Editor

Brendon J. Coventry, BMBS, PhD,

FRACS, FACS, FRSM

Discipline of Surgery

Royal Adelaide Hospital

University of Adelaide

Adelaide, SA

Australia

ISBN 978-1-4471-5468-6

ISBN 978-1-4471-5469-3

(eBook)

DOI 10.1007/978-1-4471-5469-3

Springer London Heidelberg New York Dordrecht

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Foreword I

This comprehensive treatise is remarkable for its breadth and scope and its author-

ship by global experts. Indeed, knowledge of its content is essential if we are to

achieve optimal and safe outcomes for our patients. The content embodies the

details of our surgical discipline and how to incorporate facts and evidence into our

surgical judgment as well as recommendations to our patients.

While acknowledging that the technical aspects of surgery are its distinguishing

framework of our profession, the art and judgment of surgery requires an in depth

knowledge of biology, anatomy, pathophysiology, clinical science, surgical out-

comes and complications that distinguishes the theme of this book. This knowledge

is essential to assure us that we are we doing the right operation, at the right time,

and in the right patient. In turn, that knowledge is essential to take into account how

surgical treatment interfaces with the correct sequence and combination with other

treatment modalities. It is also essential to assess the extent of scientific evidence

from clinical trials and surgical expertise that is the underpinning of our final treat-

ment recommendation to our patient.

Each time I sit across from a patient to make a recommendation for a surgical

treatment, I am basing my recommendation on a “benefit/risk ratio” that integrates

scientific evidence, and my intuition gained through experience. That is, do the

potential benefits outweigh the potential risks and complications as applied to an

individual patient setting? The elements of that benefit/ risk ratio that are taken into

account include: the natural history of the disease, the stage/extent of disease, sci-

entific and empirical evidence of treatment outcomes, quality of life issues (as per-

ceived by the patient), co-morbidity that might influence surgical outcome, risks

and complications inherent to the operation (errors of commission) and the risk(s)

of not proceeding with an operation (errors of omission).

Thus, if we truly want to improve our surgical outcomes, then we must under-

stand and be able to either avoid, or execute sound management of, any complica-

tions that occur (regardless of whether they are due to co-morbidity or iatrogenic

causes), to get our patent safely through the operation and its post-operative course.

These subjects are nicely incorporated into the content of this book.

vii

Foreword II

Throughout my clinical academic career I have aspired to improve the quality and

safety of my surgical and clinical practice. It is very clear, while reading this impres-

sive collection and synthesis of high-impact clinical evidence and international

expert consensus, that in this new textbook, Brendon Coventry has the ambition to

innovate and advance the quality and safety of surgical discipline.

In these modern times, where we find an abundance of information that is avail-

able through the internet, and of often doubtful authenticity, it is vital that we retain

a professional responsibility for the collection, analysis and dissemination of evi-

denced-based and accurate knowledge and guidance to benefit both clinicians and

our patients.

This practical and broad-scoped compendium, which contains over 250 proce-

dures and their related complications and associated risks, will undoubtedly become

a benchmark to raise the safety and quality of surgical practice for all that read it. It

also manages to succeed in providing a portal for all surgeons, at any stage of their

careers, to reflect on the authors’ own combined experiences and the collective

insights of a strong and influential network of peers.

This text emphasizes the need to understand and appreciate our patients and the

intimate relationship that their physiology, co-morbidities and underlying diagnosis

can have upon their unique surgical risk with special regard to complications and

adverse events.

I recognize that universally across clinical practice and our profession, the evi-

dence base and guidance to justify our decision-making is growing, but there is also

a widening gap between what we know and what we do. The variation that we see

in the quality of practice throughout the world should not be tolerated.

This text makes an assertive contribution to promote quality by outlining the

prerequisite foundational knowledge of surgery, science and anatomy and their

complex interactions with clinical outcome that is needed for all in the field of

surgery.

Conditions of Use and Disclaimer

Information is provided for improved medical education and potential improvement

in clinical practice only. The information is based on composite material from

research studies and professional personal opinion and does not guarantee accuracy

for any specific clinical situation or procedure. There is also no express or implied

guarantee to accuracy or that surgical complications will be prevented, minimized,

or reduced in any way. The advice is intended for use by individuals with suitable

professional qualifications and education in medical practice and the ability to

apply the knowledge in a suitable manner for a specific condition or disease, and in

an appropriate clinical context. The data is complex by nature and open to some

interpretation. The purpose is to assist medical practitioners to improve awareness

of possible complications, risks or consequences associated with surgical proce-

dures for the benefit of those practitioners in the improved care of their patients. The

application of the information contained herein for a specific patient or problem

must be performed with care to ensure that the situation and advice is appropriate

and correct for that patient and situation. The material is expressly not for medico-

legal purposes.

The information contained in Surgery: Complications, Risks and Consequences

is provided for the purpose of improving consent processes in healthcare and in no

way guarantees prevention, early detection, risk reduction, economic benefit or

improved practice of surgical treatment of any disease or condition.

The information provided in Surgery: Complications, Risks and Consequences is

of a general nature and is not a substitute for independent medical advice or research

in the management of particular diseases or patient situations by health care profes-

sionals. It should not be taken as replacing or overriding medical advice.

The Publisher or Copyright holder does not accept any liability for any injury,

loss, delay or damage incurred arising from use, misuse, interpretation, omissions

or reliance on the information provided in Surgery: Complications, Risks and

Consequences directly or indirectly.

xii

Conditions of Use and Disclaimer

Currency and Accuracy of Information

The user should always check that any information acted upon is up-to-date and

accurate. Information is provided in good faith and is subject to change and alter-

ation without notice. Every effort is made with Surgery: Complications, Risks and

Consequences to provide current information, but no warranty, guarantee or legal

responsibility is given that information provided or referred to has not changed

without the knowledge of the publisher, editor or authors. Always check the quality

of information provided or referred to for accuracy for the situation where it is

intended to be used, or applied. We do, however, attempt to provide useful and valid

information. Because of the broad nature of the information provided incomplete-

ness or omissions of specific or general complications may have occured and users

must take this into account when using the text. No responsibility is taken for

delayed, missed or inaccurate diagnosis of any illness, disease or health state at any

time.

External Web Site Links or References

The decisions about the accuracy, currency, reliability and correctness of informa-

tion made by individuals using the Surgery: Complications, Risks and Consequences

information or from external Internet links remain the individuals own concern and

responsibility. Such external links or reference materials or other information should

not be taken as an endorsement, agreement or recommendation of any third party

products, services, material, information, views or content offered by these sites or

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We maintain confidentiality and privacy of personal information but do not guaran-

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Errors or Suggested Changes

If you or any colleagues note any errors or wish to suggest changes please notify us

directly as they would be gratefully received.

How to Use This Book

This book provides a resource for better understanding of surgical procedures and

potential complications in general terms. The application of this material will

depend on the individual patient and clinical context. It is not intended to be abso-

lutely comprehensive for all situations or for all patients, but act as a ‘guide’ for

understanding and prediction of complications, to assist in risk management and

improvement of patient outcomes.

The design of the book is aimed at:

• Reducing Risk and better Managing Risks associated with surgery

• Providing information about ‘general complications’ associated with surgery

• Providing information about ‘specific complications’ associated with surgery

• Providing comprehensive information in one location, to assist surgeons in their

explanation to the patient during the consent process

For each specific surgical procedure the text provides:

• Description and some background of the surgical procedure

• Anatomical points and possible variations

• Estimated Frequencies

• Perspective

• Major Complications

From this, a better understanding of the risks, complications and consequences

associated with surgical procedures can hopefully be gained by the clinician for

explanation of relevant and appropriate aspects to the patient.

The Estimated frequency lists are not mean’t to be totally comprehensive or to

contain all of the information that needs to be explained in obtaining informed con-

sent from the patient for a surgical procedure. Indeed, most of the information is for

the surgeon or reader only, not designed for the patient, however, parts should be

selected by the surgeon at their discretion for appropriate explanation to the indi-

vidual patient in the consent process.

xiii

Preface

Over the last decade or so we have witnessed a rapid change in the consumer

demand for information by patients preparing for a surgical procedure. This is

fuelled by multiple factors including the ‘internet revolution’, altered public con-

sumer attitudes, professional patient advocacy, freedom of information laws, insur-

ance issues, risk management, and medicolegal claims made through the legal

system throughout the western world, so that the need has arisen for a higher, fairer

and clearer standard of ‘informed consent’.

One of the my main difficulties encountered as a young intern, and later as a

surgical resident, registrar and consultant surgeon, was obtaining information for

use for the pre-operative consenting of patients, and for managing patients on the

ward after surgical operations. I watched others struggle with the same problem too.

The literature contained many useful facts and clinical studies, but it was unwieldy

and very time-consuming to access, and the information that was obtained seemed

specific to well-defined studies of highly specific groups of patients. These patient

studies, while useful, often did not address my particular patient under treatment in

the clinic, operating theatre or ward. Often the studies came from centres with vast

experience of a particular condition treated with one type of surgical procedure,

constituting a series or trial.

What I wanted to know was:

• The main complications associated with a surgical procedure;

• Information that could be provided during the consent process, and

• How to reduce the relative risks of a complication, where possible

This information was difficult to find in one place!

As a young surgeon, on a very long flight from Adelaide to London, with much

time to think and fuelled by some very pleasant champagne, I started making some

notes about how I might tackle this problem. My first draft was idle scribble, as I

listed the ways surgical complications could be classified. After finding over 10 dif-

ferent classification systems for listing complications, the task became much larger

and more complex. I then realized why someone had not taken on this job before!

xvi

Preface

After a brief in-flight sleep and another glass, the task became far less daunting

and suddenly much clearer - the champagne was very good, and there was little else

to do in any case!

It was then that I decided to speak with as many of my respected colleagues as I

could from around the globe, to get their opinions and advice. The perspectives that

emerged were remarkable, as many of them had faced the same dilemmas in their

own practices and hospitals, also without a satisfactory solution.

What developed was a composite documentation of information (i) from the

published literature and (ii) from the opinions of many experienced surgical practi-

tioners in the field - to provide a text to supply information on Complications,

Risks and Consequences of Surgery for surgical and other clinical practitioners to

use at the bedside and in the clinic.

This work represents the culmination of more than 10 years work with the sup-

port and help of colleagues from around the world, for the benefit of their students,

junior surgical colleagues, peers, and patients. To them, I owe much gratitude for

their cooperation, advice, intellect, experience, wise counsel, friendship and help,

for their time, and for their continued encouragement in this rather long-term and

complex project. I have already used the text material myself with good effect and

it has helped me enormously in my surgical practice.

The text aims to provide health professionals with useful information, which can

be selectively used to better inform patients of the potential surgical complications,

risks and consequences. I sincerely hope it fulfils this role.

Adelaide, SA, Australia

Brendon J. Coventry, BMBS, PhD,

FRACS, FACS, FRSM

Acknowledgments

I wish to thank:

The many learned friends and experienced colleagues who have contributed in

innumerable ways along the way in the writing of this text.

Professor Sir Peter Morris, formerly Professor of Surgery at Oxford University,

and also Past-President of the College of Surgeons of England, for allowing me to

base my initial work at the Nuffield Department of Surgery (NDS) and John

Radcliffe Hospital in the University of Oxford, for the UK sector of the studies. He

and his colleagues have provided encouragement and valuable discussion time over

the course of the project.

The (late) Professor John Farndon, Professor of Surgery at the University of

Bristol, Bristol Royal Infirmary, UK; and Professor Robert Mansel, Professor of

Surgery at the University of Wales, Cardiff, UK for discussions and valued advice.

Professor Charles Balch, then Professor of Surgery at the Johns Hopkins

University, Baltimore, Maryland, USA, and Professor Clifford Ko, from UCLA and

American College of Surgeons NSQIP Program, USA, for helpful discussions.

Professor Armando Guiliano, formerly of the John Wayne Cancer Institute,

Santa Monica, California, USA for his contributions and valuable discussions.

Professor Jonathan Meakins, then Professor of Surgery at McGill University,

Quebec, Canada, who provided helpful discussions and encouragement, during our

respective sabbatical periods, which coincided in Oxford; and later as Professor of

Surgery at Oxford University.

Over the last decade, numerous clinicians have discussed and generously con-

tributed their experience to the validation of the range and relative frequency of

complications associated with the wide spectrum of surgical procedures. These cli-

nicians include:

Los Angeles, USA: Professor Carmack Holmes, Cardiothoracic Surgeon, Los

Angeles (UCLA); Professor Donald Morton, Melanoma Surgeon, Los Angeles;

Dr R Essner, Melanoma Surgeon, Los Angeles.

xvii

xviii

Acknowledgments

New York, USA: Professor Murray Brennan; Dr David Jacques; Prof L Blumgart; Dr

Dan Coit; Dr Mary Sue Brady (Surgeons, Department of Surgery, Memorial

Sloan-Kettering Cancer Centre, New York);

Oxford, UK: Dr Linda Hands, Vascular Surgeon; Dr Jack Collin, Vascular Surgeon;

Professor Peter Friend, Transplant and Vascular Surgeon; Dr Nick Maynard,

Upper Gastrointestinal Surgeon; Dr Mike Greenall, Breast Surgeon; Dr Jane

Clark, Breast Surgeon; Professor Derek Gray, Vascular/Pancreatic Surgeon;

Dr Julian Britton, Hepato-Biliary Surgeon; Dr Greg Sadler, Endocrine Surgeon;

Dr Christopher Cunningham, Colorectal Surgeon; Professor Neil Mortensen,

Colorectal Surgeon; Dr Bruce George, Colorectal Surgeon; Dr Chris Glynn,

Anaesthetist (National Health Service (NHS), Oxford, UK).

Bristol, UK: Professor Derek Alderson.

Adelaide, Australia: Professor Guy Ludbrook, Anesthetist; Dr Elizabeth Tam,

Anesthetist.

A number of senior medical students at the University of Adelaide, including

Hwee Sim Tan, Adelaine S Lam, Ramon Pathi, Mohd Azizan Ghzali, William Cheng,

Sue Min Ooi, Teena Silakong, and Balaji Rajacopalin, who assisted during their stu-

dent projects in the preliminary feasibility studies and research, and their participa-

tion is much appreciated. Thanks also to numerous sixth year students, residents and

surgeons at Hospitals in Adelaide who participated in questionnaires and surveys.

The support of the University of Adelaide, especially the Department of Surgery,

and Royal Adelaide Hospital has been invaluable in allowing the sabbatical time to

engineer the collaborations necessary for this project to progress. I thank Professors

Glyn Jamieson and Guy Maddern for their support in this regard.

I especially thank the Royal Australasian College of Surgeons for part-support

through the Marjorie Hooper Fellowship.

I thank my clinical colleagues on the Breast, Endocrine and Surgical Oncology

Unit at the Royal Adelaide Hospital, especially Grantley Gill, James Kollias and

Melissa Bochner, for caring for my patients and assuming greater clinical load when

I have been away.

Professor Bill Runciman, Australian Patient Safety Foundation, for all of his

advice and support; Professors Cliff Hughes and Bruce Barraclough, from the Royal

Australasian College of Surgeons, the Clinical Excellence Commission, New South

Wales, and the Australian Commission (Council) on Safety and Quality in Healthcare.

Thanks too to Kai Holt, Anne-Marie Bennett and Carrie Cooper who assisted and

helped to organise my work. I also acknowledge my collaborator Martin Ashdown for

being so patient during distractions from our scientific research work. Also to Graeme

Cogdell, Imagart Design Ltd, Adelaide, for his expertise and helpful discussions.

I particularly thank Melissa Morton and her global team at Springer-Verlag for

their work in preparing the manuscript for publication.

Importantly, I truly appreciate and thank my wife Christine, my four children and

our parents/ wider family for their support in every way towards seeing this project

through to its completion, and in believing so much in me, and in my work.

Adelaide, SA, Australia

Brendon J. Coventry, BMBS, PhD,

FRACS, FACS, FRSM

Chapter 1

Introduction

Brendon J. Coventry

This volume deals with complications, risks, and consequences related to a range of

procedures under the broad headings of colorectal surgery, anal surgery, perineal

surgery, and penile and scrotal surgery.

Important Note

It should be emphasized that the risks and frequencies that are given here repre-

sent derived figures. These figures are best estimates of relative frequencies

across most institutions, not merely the highest-performing ones, and as such are

often representative of a number of studies, which include different patients with

differing comorbidities and different surgeons. In addition, the risks of complica-

tions in lower- or higher-risk patients may lie outside these estimated ranges, and

individual clinical judgment is required as to the expected risks communicated to

the patient and staff or for other purposes. The range of risks is also derived from

experience and the literature; while risks outside this range may exist, certain

risks may be reduced or absent due to variations of procedures or surgical

approaches. It is recognized that different patients, practitioners, institutions,

regions, and countries may vary in their requirements and recommendations.

Individual clinical judgment should always be exercised, of course, when apply-

ing the general information contained in these documents to individual patients in a

clinical setting.

The authors would like to thank Professor Neil Mortensen, Oxford, United Kingdom,

who as an experienced clinician discussed the chapters and acted as an advisor.

B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM

Discipline of Surgery, Royal Adelaide Hospital, University of Adelaide,

L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia

e-mail: brendon.coventry@adelaide.edu.au

B.J. Coventry (ed.), Lower Abdominal and Perineal Surgery,

Surgery: Complications, Risks and Consequences,

DOI 10.1007/978-1-4471-5469-3_1, © Springer-Verlag London 2014

Chapter 2

Colorectal Surgery

Bruce Waxman, Brendon J. Coventry, David Wattchow, and Clifford Ko

General Perspective and Overview

The relative risks and complications increase proportionately according to the site

of resection and anastomosis within the colon/rectum from cecum to the anus. This

is principally related to the surgical accessibility, ability to reduce tension, blood

supply, risk of tissue injury, hematoma formation, and technical ease of achieving

anastomosis. Photographs that illustrate various aspects of colorectal surgery are

shown in Figs. 2.1 and 2.2.

The main serious complication is anastomotic leakage, which can be minimized

by the adequate colonic mobilization, reduction of tension, and ensuring satisfac-

tory blood supply to the bowel. Avoidance of twisting or obstruction of bowel,

either at the anastomosis or ileostomy, is imperative. The anastomosis can be tested

in a variety of ways, including with air or povidone-iodine, so a small leak can be

detected intraoperatively and sutured. Infection is the main sequel of anastomotic

leakage or hematoma formation and may lead to abscess formation, peritonitis,

B. Waxman, BMedSc, MBBS, FRACS, FRCS(Eng), FACS (*)

Academic Surgical Unit, Monash University, Monash Health

and Southern Clinical School, Dandenong, VIC, Australia

e-mail: bruce.waxman@southernhealth.org.au

B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM

Discipline of Surgery, Royal Adelaide Hospital, University of Adelaide,

L5 Eleanor Harrald Building, North Terrace, 5000 Adelaide, SA, Australia

D. Wattchow, BM, BS, PhD, FRACS

Department of Surgery, Flinders Medical Centre, Bedford Park, SA, Australia

C. Ko, MD, MS, MSHS

Division of Research and Optimal Patient Care, American College of Surgeons,

Chicago, IL, USA

Department of Colorectal Surgery, University of California,

Los Angeles, USA

B.J. Coventry (ed.), Lower Abdominal and Perineal Surgery,

Surgery: Complications, Risks and Consequences,

DOI 10.1007/978-1-4471-5469-3_2, © Springer-Verlag London 2014

2 Colorectal Surgery

a longer-term reservoir function. Despite all these maneuvers, low rectal anastomoses

still have a higher overall leak rate and mortality than standard colonic anastomoses.

The risk of bowel, bladder, and sexual dysfunction increases with proximity of

colorectal resection to the pelvis and is almost exclusively associated with lower

rectal surgery. Technical refinements, like meso-rectal dissection with preservation

of the hypogastric nerves, depending on tumor involvement, can reduce disability

significantly. The introduction of robotic-assisted laparoscopic surgery, with better

visualization and improved tissue dissection, may further reduce the incidence of

nerve injury but with a considerable increase in economic cost. Rectal, bladder, and

sexual sensation may be altered, and rectal surgery may be associated with more

frequent bowel actions and reduced control, all of which may recover partially or

completely over the months postoperatively.

Positioning on the operating table has been associated with increased risk of

deep venous thrombosis and nerve palsies, especially in prolonged procedures.

With the modified Lloyd-Davies position, especially if placed in the steep

Trendelenburg position, limb ischemia, compartment syndrome, and common

peroneal nerve palsy are recognized potential complications, which should be

checked for, as the patient’s position may change during surgery.

Mortality associated with colorectal procedures ranged from 4.4 % to 6.5 %

overall (30-day perioperative mortality); however, in a study of 11,036 patients

(1987-1996), this varied from 3.7 % for elective to 11.2 % for emergency proce-

dures. Variation for the type of procedure also occurred from 6.9 % for right hemi-

colectomy and 8.6 % for left hemicolectomy to 3.8 % for anterior resection.

With these factors and facts in mind, the information given in these chapters

must be appropriately and discernibly interpreted and used.

The use of specialized colorectal surgery units with standardized preopera-

tive assessment, multidisciplinary input, and high-quality postoperative care is

essential to the success of complex colorectal surgery overall and can significantly

reduce risk of complications or aid early detection, prompt intervention, and cost.

Furthermore, there is evidence that high-volume surgery units have better outcomes

than low-volume units particularly for low rectal surgery.

Important Note

It should be emphasized that the risks and frequencies that are given here repre-

sent derived figures. These figures are best estimates of relative frequencies

across most institutions, not merely the highest-performing ones, and as such are

often representative of a number of studies, which include different patients with

differing comorbidities and different surgeons. In addition, the risks of complica-

tions in lower- or higher-risk patients may lie outside these estimated ranges, and

individual clinical judgment is required as to the expected risks communicated

to the patient and staff or for other purposes. The range of risks is also derived

from experience and the literature; while risks outside this range may exist, cer-

tain risks may be reduced or absent due to variations of procedures or surgical

approaches. It is recognized that different patients, practitioners, institutions,

regions, and countries may vary in their requirements and recommendations.

B. Waxman et al.

Rigid Sigmoidoscopy and/or Rectal Biopsy

Description

This can be performed without anesthesia as an office procedure or under general

anesthesia at initiation of a colorectal procedure to define the level of a rectal lesion,

during examination of the anorectal region under anesthesia, and at the time of rou-

tine surgery for benign anal conditions (e.g., hemorrhoidectomy, fissure-in-ano) to

check for any pathology in the lower rectum. The objective is to examine the rectum

into the lower sigmoid colon up to 25 cm to define any lesion(s) and perhaps biopsy

these. Preferably the patient would have been prepared with an enema to clear the

rectum.

The procedure is best performed by an experienced surgeon, with an assistant or

a nurse, with a long suction catheter and biopsy forceps available.

Rigid sigmoidoscopy may also be used to decompress a sigmoid volvulus. This

may be performed either on the patient’s bed or on the operating table, and it is

essential that adequate preparation is given in anticipation of large volumes of fecu-

lent fluid coming through the sigmoidoscope. The availability of suction and a rectal

tube is mandatory.

Anatomical Points

The anorectal anatomy is usually constant but can be altered by abscesses, sepsis,

fissure, fistula, rectal tumors, pelvic pathology, and sigmoid colon pathology,

including diverticular disease, strictures, volvulus, intussusception, and tumors.

The lower rectum is directed backwards, the mid-rectum upwards, and then the

upper rectum forwards.

Perspective

See Table 2.1. Rectal perforation is the most serious complication. This may be

either extraperitoneal or intraperitoneal and should be recognized by the operator

as a tear associated with bleeding. This most commonly occurs when an inexpe-

rienced operator is performing the procedure, when undue force is used, or when

the rectum or sigmoid is fixed by either a tumor or an inflammatory process.

Extraperitoneal perforation may not require any surgery, whereas intraperitoneal

perforation is more serious and may require colonic defunctioning for diversion of

the fecal stream. The risk of perforation from colonoscopy is approximately double

2 Colorectal Surgery

Table 2.1 Rigid sigmoidoscopy (and/or rectal biopsy) estimated frequency of complications,

risks, and consequences

Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Bleeding without biopsy (major)

0.1-1 %

Bleeding with biopsy (major)

5-20 %

1-5 %

Rare significant/serious problems

0.1-1 %

Infection

0.1-1 %

Less serious complications

Discomfort

>80 %

^aDependent on underlying pathology, anatomy, surgical technique, and preferences

that from sigmoidoscopy. Hemorrhage following biopsy may also occur and is more

likely to occur in biopsying normal rectal mucosa than biopsying tumors. Overall,

infection is rare, but perineal necrotizing fasciitis or Fournier’s gangrene is reported.

Discomfort from insufflation of gas or instrument insertion is common, and the

patient should be warned of this.

Major Complications

Major complications are very rare. The procedure is usually very straightforward.

Rectal tears and/or bowel perforation may rarely occur, potentially leading to

local sepsis, abscess formation, and sometimes systemic sepsis and very rarely

multi-system organ failure. Bleeding may be severe especially after biopsy, some-

times associated with anticoagulant therapy or bleeding diatheses. Particular care

should be taken in immunosuppressed patients, those with ulcerative colitis and

carcinoma, following radiation therapy and rectosigmoid tethering, or where vision

is obscured by blood or feces. The need for general anesthesia and further sur-

gery is possible if a severe injury occurs and requires diversion colostomy/ileos-

tomy and/or repair.

Consent and Risk Reduction

Main Points to Explain

• Discomfort

• Bleeding

• Perforation

B. Waxman et al.

Colonoscopy (Including Flexible Sigmoidoscopy

or Endoscopy of the Rectum and Left Colon)

Description

This procedure is ideally performed under general anesthesia or IV sedation in the

presence of a qualified anesthetist for adequate monitoring. This provides the patient

with adequate relaxation, analgesia, and the ability for the assistant to aid the endos-

copist in providing pressure or changing the posture of the patient from lateral to

lithotomy or even to prone position while maintaining the airway. Occasionally, no

anesthesia is required. Preoperative preparation of the bowel is mandatory to pro-

vide adequate views and to reduce the chances of complication.

Anatomical Points

The basic anatomy of the anus, rectum, and colon is relatively constant; however,

the length and tortuosity of various sections of the colon (notably the sigmoid and

transverse colon) may vary considerably. The cecum may also be very mobile. The

hepatic and splenic flexures and sigmoid loop may be tethered and make negotia-

tion with the colonoscope difficult.

Perspective

See Table 2.2. Colonoscopy in experienced hands is a relatively safe procedure.

However, because perforation is such a significant complication, the informed con-

sent process is vital so that the patient has full understanding of the risks.

The risks of perforation are significantly increased when therapeutic endoscopy

is performed using either the “hot biopsy” technique or the snare and diathermy

technique. Therapeutic biopsy-related perforations are more likely in the right

colon, and perforation associated with diagnostic colonoscopy is more likely in the

left colon, particularly in the sigmoid. The overall risk of perforation is about

1:1,000.

Early recognition and aggressive management of perforations following flexible

endoscopy is vital to reduce long-term septic complications. Extraperitoneal per-

forations are usually less serious but may require antibiotics in addition to careful

observation, whereas intraperitoneal perforation may require surgical intervention,

including laparotomy and colostomy or ileostomy to divert the fecal stream in some

cases, with or without resection or oversewing of the perforation site. The risk of

perforation from colonoscopy is approximately double that from sigmoidoscopy.

2 Colorectal Surgery

Table 2.2 Colonoscopy estimated frequency of complications, risks, and consequences

Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Failure to visualize parts of colon^a,b

1-5 %

Bleeding/hematoma formation (major)

0.1-1 %

Perforation^a,b

0.1-1 %

Laparotomy

0.1-1 %

Infection

0.1-1 %

Rare significant/serious problems

Aspiration pneumonitis^a

0.1-1 %

Hypoxia^a

0.1-1 %

<0.1 %

Less serious complications

Gas bloating (transient)

50-80 %

Paralytic ileus

5-20 %

Injury to hemorrhoids^a

1-5 %

From purgative bowel preparation

From colonoscope

Glutaraldehyde^a

Subcutaneous emphysema/pneumothorax/pneumomediastinum

0.1-1 %

Traumatic anal fissure^a

0.1-1 %

Pain and discomfort^a

5-20 %

^aRisks and complications that should be avoidable with particular safety measures

^bDependent on underlying pathology, anatomy, surgical technique, and preferences

Bleeding is rarely severe, but a small amount of bleeding after biopsy is not

uncommon.

Major Complications

Colonoscopy is usually a straightforward procedure. Major complications are rare

but include full-thickness perforation of the rectum or colon, which can require

further surgery (laparotomy or per-anal procedure). Local infection, abscess for-

mation, fistula, systemic sepsis, and multi-system organ failure may follow per-

foration. Particular care should be taken in immunosuppressed patients, those with

ulcerative colitis and carcinoma, following radiation therapy and rectosigmoid teth-

ering, or where vision is obscured by blood or feces. Hypoxia from sedation is rare,

and brain damage exceedingly rare with the use of oxygen monitors and an anesthe-

tist supervising. Severe bleeding is uncommon, but can rarely require blood trans-

fusion or further surgery. Failure to diagnose is possible, and inability to complete

the full colonoscopy is not uncommon, related to the anatomy, previous surgery,

bowel preparation, and experience of the colonoscopist. A repeat colonoscopy or

B. Waxman et al.

another method may be required. Although rare, aspiration pneumonitis can be a

serious and lethal complication but is reduced by an adequate fasting period and

good airway management.

Consent and Risk Reduction

Main Points to Explain

• Discomfort and gas bloating

• Bleeding

• Problems with sedation

• Failure to visualize parts of the colon

• Perforation

• Infection

• Further surgery: laparotomy

Open Appendectomy

Description

General anesthesia is used. The patient is positioned in the supine position and is

best examined when anesthetized to assess whether there is a mass to determine the

best site for the incision. Rectal examination under anesthesia may be useful to

assess the presence of any pelvic mass particularly in the female.

The objective of the operation is to perform removal of the appendix and also to

examine the pelvis for pelvic pathology, particularly in the female, and the terminal

ileum for the presence of a Meckel’s diverticulum or other pathology causing local

peritonitis, particularly if the appendix appears normal. Occasionally, the inflamma-

tory process, phlegmon or abscess, is so extensive that the appendix cannot be

removed, and it may be judicious to simply drain the abscess.

Under most circumstances the appendix can be removed using a transverse

(Lanz) skin incision and a muscle splitting incision of the internal oblique and

transversus muscles. When other pathology is encountered, either Crohn’s dis-

ease affecting the terminal ileum and cecum, diverticular disease affecting the

sigmoid colon or cecum, or an abscess involving the right fallopian tube, ovary,

and uterus, the incision may be extended or an alternative midline incision

performed.

The surgical approach in open appendectomy is a paradox in that it disobeys the

primary principle of abdominal surgery that being adequate access and exposure.

A small incision is often made to obtain a good cosmetic result, making access more

difficult. Surgeons should never hesitate to increase the length of the skin incision

and divide the abdominal muscles to provide better access to the peritoneal cavity.

2 Colorectal Surgery

Under these circumstances, the cecum should be mobilized by dividing the congeni-

tal adhesions to bring the cecum well into the wound to show the display and full

length of the appendix, particularly its junction with the cecum.

Anatomical Points

The appendix origin lies at the confluence of the taenia coli; however, its tip can

vary enormously in position, lying retrocecally (~75 % cases), pelvic (20 %), or

retro-ileal/pre-ileal (5 %). The length of the appendix varies also and can reach the

upper ascending colon posteriorly. The appendix and cecum may enter a large

inguinal hernia sac. An inflamed appendix, if retrocecal or pelvic in location, may

irritate the ureter. Hematuria or dysuria may occur. Irritation of the bladder or colon

can cause urinary urgency and/or diarrhea. Irritation of the psoas muscle by an

inflamed retrocecal appendix or abscess may cause hip discomfort on movement.

Maldescent of the appendix is rare, due to malrotation of the cecum, which remains

high in the hepatic region. Agenesis, duplication, and situs inversus (L-side appen-

dix) are exceedingly rare but can occur.

Perspective

See Table 2.3. Infective complications are the most common following appendec-

tomy, wound infection being the most significant. This may be minimized by ade-

quate exposure, preoperative prophylactic antibiotics, and copious lavage of the

abdominal cavity and the wound with large volumes of warm saline.

In grossly contaminated (dirty) wounds, drainage of the pelvis and wound,

delayed primary skin closure, or the use of gauze pledgets impregnated with anti-

septic may be used in an effort to reduce risk of infection. The other option is to

leave the skin wound open and use vacuum-assisted dressings.

Abscess formation can occur in the pelvis, right paracolic gutter, between loops

of small bowel, or occasionally subphrenic space, but are uncommon. Damage to

anatomical structures in the region may occur, particularly the ilioinguinal or iliohy-

pogastric nerves as they traverse close to the incision or the inferior epigastric ves-

sels. Right inguinal hernia and right femoral hernia are more common after

appendectomy.

Different techniques of dealing with the appendix stump can avoid complica-

tions associated with the stump including intraperitoneal abscess,

“recurrent”

appendicitis, and fecal fistula from breakdown of the wound closure of the cecum.

Moreover, long-term complications of small bowel obstructions with adhesions

either to the appendix base or to the aperture of the appendix mesentery can occur.

Inversion of the stump has been associated with increased risk of small bowel

obstruction. Firm suture transfixion/ligation of the appendix base against the cecum

B. Waxman et al.

Table 2.3 Open appendectomy estimated frequency of complications, risks, and consequences

Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infection^a

5-20 %

Subcutaneous

5-20 %

Intraabdominal/pelvic (peritonitis, abscess)

0.1-1 %

Systemic sepsis

0.1-1 %

Hepatic portal sepsis (rare)

<0.1 %

Bleeding/hematoma formation^a

Wound

1-5 %

Intraabdominal

0.1-1 %

Extension of wound for access/safety (for improving exposure)^a

1-5 %

Midline laparotomy (possibility if other pathology found)^a

0.1-1 %

Rare significant/serious problems

Multi-system failure (renal, pulmonary, cardiac failure)

0.1-1 %

Small bowel obstruction (early or late)^a

0.1-1 %

[Anastomotic stenosis/adhesion formation]

Deep venous thrombosis

0.1-1 %

Inguinal hernia (right side)

0.1-1 %

Fecal fistula^a

<0.1 %

Ureteric injury (v. rare)^a

<0.1 %

Vascular injury (v. rare)^a

<0.1 %

Less serious complications

Paralytic ileus

50-80 %

Nerve paresthesia

0.1- %1

Iliohypogastric/ilioinguinal nerve

Seroma formation

0.1-1 %

Incisional hernia (delayed heavy lifting/straining for 8 weeks)

0.1-1 %

Pain/tenderness [wound pain]

Acute (<4 weeks)

>80 %

Chronic (>12 weeks)

1-5 %

Nasogastric tube^a

1-5 %

Wound scarring (poor cosmesis/wound deformity)^a

1-5 %

Wound drain tube(s)^a

1-5 %

^aDependent on underlying pathology, anatomy, surgical technique, and preferences

usually avoids appendix stump complications. Complete appendectomy with tran-

section of the appendix flush with the cecum and closure in two layers with a

monofilament absorbable suture will eliminate an appendix stump.

Major Complications

Serious complications are abscess formation, fistula or sinus formation, and sys-

temic sepsis, which may rarely lead to multi-system organ failure and even mor-

tality. Early surgery and preoperative antibiotics have reduced these complications

2 Colorectal Surgery

significantly. Preexisting comorbidities including age, established generalized peri-

tonitis, and immunosuppression can increase risk of infection greatly. Wound

infection may be reduced by delaying skin closure for several days. Further surgery

may be warranted. Severe bleeding is rare, and transfusion uncommon. Concealed

postoperative bleeding is rare. Persistent wound sinuses or a fecal fistula requires

prolonged hospitalization and dressings but most close within 2 months. Prolonged

ileus and later (even decades later) small bowel obstruction can occur, but are

surprisingly uncommon even with extensive adhesions. The possibility of a lapa-

rotomy and even a colostomy should be mentioned, should other pathology be

found, although uncommon. Nerve injury, either at surgery or later scar adhesions,

can cause severe discomfort and rarely chronic pain problems. Incisional hernia

formation is more common after wound infection and/or dehiscence. Ureteric

injury or iliac arterial injury is exceedingly rare, although reported, but can be

catastrophic.

Consent and Risk Reduction

Main Points to Explain

• GA risk

• Wound infection

• Abscess formation

• Bleeding

• Further surgery: laparotomy

Laparoscopic Appendectomy

Description

General anesthetic is used. The patient is positioned in the supine position and is

best examined when anesthetized to assess whether there is a mass to determine the

best site for the incision. Rectal examination under anesthesia may be useful to

assess the presence of any pelvic mass. Some surgeons prefer the modified Lloyd-

Davies position.

The objective of the operation is to perform removal of the appendix, using the

principles of minimal invasive surgery, and should include laparoscopic examination

of the peritoneal cavity to examine the pelvis for pelvic pathology, particularly in the

female, and the terminal ileum for the presence of a Meckel’s diverticulum or other

pathology causing local peritonitis, particularly if the appendix appears normal.

Occasionally, the inflammatory process, phlegmon or abscess, is so extensive that

the appendix cannot be removed and it may be judicious to simply drain the abscess.

B. Waxman et al.

When other pathology is encountered, either Crohn’s disease affecting the termi-

nal ileum and cecum, diverticular disease affecting the sigmoid colon or cecum, or

an abscess involving the right fallopian tube, ovary, and uterus, an alternative

approach and open surgery may be preferred.

Surgeons should never hesitate to convert to an open incision if the safety of the

operation is jeopardized through increased risk of injury, progress is poor, or vision

is inadequate.