as a test, so you can feel if the place is indeed correct. In some hospitals you are loaned a fake stoma you can stick to your stomach. Using surgical ink, which does not wash off in the shower, the site of the stoma is marked. In principle a stoma can be placed on any part of the stomach. However there are a number of preferred places;

* (double ended) ileostomy ~ on the right lower abdomen

* colostomy ~ on the left lower abdomen

* double ended colostomy ~ on the left lower or upper abdomen

* urostomy ~ on the right lower abdomen

In exceptional cases an ileostomy or colostomy can be placed above the navel. This cannot happen with a urostomy due to the anatomical location of the kidneys, ureters and the bladder. Muslims for example consider a stoma beneath the navel unclean; this is to do with their cultural background. For a wheelchair user it is better to site a stoma somewhat higher up the abdomen.

When you go under the aesthetic, you must be ‘empty’. This means that your stomach must be empty when you are operated on. It varies across different hospitals how long you may not eat and drink before the operation. Sometimes you have to follow a liquid diet a few days beforehand, others it is only the night before the day of the operation that you can no longer eat and drink. In some hospitals the rules are already being softened. Scientific investigations have shown that the intake of clear fluids (such as water, tea, coffee without milk and sugar) do no harm up until 2 hours before the operation. These clear drinks leave the stomach within 2 hours. More frequently hospitals are holding to this rule, and you may continue to eat until 6 hours before the operation.

 

The game "Theme hospital"

Depending on the situation, the hospital and the surgeon’s preference, the intestines must also be empty. This can happen with a laxative or rinsing of the intestines. If there is a serious blockage, or operated in an emergency, then cleansing of the intestines cannot happen. It is no longer always necessary to use a laxative before an operation. The horrible litres of drink, with the associated diarreah and the clear liquid food, often worsen the condition of your body. The reason for the laxative was that previously they thought that you had less chance of suture leakage (see further on this page for more information about this) and if you did indeed get this, fewer bacteria entered your abdominal cavity. 1400 people in 13 Dutch hospitals took part in an investigation whereby it was randomly decided if they would have a laxative or not before the operation. In the weeks after the operation the numbers of suture leaks in the 2 groups were the same. Often an enema was give the night before and in the morning of the operation, with lower rectum operations laxatives were still given. However as written previously the hospital procedures vary, so ask your doctor!

Picture source: Colonic-association.co.uk

 

If you have to be in the hospital the day before the operation, it is a good idea to have a sleeping tablet. Due to the strange environment and the tension you will perhaps sleep less well.  

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The day of the operation

During the operation the anaesthetist monitors the colour of your skin. Therefore make sure you have removed all makeup and nail varnish. Contact lenses should also be removed because they could cause damage to your eyes during the general anaesthetic. For hygiene reasons remove your jewellery, watch and piercings. Also remove your false teeth with a general anaesthetic. Often you hear in advance when it is due to be your turn. You firstly get the opportunity to shower. Sometimes it is quickly your turn for the operation, but sometimes you might have to wait a long time. You can ask the ward if it is possible for someone to wait with you, if want. A quarter of an hour before you go to the operation room you will be asked to put on an operation jacket; normally this is a jacket where the back is open. Sometimes you can keep your knickers on.

Just before the operation; already in the operation jacket Eliene’s nose stub is removed (right)

 

You get a wrist band with your name and any allergies (if this has not happened previously).

Sometimes you also get an injection in your buttock or a tablet, to make you calmer and to prepare you for the anaesthetic. You also get a paracetamol. Hereby a mirror is built up in your blood so that you already have a sort of buffer after the operation. When it is time you are taken by the nurses, bed and all to the operation centre. There you wait, often with other patients, in a room until the operating room is ready.

In the operation room you are moved from your own bed to the operating table. Then you are connected to the monitoring equipment. During a anaesthetic the anaesthetist monitors continuously the most import body functions, such as breathing, blood pressure and the heart beat. That is why stickers are stuck to your breast which monitors your heart rhythm during and after the operation.  

You also get a peg on your finger which monitors the oxygen level in your blood and a blood pressure monitor on your arm.

Picture source: EJK.de

 

A drip is inserted in the back of your hand. This is a thin tube that is placed in a blood vessel and whereby other medication and fluids can be administered during and after the operation. Sometimes the drip is placed in another place, for example in the side of the wrist, if your veins are more visible (and therefore easier to puncture) there.

Picture source: EJK.de

 

With an operation on the gastro-intestinal tract an epidural in the back is often used to regulate the pain during and after the operation. You will be told beforehand if this is to happen to you. With an epidural (Thoracic Epidural-Anaesthetic, TEA) a very small thin catheter (tube) is inserted just inside the spinal cord outer skin, between 2 vertebrae. Epidural means ‘the space just outside the hard spinal cord’. The injection therefore does not go into the spinal cord. The medication goes immediately to a good place meaning less pain killing medication is needed. By means of a pump pain relief is administered via the tubing. An epidural catheter also often has a beneficial effect on the oxygen levels if the heart and the coronary arteries which regulate the blood delivery of the heart. When you are awake you breathe better which means you recover quicker. To insert this you have to sit on the edge of the operation table in a position known as the ‘cat position’; chin on your breast, nose towards your knees, shoulders sagged/relaxed and the feet are supported on a bench. If necessary the place of the epidural is first numbed with a small injection. With an epidural your legs feel different; warm tingling and heavy. Sometimes you cannot move them anymore.

 

Picture source: AMC

 

An operation on the gastro-intestinal canal is normally done under general anaesthetic. This is also known as total anaesthetic. Anaesthesia literally means lack of feeling. The point of the anaesthetic is to protect you during the operation. Thanks to the anaesthetic your body remains in as good as a condition as possible, even during a heavy operation. During an anaesthetic your whole body is numbed and you are unconscious. Sometimes before your go to sleep you are give a mask with 100% oxygen on your mouth and nose. This gives your blood cells and there with your body an extra “boost” of pure oxygen. This helps your recovery. Then the anaesthetist injects the anaesthetic via the drip. You fall into a deep sleep with a half minute. It can feel as if a warm glow spreads over your body. It happens so fast you just have to watch. We tell ourselves that if we think of something nice at that moment, then you will also awake with a nice feeling. Sometimes people, who are given via a laparoscope a temporary stoma for example, just have an epidural whereby they can watch the operation on a TV screen.

 

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During the operation

Before the operation itself begins, the anaesthetist puts a plastic tube (the endo tracheal tube) into your throat, which ensures a clear airway during the operation. You know nothing about this because you are already under anaesthetic. However when you wake you can have a sore throat. More sedative is administered, via the drip or the breathing machine. The intestinal function is spontaneously interrupted during the operation, but the production of gastric fluids continues. To prevent a build up of gastric fluids in the abdomen and cause nausea, a stomach drain is inserted via the nose into the stomach. This drain is removed when the intestine starts working again. This can happen straight after an operation, so you will wake up without a stomach drain. However it can also happen that the stomach drain has to remain for a while longer. It is vital to keep everything sterile to prevent infection, so everything is thoroughly disinfected and the entire operation area is covered with sterile sheets. During the operation all your body functions are properly monitored and if necessary it can be supported with for example extra fluids or blood.

Picture source: MSTwente

 

How long the operation lasts is strongly dependant on the sort of stoma being made, the situation in the abdomen, the cause of the operation etc. During the construction of the stoma the intestinal part which is going to form the stoma is brought through an opening in the stomach wall about the size of a Euro coin. The intestine is turned inside out and attached to the skin. What you actually see of the stoma is therefore really the inside (the intestinal mucosa) of the intestine.

Picture source: Atlas of pelvic surgery

By the construction of a (often temporary) double ended stoma there is sometimes use made of an artificial bridge. The intestine is pulled out of the abdomen and between the intestine and the skin a so called bridge is laid. This prevents the intestine from sinking back into the skin (retraction). When the stoma is completely attached to the skin and cannot go back again, the bridge can be removed. There have been studies which show that with double ended stomas which do not use a bridge, a retraction does not happen any more often than with one.

Picture source right: Atlas of pelvic surgery

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Waking up

Left a (double ended) stoma just after the operation and right the same stoma around 3 months later

 

The drip in your hand or arm is very important. The first few days after the operation you get a fluid/saline solution (saline 0.9%). The saline content in this solution is the same as that in our body cells enabling the water content in our body to be replaced as soon as possible. Sometimes you are given in place of a water/saline solution a sugar/water infusion. One tip which can help with nausea is a special wrist band which has a plastic button on the inside. Put it in the place where a watch strap closure is. This button presses on an acupuncture point (p6 of Neiguan) and causes relaxation and can prevent nausea according to many studies. It works with about 70% of the people. Preferably men should wear it on the left wrist, women the right wrist. This is for sale in holiday shops and chemists. You can also massage this point yourself. Ginger is also a good remedy for nausea.

Also if you have problems with nausea they can give you medication for this via the drip. Pain killing medication can be spurted in the drip (if you do not have an epidural). You may have been given a pain pump which you administer yourself. In this case you can, if you feel pain, press the button on the pain pump, whereby you get small doses of morphine in your blood. The pump is completely safe and you cannot overdose on it. Just be aware that morphine slows down the working of the intestines.

 Pain is caused because cells in the damaged tissue make hormonal materials which irritate the nerve endings (pain receptors/nociceptor). Through these irritations an electrical signal is sent via the nerves and the spinal column to our brain and these are translated as pain. The nurse will come along regularly to ask how high the pain is (pain monitoring), which you give on a scale of 0 (low) to 10 (high). This is the VAS score, which means Visual Analogue Scale. Be honest, because the pain can be treated in different ways. Often with a combination of medicines. With serious pain an intramuscular injection can be given (in the muscle). This is not very nice, but it quickly helps against the pain. In the past it was usual to only calm the pain if it was unbearable. Meanwhile tests have shown that you are better to have continuous pain killers for a while with a long lasting pain to prevent it becoming worse. A good pain relief leads to a quicker recovery. The pain is mostly worse immediately after the operation and gradually reduces. The aim of the doctors and nurses is that 72 hours after the operation you have a pain number of less than 4. The difficulty with pain is that it is subjective; pain is very much a personal experience.

Apart from the drip and the pain pump when you wake up there will be a tube in your nose for oxygen. As previously discussed you can also wake with a tube which goes to the stomach via the nose and throat (gavage). The gavage ensures that the gastric juices run into a collection bag via the tube. Especially in the beginning this can be good because the intestines are still not working and otherwise you want to throw up. It takes some getting used to the tube from the nose to the stomach, and sometimes it is not nice, but luckily the gavage is soon removed because of it. Sometimes it is already gone when you wake up from the anaesthetic, and other times they measure the gastric retention 3 times a day. If it is less than 50ml each time, then the intestines are starting to recover and the tube can come out.

If an intestinal stoma has been created then you may wake up with a bladder catheter. This is a flexible tube which is pushed along the natural ureters into the bladder. The urine can drain away by itself and is caught in a bag which hangs on the bed. As a result of the anaesthetic it can be that you cannot pee by yourself. Also they can monitor your fluid levels after the operation and you do not have to go and sit on a cold toilet immediately. You do not feel the presence of the catheter.

As written earlier it totally depends on what sort of operation, the hospital, your condition etc which bells and whistles you wake up with. For example you may have a tube (drain) in the abdomen wall to ensure drainage of wound fluids and blood. Also some people need feeding tubes before or after the operation. Discuss this with your doctor; there are only examples on this website!

Just back from the operation

 

On the operation day all your body functions are checked regularly, the “checks” are done by nurses. Your temperature, heart rate, blood pressure and oxygen levels in the blood. As you start to get better these lessen slowly.

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The Recovery

You are not worth much the first days after the operation. You can feel sick or even throw up, you feel weak and cannot, certainly not the first day, get out of bed. The first time you are really dependant on the nurses. They help you to wash, change, the toilet etc. If something is wrong you can press a bell to call a nurse. You will sleep and rest a lot.

Every day step by step things get better and you can do a little more. How quickly this is depends on all sorts of factors. Once you are able to they will help you out of bed so you can sit on a chair. It feels like a journey around the world the first time. You must not forget that an operation is a blow to your body; it needs time to recover again.

Just “dangling”

 

Slowly you can eat and drink again. In the first days only liquids (soup, porridge etc), then light food (mashed potatoes, crackers, fruit etc), building up until you can eat normal food again. You may get stomach cramps because your intestines have to slowly get used to working again. If you want you can ask the nurses to warm you up a hand towel, this can help reduce cramps. A towel also helps with too much coughing, so that you can apply pressure to your abdomen. Often a dietician comes to see you after you are given a stoma. They will discuss the impact of your food on your newly formed stoma. The surgeon will also come to visit to tell you how the operation went and to see how things are going with you now.

A few days after the operation Eliene can eat light food again

 

A colostomy can take a few days before it starts working again, this happens because you slowly build up your food. An ileostomy must produce stool immediately after the operation, although it will be watery and green in the beginning. Also a urostomy produces urine immediately after the operation.

Eliene's abdomen just after the operation

Jaime's abdomen a week after the (laparoscopic) operation

 

In the first days after the operation begins the learning how to care for your stoma. A ward nurse looks after the basic care, the stoma nurse deals more in depth. In most hospitals the largest part of the learning to care is done together with a stoma nurse. In the beginning you just watch and the stoma nurse explains everything. This is called bed-side teaching. There seems to be a lot happening all at once and you have the feeling that you will never remember it all, but believe, it will happen! When you are ready you can help to care for your stoma, and before you go home you must show that you can do it for yourself at least once. It is also important that once someone close to you also watches closely, so that they know how to care for a stoma. The stoma nurse begins in the hospital with one brand, at home you can try out other brands of stoma materials to find out which you find the best.  

Every day a tube or a drip vanishes. The drip is first closed off, and if everything is going well and you are drinking and eating enough, then the drip can be completely taken away.

The fitter you enter the operation, the quicker your recovery. Therefore it is impossible to say precisely beforehand how many days it will be before you can eat normally, you can go home etc. Naturally it depends on the type of operation, the condition of your body, how quickly you lose the tubes etc. In principle you can leave the hospital after the construction of a stoma after 10 to 14 days. With a laparoscopic operation it can even be within 5 or 6 days. Naturally it can be that you recover a little slower, for example because of complications, whereby you have to remain a bit longer before you can go home again.

The first steps together with the drip pole

 

The day that you can go home you get a complete explanation from the stoma nurse. You also get some stoma material for the first few days. The stoma nurse will write a prescription and send it to the ostomy products supplier, so that everything is organised for when you are home again. Also you can, together with the social worker or the nursing carer from the hospital, organise help for home. This can be household help, nursing care or for example aids such as a temporary wheelchair, hospital bed or raised toilet but also laying the table. If you think you need help at home, ask so that the nurses can inform the nursing care.

Picture source: magazine Gezond.nu

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Home again

In the hospital you can have 2 contradictory thoughts: on the one hand you will be glad to go home and sleep in your own bed. But on the other hand you feel safe in the hands of all the professionals. Once you are home it can seem a larger step than you thought. Then you have to do everything yourself and slowly pick up the threads of your life again. Also you are more active at home and so you notice quicker your worth, and that can go against it sometimes….Certainly for the first 2 weeks you should give yourself the time to get used to everything. It can be good to review what has recently happened. Do not push it away, because you haven’t done it for nothing. Talk to others about it, it can give enormous insights and make it all less heavy.

 

On one of the first days that you are home again, you will get a welcome package from the supplier who will be delivering your ostomy supplies in the future, sometimes personally delivered. Herein is everything you need to care for you stoma: from scissors to a template. Often they put something nice in as well, such as a book, toiletry bag etc. If the packet is delivered personally to you, you will also get a detailed explanation. You can compare such a supplier to Wehkamp, (A catalogue company), but where you order ostomy materials. You can often do it via the internet.

The first time is also in the sign of finding “the perfect material”. One person finds it straight away which for another it is a long search with problems such as leaks and skin irritation. Do not do this alone, but together with your stoma nurse. They can help you, because at that time you cannot see the wood for the trees, there are so many different makes and types. Trying out a stoma bag is also nothing like trying on a new pair of jeans. With jeans you can see immediately if it fits well or not; sometimes you have to try a stoma bag for a few days before you know. But don’t worry: there are nowadays so many different variations in the ostomy area, that there is a stoma bag and base plate suitable for everyone that you can be satisfied with. You can always ask your stoma nurse. Certainly in the beginning you will need this help, but also if your weight changes for example, you could need their help to find another stoma bag that is more suitable. Remember also that in the first weeks after the operation your abdomen and shape of your stoma can change whereby the materials sometimes have to be adjusted. Often a stoma has his final shape around 3 months after shrinking through losing excess fluids. Also you become more mobile once you are home and you may need different material that sits more comfortably. Also your skin has to adjust to the fact that there is constantly a plaster on the skin. Therefore in the beginning it can be an epic search, but once you have found the correct material you are often set for years, apart from small adaptations!

The care will be hard at first. Where do you go to care for the stoma? Can I do it all alone? I had an accident, why and how do I solve it? The care will also take longer that it will in the future. It is new, strange and you have to get used to it. Meanwhile a new element enters your daily body care. You will notice that the daily care of your stoma becomes easier and goes faster. Also things have changed which you need to get used to. Watch your food and make sure you get enough fluid and salts with an ileostomy, regular changing or emptying of your stoma bag. You will also notice that the smell of your stool with a colostomy and especially an ileostomy, is different. This happens because of the shortening or removal of the large intestine changing the consistency of the stool. The recovery often goes with ups and down; 1 step forward and 2 back. In the beginning you might have the idea that your stoma rules your life, but there will come a time when the roles are reversed.  

Think about the fact that your abdomen had been cut open and there is now a hole in it, a weak spot. Certainly in the first 6 weeks after the operation it is better not to lift anything in order to prevent a hernia. Your stomach muscles will grow back together after a month or 2, if you are older then you should reckon on 5 to 6 months. Give your stoma and your scars the chance to recover and try not to force anything. If you do get a hernia then you will be set back much further. Things such as vacuuming, cleaning windows, lifting heavy objects, pushing a shopping trolley; these are all unadvisable during the first weeks after the operation. In the beginning your stoma and your abdomen will be very sensitive. Consider it nicer to wear looser clothing during the first weeks after the operation, such as jogging trousers with elastic. But as you recover, you can try things like your jeans again. This will be easier once the stitches around the stoma have been removed by the stoma nurse. This can give a pulling feeling or even become a bit inflamed. If they stay in place too long, scars can form, also known as strictures or granulated tissue. It is therefore important that the stitches are removed in time. Remember to take a set of your own stoma material with you when you go to the stoma nurse. If the situation permits you do not have to care for the stoma at home. This is because the stoma nurse can tell a lot through looking at the old base plate.

After an operation you always have scars, but these vary per person and what sort of operation you have had. What can you do yourself? The first 6 months do not reveal your scar to the sun. The scar can burn very easily. Only when the sutures have been removed can you use a cream on the scar. It has been scientifically proven that a cream which contains vitamin E, increases the healing rate. If the wound(s) remain red for a long time and are still clearly visible after 4 weeks, a silicon gel is an option. There are also special scar creams such as PCLE cream from Biodermal. No scientific trials have been done on this but the experiences are primarily positive. Another option is calendula cream, which softens and heals wounds. There are also self adhesive silicon gel sheets ( not to be used on an open or infected wound).For example Cica-Care, which is proven up to 90% effective in the improvement of red, dark and thick scars. You cut out a piece thereof, which you attach to the scar. You can apply this (for 2 – 3 weeks) daily. You wash it with soap and water and dry it off. You can be reimbursed for this if you have a prescription from the doctor.

Jaime’s abdomen 4 months after the (laparoscopic) operation

This can be the result of a non laparoscopic operation (War)

 

Your appetite can change after the operation; more or less, or other changes. Your body can for example crave specific foods like salt, fibre or proteins. Listen to your body, because protein (meat, fish and dairy products) are good for the recovery of your body. Watch and try gently to see which foods you can tolerate, and which not. For a handy food list with products which can cause an obstruction, air etc, click on the page FOOD on this website. What you can and cannot eat varies person to person and also on the opening of your stoma. The narrower, the harder it is to digest difficult products. Try everything quietly, not at the same time, and if something doesn’t appeal try it again later.

What many people find difficult is the bumps you get when you first do something with your stoma. For example the first time you do to the cinema again, a birthday party or some other outing. The swimming pool, on holiday and sports. Even such simple things as the first shower, to a clothes shop to try some trousers on or caring for your stoma somewhere else. With everything you do you have to cross yet another threshold. And it can be higher for one person than another. But once you have taken once a daring step then it feels like a huge victory. And then you realize that it is absolutely not a problem: living with a stoma.

If you are ever admitted to hospital, consider that if you wish to continue using your own trusty stoma bags, then you should take them with you. It can be that they use a different brand in the hospital. You can however make use of the wipes, disposal bags etc. Often the stoma nurse will make a box for you with everything collected in it for you. Consider that after an operation you may need alternative collection material, which will be placed on in the operating room and is clear (Post Op bag).

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Laparoscopy

A technique that is used more often in the construction of a stoma is laparoscopy. It is a investigative operation (also known as keyhole surgery or minimal invasive operation) whereby small tiny cuts (incisions) are made in the skin, in place of one large one. The word “investigative operation” is actually misleading, because they do not just look but also actually operate. Laparoscopy is much less taxing because you have fewer scars, meaning less pain and therefore also a quicker recovery.

Also the abdomen does not have to be completely opened, meaning the intestines can remain lying nicely warm, so that you have less change of adhesions of the intestines over the long run. You lose less blood and the chance of complications later on is reduced. Despite the fact that during a laparoscopic operation only small cuts are made, it still remains a large operation. Do not forget: although they can begin with a laparoscopic operation, your doctor can decide to operate further via a larger cut to reach inside. Also not everyone is suitable for a laparoscopy; if you have had many operations on your abdomen previously (result: adhesions) they may prefer to operate the “old-fashioned way”.

 

Firstly a small cut is made in or nearby the navel, through which the first tube (canula) is inserted. Air is blown through here (CO2 - gas, carbon dioxide) (inflated) to create some ‘working room’ in the abdomen. Because of this air you can have some problems after the operation with cramps in the abdomen, but also muscle pain in the back. Then a number of cuts (around 5 to 12 mm), normally 2 or 3, are made, through which the precision instruments are inserted. There are at least two openings needed: one for the camera so that the surgeon can follow everything on a monitor and one for a working instrument with which the operation is performed. During the laparoscopic operation the surgeon controls the surgical instruments via the monitor. Through the superb quality of the cameras and the enlargement capacity up to 20 times, the surgeon can see the anatomy in the smallest detail. Eventually a larger cut is made (often by the bikini line) in order to remove a part of the large intestine.

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Bowel removal/colectomy

If a stoma is formed, then it is normally necessary to remove (a part of) the large intestine (resection of the colon). If it is completely removed then it is called a total colectomy, leaving the rectum as a stump. If the rectum and anus are removed then it is called a proctocolectomy. In a subtotal colectomy a large part of the large colon is removed. In a partial colectomy a piece of the large colon is removed. Finally, the removal of half the large colon is a hemicolectomy (and this can be of the left or the right). These are the medical names of these techniques. The removal of the large colon can be done in the classical way whereby the abdomen is opened, or laparoscopically. The way it is done with you lies totally on the situation within your abdomen, or if you have been previously operated on, how many adhesions you have, the reason for the operation etc.

It is also possible that a piece of the small colon has to be removed (partial ileum resection). You can also do without a large piece of this. The body appears to adjust to the new situation, whereby the rest of the colon takes over the missing part and the digestion can continue. If you have less than a 1/3 of the normal length of the small colon (the small colon is 6 meters long on average), then the body cannot cope any more and it can be that your small colon is not capable of absorbing nutrients any longer (short bowel syndrome). You can therefore miss a large section, however preferably not the last piece of the small colon. If the last 20cm of the small intestine is removed, you can have a deficiency of vitamin B12. This vitamin is specifically absorbed in this piece. If this last piece of the small colon must be removed, it is judicious after the operation to have your blood values checked and possible to have regular vitamin B12 injections so that you do not have a deficiency.

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Rectum removal/rectum amputation

Sometimes it is not sufficient to remove (a part of) the large intestine, but the rectum is also amputated. For example with cancer of the rectum or if Crohn’s or Colitis Ulcerosa severely affects that place. Sometimes a rectum if removed as a preventative for a similar illness. If someone has an ileostomy whereby the rectum is still in place, there can be no problems for years, but after many years the chance of cancer in the rectum raises. Finally, the rectum alone can be affected whereby this has to be removed. Sometimes it is then possible to rejoin the ends of the intestines (anastomose) so that no stoma has to be formed, or just a temporary one. If the anus/sphincter has to be removed then one talks of an abdomino perineale rectum expiration. By the last there is often no anastomose possible.

 

Picture source: Medline plus

 

For the removal of the rectum it can be done by an open surgery of the abdomen, a laparoscopic rectum amputation or an operation via the rectum, from beneath (transanale pull through). Because an open operation is done in the pelvis, where there are many nerves from the sexual organs and the bladder, complications can develop. Therefore a laparoscopic operation or an operation via the anus, (an intersphincteral rectum amputation) is preferable. The last one is operated on between the 2 sphincter muscles. The chance of nerve damage in the pelvis is a bit less because the surgeon remains close to the wall of the rectum, and the pelvis base and the exit sphincter remain intact. This has advantages again for the wound healing and reduces the chance of sitting pain after the operation. Unfortunately it is not advisable to use this operation on people with cancer, because it is necessary to operate further into the rectum. Hereby it is necessary to enter via the abdomen.

Picture source: BBraun

 

Your rectum and anus support your organs in the pelvis. Therefore you can imagine that if these are removed, a subsidence can occur. The surgeon can close this hole which develops can be closed in various ways. For example this can be by using the fat roll which hangs on the large intestine as a sort of shawl hanging in the pelvis. Because the small intestine falls above this, it cannot sag. You can also use the technique of rectus-abdominus-plastic, whereby the right hand abdomen muscles are used to fill the hole.

Picture source: the book "Atlas van de anatomie".

 

If you are “sewn closed” from beneath, the anus is closed and you have an anal wound. An anal wound needs time to heal. This can vary from several weeks to sometimes up to a year. In the beginning you can have problems with sitting pain. Then it can be advisable to acquire a special cushion pr to borrow one from the nursing care for example. You can also use a gel saddle cover if you have trouble cycling. Click here for the subject sittingpain. People, who have to undergo an amputation, are often not prepared for that they, after the operation, still feel the amputated body part as if it is still there. This is a normal occurrence which happens with more than half the people. This is called phantom feelings/pain. By an amputation you can still experience feelings in the affected body part. This happens because the part of the brain which is responsible for the “feelings” is still present. If you get the feeling of urgency, it can help to go and sit on the toilet as usual.

  

Brand: left Tempur right: Roho

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Hernia operation/parastomal hernia

A hernia can occur by an operation scar (wound fracture) or by a stoma (also known as a parastomal hernia). This occurs because there is a weak spot around the stoma in the abdomen or near a scar. The abdomen is surrounded by a strong layer of muscles and covered with peritoneum which holds everything in place. By creating a stoma there exists a weak spot in the abdomen, and there is talk of a too large opening in the abdomen muscle layer. Due to this too large opening, the abdominal contents can shove against the stoma, and a part of the intestines then is pushed in front of rather than behind the abdomen muscles. The result is a large or small swelling or curvature of the abdomen (Sometimes D cup size). Almost a third of all ostomists develop a hernia (predominately this happens within the first year of construction). Sometimes you only see this hernia during effort; others walk around with a huge bulge on the abdomen. This sort of hernia normally occurs after too much pressure on the abdomen, such as by heavy lifting or a coughing fit. In some instants the doctor will decide to help operatively, for example by moving the stoma to the other side of the abdomen or by strengthening the abdomen wall with pads. In many cases this is not possible and only people with serious problems, such as heavy leaks, are considered for this. A new operation will always weaken the abdomen, meaning the chance of a return of the hernia is large. Therefore it is best to prevent a hernia.

Often if there is a repeat of the hernia the stoma is moved to the other side of the abdomen. The old stoma place is tightly sewn together and a new place is chosen for the stoma. Moving a stoma is not always technically possible. Also, after investigation, it appears that in 25–30% of the occurrences when a stoma is moved the scar leads to a hernia. Another good possibility is to strengthen the abdomen wall with an artificial mat around the stoma. This can also be done laparoscopically meaning you have less scars.

Picture source: De Vooruitgang from De Nederlandse Stomavereniging  

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Stoma revision

For a number of reasons (problems) it can be that a stoma has to be corrected (revised), for example with a narrowing of the stoma, a retraction or a prolapse. The stoma remains on the same spot, but is replaced. This can often be done laparoscopically; they make 1 or more incisions around the stoma, pull the stoma loose from the surrounding tissue, solve the problem and attach it (sometimes after removing a small piece of intestine) again to the skin.

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Stoma reversal

Apart from a stoma being formed, it can also be reverse. If a recovery operation can happen depends on a number of factors. The rectum and the sphincter must look good, it is important that you are in good health and it can be that a stoma cannot sometimes be returned due to the situation in your abdomen, for example such as adhesions. Your stoma, the piece of intestine, is replaced via the stoma opening. The wound where your stoma sat grows closed by itself. It depends on your situation if this can be done by laparoscope or your abdomen must be opened. Often the operation happens under a general anesthetic, sometimes through using a epidural. Despite the fact the reversal of a stoma is generally a smaller operation that the creation thereof, there are still complications possible. The most important is the leakage from the suture where the two pieces of intestine are sewn together (seam leakage), more about this later. Another complication is that after the operation the intestines have to adjust again and it can be in the beginning that you have to go more often to the toilet and it is also very thin. It takes time; one person can have a lot of trouble whilst another is as good as new.

Closere of a loop colostomy. Source picture: Atlas of pelvic surgery

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Fast track/ERAS

The ERAS-protocol (enhanced Recovery Aster Surgery) or Fast Track Program (literally fast route) is being used increasingly more often. These are programs for a faster recovery after an operation, often used by a laparoscopic operation. This is a programme wherein all the factors which have a positive influence on recovery are brought together. Briefly this is: quickly feed and quickly mobilise. The idea is that in place of the average 8 – 14 days in hospital for an intestinal operation, you can go home after around 5 days already. On average the time in hospital is reduced by 2 or 3 days. The program consists of a number of elements.

Often you no longer have to avoid food before the operation. You are given a liquid food (PreOp) and after the operation packets of energy rich supplements. There are also other rules about laxatives. The intestines are not completely cleared, just the last piece using an enema. Because the intestines are not completely relaxed, you can eat quickly after the operation. The insertion of a nose and stomach tube is then also unnecessary. It seems that is you give your intestines food; it starts working again by itself. You can often be operated on in the morning and already eat in the evening. In this way you get all the necessary building materials to recover. The idea is also that the day after you can already sit on a chair next to the bed. Moving is good and stimulates not only the intestines but also blood flow and lung function. This helps the recovery of your whole body but specifically your wound. Good medication against nausea and pain is very important as well. The more these are under control, the quicker you will eat and move.

Picture source: Uniek van UMC Utrecht

 

If there are no complications, It is often better if people return home sooner, because you recover much faster at home. You also prevent such complications as thrombosis, reduction of muscle strength or a hospital bacterium. What is however important is that you have help afterwards in your environment or home nursing care. After you have been home for a number of days the hospital will normally contact you to find out how you are doing, and you can return if there are complications. Because you are in the hospital for a shorter time primary care (such as from a stoma nurse) becomes even more important. Naturally the intention is that you can care for your stoma yourself before you return home. Therefore it is also important that you cooperate, and have an active role in the whole process. If you take part in this program it will be discussed with you previously.

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Complications

Not the nicest subject, but definitely an important one. After every operation complications can develop, no matter how small the operation is. A complication is not always due to a mistake by the doctor, but is an ‘undesirable, unexpected result of receiving medical care’. The complications occur despite the correct treatment and it one of the aims of the doctor to prevent or reduce these.

Firstly a generality: the hospital bacteria. This is a collective name for bacteria that is resistant (insensitive, immune) to the most, usual antibiotics, whereby they are difficult to combat. Healthy people carry certain bacteria and do not become sick from them, but in a hospital environment they thrive due to the use of all sorts of antibiotics and people with a seriously diminished resistance. The most well known one is probably the MRSA bacteria, which stands for Meticilline Resistant Staphylococcus Aureus. The Staphylococcus Aureus is carried by roughly 1 in 3 (healthy) people. MRSA is a special variation of the usual Staphylococcus Aureus, because this is insensitive to many antibiotics. Less than 1% of the population of this country carries MRSA, and it usually goes by itself. Only when people are really sick or have just been operated on does it form a threat. If you become infected with the virus in a hospital, you are treated in isolation to prevent you infecting other people. This can be unpleasant because everyone that comes into your room must be protected with a mouth mask, gloves etc and have to disinfect them selves afterwards. Thanks to a strict regime in The Netherlands ‘only’ 0.5-1% of hospital patients become infected with these bacteria. In other countries, where a less intensive antibiotic regime is in place, 20-50% of hospital patients become infected with MRSA. People with a stoma belong to the group with a heightened risk of acquiring MRSA (MRSA carriers).

 

Picture source: MRSA-net

 

A consequence of bacteria can be a hospital infection (nosocomial infection). This infection can reveal itself on operation wounds (post-operative wound infection), airways and urinary tract or in the blood stream (sepsis) and happens in 1 in 15 hospital patients. This is an average; a wound infection rarely happens in certain operations (for example investigation of the knee), whilst in the removal of (a part of) the large intestine the chance is a bit higher because the intestines are full of micro organisms. The consequence of an infection is that you often have to remain longer in the hospital and have to be given medicines, however sometimes a further operation and serious complications may occur. This depends entirely on the sort of infection; a urine infection (for example due to a catheter) is over quicker.

    

Picture source: Gezondheidsnet

 

One complication of a disrupted wound healing is wound trauma. Through tension on the operation wound, for example through an infection, much coughing or another cause, the wound edges can disappear.1 or more layers of the operation wound can tear open. When all the layers of a wound tear one speaks of wound disruption or evisceration, also called “Platzbauch” or “burst abdomen”. In this case the contents of the abdomen can exit.

The intestinal working is spontaneously interrupted during the operation, and sometimes it can (certainly due to an operation) happen that the stomach and intestines have trouble starting up again. The rhythm of the intestines is temporarily disrupted after an operation. The intestines start up again in sections; the stomach has the most problems from an operation and it can take between 1 to 5 days to start working again, the small intestine already starts 4 to 8 hours after the operation and the large intestine also 1 to 5 days. If you, such as because of the new rules, start eating quickly again, the small bowel will start working quicker. The stopping of the intestines after an operation is also known as post operative ileus. It can happen with a laparoscopic as well as a conventional operation, but the chance is much less with a laparoscopic operation. From investigations it appears that it is a combination of nerves and the immune system. During an abdominal operation the bowels are touched (surgically manipulated) whereby a tissue trauma develops. The irritated nerves in the abdomen wall make proteins to activate certain white blood cells, specifically fertilisers. These fertilisers cause an infection reaction in the abdomen wall; resulting in microscopically small inflammations in the muscle layer of the manipulated piece of intestine. Another cause of the intestines stopping can be medicines such as morphine, which decrease the movements of the intestines. Results of a post operative ileus are abdomen pain, nausea, chance of sickness, unable to pass stool through the stoma and a higher risk of complications. People are searching for medication which can reduce or even prevent this in a post operative ileus. Afterwards a speedy commencement with (suitable) food is important, the type of pain medication and the speed of mobilisation can also promote a good bowel working.

 

If you have to lie in bed for a longer time (and we really mean a longer time) certain complaints can also develop. You can have problems with pointed feet (pes equinus). The base of your foot is in line with your lower leg and it makes walking painful. This is preventable with a cushion or a rolled up towel behind your feet so that whilst laying the toes still point upwards. It is also good for you to do foot exercises. You can also have problems with bed sores (decubitus). These are damages to the skin, pressure points as a follow on of permanent pressure and thereby a reduced blood flow. It is therefore very important to move sufficiently and if you cannot get out of bed, then to turn every now and again. Avoid staying in the same position for too long. The first phase is noticing a red spot on the skin. Recognised places are the coccyx and the heels. If nothing is done about this and t continues for too long, the tissues can die (necrosis). If it is not possible to turn, then a bed with an anti bed sore mattress offers a solution. This is a mattress with air inside and using a machine which alters the positions, and so changes the pressure points. If you are bed ridden for a long time you can ask the nursing staff for this. Watch out for creases in clothing or the bed, which can also cause bed sores.

Finally a serious complication but unfortunately a realistic one when a join of two bowel parts in being worked on: seam leakage. Scientific literature reports that approximately 5% of operated patients seam leakage develops; from another investigation it appears to be 10%. Seam leakage can develop if the bowel ends are sown together again or stapled. This seam can leak, causing intestinal bacteria and irritating fluids to leak into the abdominal hollow. Usually a repeat operation has to take place immediately. If it is dealt with quick enough, abdominal infections (peritonitis) can be prevented or the damage limited.

 Picture source: Atlas of pelvic surgery

 

Peritonitis is a serious bacterial infection of the abdomen (peritoneum); a thin, transparent membrane of approximately 2 square meters. The most important difference hereby is serious abdominal pain and swelling of the abdomen. Nausea, throwing up and fever are also amongst the symptoms. The movements of the intestines are usually totally disturbed during a peritoneum infection and stomach acids and gasses accumulate, whereon a nasal gastric tube is inserted. Antibiotics are required (often a certain cocktail based on the type of bacteria/infection which is indicated in your blood) in order to remove the infection.

Often the abdominal cavity has to be rinsed out via an operation, once the cause of the leak has been resolved. If it is solved quickly enough, a good recovery with complications is possible. If this does not happen and the bacteria has the chance to spread itself further, the situation becomes life threatening and further operations may be necessary whereby you often end up in intensive care. Sometimes it can be necessary to leave the abdomen open whereby they insert a material mat in order to keep everything in its place. This has to be done because the abdomen is too swollen to close again, but also so that bacteria (for example using a vacuum pump) can find its way out. But this can all be avoided if the doctors realise quickly enough and react adequately.