Intestine

In 1844, the first anesthesia with nitrous oxide was performed by Horace Wells, and in 1901, Karl Landsteiner discovered the blood groups of humans. This opened up the possibility for the first time to perform blood transfusions during major surgical operations and to successfully treat hemorrhage shock. The greatest achievement, however, was Ignatz Philipp Semmelweiss’ realization that the wound infections, which were usually fatal at the time, especially puerperal fever, were caused by poor hygiene of hands and instruments. Until then, thorough hand disinfection was completely unknown in hospitals. Doctors and nurses, without knowing it, carried the bacteria from one patient to another. Unfortunately, Semmelweiss was too far ahead of his time, so his appeals for hand disinfection with carbolic acid were not taken seriously at first, despite the proven effectiveness of Louis Pasteur, the famous discoverer of the bacteria.

It was the surgeon Joseph Lister from Glasgow who took up Semmelweiss’ ideas and successfully implemented them in his clinic in 1867: Before operations, the surgeons’ hands were washed with carbolic soap, and a carbolic solution was atomized over the surgical area during the operation. This significantly reduced the number of fatal complications after surgery. In the course of this knowledge, operating rooms were then created that could only be entered with a hood and mouth guard, so that the first major abdominal surgical procedures, which were then also performed aseptically, were more successful from 1880.

Exemplary for the spirit of optimism in abdominal surgery under these new conditions is the work of the surgeon Professor Ulrich Kroenlein, who worked and taught at the University Hospital Zurich since 1881. He translated the new hygiene ideas into measures in the hospital by having floors tiled, wooden bedsteads removed, and a new operating room built in the form of an amphitheater (student classroom). Kroenlein was one of the first surgeons to operate on acute appendicitis and was involved in the treatment of purulent peritonitis, a complication that occurs particularly after intestinal injuries.

In order to avoid such peritonitis caused by poor intestinal sutures (anastomoses), two other famous surgeons at that time were struggling to find new suturing techniques in intestinal surgery, Theodor Kocher and Vinzenz Czerny. “Intestinal resection has become an extraordinarily important and relatively frequent surgical procedure, by the correct performance of which the surgeon can preserve many a life otherwise irrecoverably lost,” wrote Theodor Kocher in 1894, introducing his continuous intestinal suture (Boschung U.: Milestones in the history of intestinal anastomosis. Swiss Surg 2003; 9: 99-104). Thus, as early as 1907, Sir Ernest Miles performed the first radical abdominoperineal resection for rectal carcinoma, a major operation in which the colon and rectum were completely removed.

For the removal of the diverticulum-bearing portion of the sigmoid loop, results became good especially when irrigation of the bowel before surgery, consistent antibiotic administration, and new suture techniques using today’s modern suture materials were introduced. A major step towards low complication rates, short hospital stays and good postoperative results has been achieved by the recently introduced minimally invasive laparoscopic sigmoid resection. Together with the concept of “fast track” surgery (gentle, low impact surgery for patients), sigmoid resection for diverticular disease has now become a safe surgery with low complication rates.

The descending colon moves toward the left lower abdomen (descending colon).
Thereafter, the colon describes an S-curve and is called the sigmoid colon, or sigma for short. The large intestine ends here, followed by the last part, the rectum.

The rectum is 16 centimeters long and merges into the anus. In the middle of this “large intestine frame”, below the small intestine, several large blood vessels are found, originating centrally from the aorta and then running in a protective layer of tissue, which radiate to the colon and rectum. The surgeon’s precise knowledge of which vessel supplies which segment of bowel is essential for good colon surgery and must be well considered in complex operations in this area.

But how does the intestine transport the food pulp further and how does it thicken it at the end? Even in fasting people, periodic waves run from the esophagus to the rectum over the smooth muscles of the intestine and keep it constantly moving so that the chyme is transported further. In this process, the loops of the small intestine move faster compared to the large intestine, so that the passage times of the food pulp in the small intestine are relatively short. At the same time, this mechanism counteracts the rapid “carriage” of excessive numbers of bacteria that naturally occur in the intestine.

In the large intestine, the food pulp lingers longer so that it can be thickened at rest by dehydration. This is achieved by the intestinal motor in such a way that there is not only a forward movement of the loops, but also a backward movement. At the same time, which is completely normal and desirable, the number of bacteria in the intestine increases dramatically.

The healthy intestine has a wide variety of barrier mechanisms against these bacteria and produces certain proteins that have an almost disinfecting effect and are found on the mucous membrane. Diseases such as intestinal obstruction can severely disrupt this finely tuned system and thus lead to serious consequences.

Since the intestine is a soft tube, its opening can also be squeezed shut from the outside. This often occurs due to connective tissue strands (brides) that cross the abdominal cavity and in which the mobile small intestine can quickly become entangled. This is referred to as a brittle ileus, which often affects patients who have had previous surgeries, since surgeries can fundamentally lead to the formation of strands.
The second form of mechanical ileus is strangulated ileus, which usually involves the mobile small intestine. In this process, the loops of small intestine rotate around their own axis, so to speak, and thus cause an interruption in the blood supply to the intestine. The result is a lack of oxygen supply to the intestinal tissue as well as a passage blockage for the food pulp. Furthermore, the small intestine can also become stuck in the hernial sac of a wide variety of hernias, which can also result in an ileus.

The colon, on the other hand, which is attached to the peritoneum in many places, is most commonly affected by a passage disorder caused by a tumor that either grows in the colon or presses on it from the outside. In addition to the mechanical causes now mentioned, paralysis of the intestinal muscles can also be the cause of ileus (paralytic ileus). This means that the periodic self-movement of the intestine comes to a standstill, the food pulp is not transported further and the passage is impeded. This may be the case in severe metabolic disorders or generalized bacterial infections, abdominal trauma as well as after major abdominal surgery.

But why is ileus so dangerous? The congestion of the food pulp alone, regardless of the location in the intestine and the cause, leads to severe overstretching of the intestinal wall. This triggers a sequence of reactions in the body, which will be described below and which ultimately lead to the dangerous “ileus disease”.

The overstretching of the intestinal wall due to “congestion” leads to a circulatory disturbance of the same, which locally triggers a lack of oxygen in the tissue. This causes the intestines to stop moving, resulting in a drastic increase in the number of bacteria, which then secrete certain toxins. After these events, the intestinal wall, if you think of it as a “barrier,” is weakened in several ways. There is an influx of fluid into the intestine and intestinal wall, whereby the “water” is previously, in the sense of a pathological redistribution, withdrawn from the vascular system and causes circulatory weakness in the patient. In addition, the toxins of the bacteria can now penetrate the weakened barrier of the intestinal wall, enter the circulation and trigger a shock event there via complicated mechanisms, which can affect other organs, such as the kidneys or lungs.

A frequently asked question is why you get crampy colic. As soon as the intestine is closed for any reason, it tries with all its might to fight against this obstacle. This struggling against an obstacle causes the colicky pain. In paralytic ileus, on the other hand, the intestine quickly becomes paralyzed: “It becomes deadly quiet in the abdomen,” which means that the physician can no longer hear any intestinal sounds through his stethoscope.

Abdominal palpation
Examination with the hands often reveals a bloated, tender abdomen that is very sensitive to pain. Furthermore, palpation of the abdomen looks for abnormal masses. By gently tapping the abdomen with the fingers, air accumulation can be detected. A very informative examination step is listening to the abdomen with a stethoscope to assess bowel sounds. With increasing bowel obstruction, so-called “high-pitched” bowel sounds may be heard at first, and later also “ringing” bowel sounds. After prolonged duration of mechanical ileus and transition to paralytic ileus, bowel sounds are no longer audible. The type and quality of bowel sounds are a very important sign of bowel obstruction for the surgeon.

Rectal examination
Examination of the rectum is a must for all acute abdominal complaints. However, pain and blood on the fingerstall are fairly unspecific and can also be found in other intestinal and abdominal diseases.

Abdomen blank image
X-ray of the abdomen in the standing and supine position provides an enormous amount of information regarding intestinal obstruction. On the images, you look for fluid levels and what’s called free air in the abdomen. If such levels are present, this is an almost certain sign of the presence of bowel obstruction. Based on the localization of the fluid levels, it is possible to estimate approximately where the bowel is occluded. So-called “standing bowel loops” are also a typical sign of the presence of an intestinal obstruction. Due to the obstruction of the intestine, gases accumulate in front of the obstruction, the intestinal loops inflate and give the impression on the X-ray that they are standing in the abdomen.

Ultrasound examination
An ultrasound of the abdomen provides a quick opportunity to make important statements regarding the following questions concerning the affected bowel loops: Are they filled with fluid? Is the intestinal wall thickened? Is there still any intrinsic movement of the intestinal loops?

Contrast agent administration
If small bowel ileus is suspected without strangulation, oral administration of water-soluble contrast may be attempted. On the one hand, this agent has a laxative effect, on the other hand, an X-ray can be taken after certain periods of time to see if the fluid has run up to the colon in an adequate amount of time. This allows you to better determine the location of the closure.

Blood tests
A blood test can make a certain contribution to clarify the cause of the intestinal obstruction. In contrast, only certain causes can be seen in the laboratory results, but not the bowel obstruction itself.

Computed tomography
If the cause of the bowel obstruction cannot be found with the above-mentioned examinations or if a mass is palpated on abdominal palpation, a CT scan can also be performed in certain cases as a supplementary diagnostic test.
A surgeon can only answer the most important questions by looking at the patient’s medical history and various examination results together: Is it a small bowel obstruction or a large bowel obstruction? Is the occlusion mechanical or paralytic? Is it complete or partial? Is the patient suffering from another, previously unknown disease (tumor, inflammation, hernia)? Does he have to operate on the patient immediately or can he wait under close supervision?
At least one severe inflammation has already taken place, which had to be treated with antibiotics and may have required hospitalization.
Recurrent inflammation of the sigmoid colon and/or stenosis of the colon have been demonstrated.

Emergency surgery
In an inflammatory episode, an abscess, a collection of pus in the abdomen, has developed around the inflamed bowel. Emergency surgery is indicated when breakthrough of intestinal contents into the abdomen is demonstrated or at least suspected.

Ileus disease
Sometimes patients with advanced “ileus disease” need to be treated in the intensive care unit. So how do you proceed? In paralytic ileus (i.e., non-mechanical), the above measures are taken and the underlying condition is treated at the same time. The procedure in this case tends to be nonoperative unless there is massive overdistension of the bowel. In this case, special surgery must be performed to relieve the bowel.

What about mechanical ileus? Mechanical ileus is often due to adhesions in the abdominal cavity and predominantly affects the small intestine because it is relatively mobile in the abdominal cavity. In the colon, mechanical obstruction is most often caused by a tumor. In both situations, surgical measures are necessary to remove the obstacle to passage and restore the continuity of the bowel. In this context, open surgery is the method of choice for the treatment of intestinal obstructions.

Depending on the patient’s condition, laparoscopic surgery may be attempted. Nevertheless, it is often necessary to switch to the open technique because the problem is either not seen properly or the cause is difficult to correct laparoscopically. Depending on where the obstruction is suspected to be (upper, middle or lower abdomen), the surgery involves making a vertical incision in the middle of the abdomen as an approach. Then, in a second step, all layers of the abdominal wall are carefully cut. Several hooks are used to stretch the edges of the incision so that the view of the abdominal organs is unobstructed. Now the entire abdominal cavity can be searched for the cause of the bowel obstruction.

The first thing the surgeon usually notices is the highly distended bowel loops in front of the passage obstruction (bride or tumor). Behind the occlusion, the so-called “hunger gut” is often found. At this point, the intestine is completely empty and quite thin, as no food has been transported through here for a long time. Once the site of the occlusion has been found, the cause is usually clear. In the vast majority of cases, these are simple adhesions that lead to kinking or strangulation of the bowel. The adhesions are cut sharply with scissors, and the bleeding is stopped with single stitches. As soon as the bowel has been freed from adhesions, its vitality must be checked, i.e. it must be checked whether the section of bowel that was kinked is still “alive”.

If the intestine moves on contact, its function is still preserved. Another vitality criterion is the color and blood circulation. If the color and mobility of the intestine are in order after the adhesions have been dissolved, the abdomen with all its layers can be closed again. Sections of the intestine that have been clamped off and are poorly perfused turn blue.

If the bowel does not become nicely pink after the cause of the obstruction has been removed, it must be assumed that the section of bowel in question has already died and therefore be removed. In this procedure, the bowel above and below the dead bowel portion is cut and closed with a special stapling device. Two blind ends are created, which are joined together again by two continuous seams. This is followed by checking for blood dryness, insertion of two drains, and layer-by-layer closure of the abdominal wall.

It is important to check bowel activity once or twice a day postoperatively. This is done mainly by listening to the abdomen. After any abdominal procedure, the bowel may “strike” for the first few days. He is offended, so to speak, and refuses his transportation service. This is a normal reaction, but it will return in the first few days after surgery.

If the bowel resumes its activity, the patient can try to consume small amounts of tea or water. If the gastric tube does not deliver any gastric juice or delivers significantly less, the patient can be released from the previously inserted tube. Fluid amounts can now be increased daily. The diet begins first with soups, is then supplemented with stock and sauce, and finally the patient is allowed to eat finely chopped food and finally normal food. The skin sutures can be pulled on the tenth postoperative day. Patients can be discharged home within about eight days if they do well.

Other, rare carcinomas found are called mucinous (mucinous) adenocarcinomas or signet ring cell carcinomas. The external shape that the tumor takes in the intestine can also be very different: it can be pedunculated, crater-shaped and diffusely growing, or it can be ring-shaped constricting the intestinal clearing. Depending on the manifestation, the early symptoms that may be associated with this tumor are also very different.

The causes of the development of these carcinomas are not precisely known. Genetic, but also nutritional factors such as a high fat content in the diet are discussed. However, some risk factors are also fairly well established. These include certain pre-existing conditions of the intestine, such as ulcerative colitis, Crohn’s disease, or familial poliposis coli. The latter is even considered a precancerous condition (precursor to a tumour), since the many proliferations of the intestinal mucosa (polyps) become malignant after a certain period of time. A known family history of colon cancer in the immediate family also increases the likelihood of developing such a tumor.

Then the doctor will examine the abdomen and feel if there is significant distension, if there is palpable tumor, or if there are hernial orifices. A laboratory examination is certainly performed to get an overview of all organ functions and to rule out anemia, for example. Since the majority of carcinomas are found in the rectum, the slightest suspicion of a tumor in this area includes a digital examination of the rectum by the physician.

If the suspicion of colon or rectal cancer has been confirmed by this time, an additional rectoscopy and/or colonoscopy must be performed and tissue samples taken from all suspicious areas of the mucosa. Furthermore, an ultrasound of the abdomen will be done to evaluate the liver (metastases), gallbladder, bile ducts, pancreas and kidneys. Depending on the location and size of the tumor as well as other concomitant diseases of the patient, additional special examinations may be necessary, such as a CT scan, an endosonography of the rectum (the exact location of the tumor is very important for surgical planning), a heart ultrasound or a lung function diagnosis.

In the next step, the vessels running from the “center of the frame” outward to the colon are carefully dissected free in their tissue strand. At the required distance from the tumor, the bowel is clamped on both sides. The vessels that have already been dissected free are cut off, and the intestine is cut and removed at the two sites. The remaining stumps are disinfected, and the colon and small intestine are carefully sutured back together. A silicone drain is placed near the anastomosis and drained separately. After checking for blood dryness, the abdominal wall is closed again in layers. If a tumor is located in the transverse or descending part of the colon, the surgical sequence is the same as for hemicolectomy, with special consideration of the vascular supply and other details, except that a different area of the colon is affected.

The procedure becomes more complicated if the tumor is located in the rectum, since here the intestine already runs in the small pelvis and is therefore more difficult to access surgically. Curative therapy of rectal carcinoma is performed, for example, by anterior rectal resection. Access to the abdominal cavity is the same as for hemicolectomy. The surgeon then turns to the left lower abdomen and locates the tumor-bearing section of bowel. From the preliminary examinations, the surgeon usually knows at what level the tumor can be found. This knowledge is very important, especially in rectal tumors, because the distance from the tumor to the anus plays a major role in surgical planning, and especially when performing anastomosis in this area. In order to be able to resect bowel in the rectal region, the descending colon as the advancing part of the bowel must first be detached from the substrate and mobilized.

In the case of malignant tumors, the associated lymph nodes on the large vessels are visited and removed. The vessels originating from the center of the abdomen in the suspensory ligaments of the intestinal segments (mesenteries) are visualized and set off very centrally, at the lower edge of the pancreas. This radically removes the entire drainage area of the lymph, including the lymphatic channels and the lymph nodes. This step is important in the case of tumor disease. The number of lymph nodes found and affected by the tumor is crucial for the future (prognosis) and for adequate treatment with chemotherapy. Subsequently, the rectum, which is located in the lesser pelvis, is mobilized, and the surgeon must be careful not to injure either ureter. The rectum lies within a suspensory band of surrounding fatty tissue (mesorectum), in which the vessels and lymphatic channels run.

The mesorectum is thoroughly removed to eliminate any metastases that may be present. This modern surgical method (TME, Total Mesorectal Excision) was introduced in 1985 by Professor Bill Heald. The tumor-bearing bowel section with the associated suspensory ligaments (mesenteries) and all possibly tumor-involved lymph vessels and lymph nodes are removed. The nervicavernosi, which are important for male potency and which run close to the place where the rectal part has to be removed, can practically always be preserved thanks to this technique. The next step is to restore the continuity of the intestine. The most modern stackers and stapling machines are used for this purpose. They allow anastomoses of the intestine even only a few centimeters from the anus, i.e. in places where sutures were not possible a few years ago and patients therefore had to live with an artificial anus praeter.

Today, less than one in five affected patients still needs an anus praeter. Finally, the patient is checked for blood dryness, a silicone drain is inserted, and the abdominal wall is closed in layers. Finally, two surgical measures should be mentioned, which find their application in very special situations. One is ileotransversostomy, which is performed for large, bowel-constricting tumors in the right colon. This involves “bypassing” the tumor, so to speak. The small intestine is sutured side to side with the part of the transverse colon located downstream of the tumor to allow unobstructed passage through the intestine.

Even though medical care is good in this country, a stoma remains a limitation that is not always easy to live with. No one knows and feels as well as those affected themselves what they need for their well-being and how everyday problems can be solved. Therefore, patients who have just undergone surgery benefit particularly from the experience of long-term stoma patients. The self-help organization ilco Switzerland was born out of this consideration.

In patients with more extensive tumors in the rectum, additional chemotherapy or radiotherapy must be discussed in consultation with the oncologists and radiation oncologists. This is because treatment with chemotherapeutic agents is often important prior to surgery to allow resection in the first place or to improve outcomes with combination therapy. In advanced tumors, this procedure is quite important today. Nevertheless, the most important therapy remains total mesorectal excision (TME) of the rectum by an experienced surgeon.

If the patient has a stoma, a special stoma advisor will familiarize him or her with the procedures and materials involved in stoma care. Depending on the size and type of tumor removed, each patient is followed up individually. Tumor markers are checked at certain intervals, and an ultrasound or CT scan of the abdomen and possibly a colonoscopy are performed to make sure that no metastases have occurred or that no new tumor has developed.

For the surgical aspect of the disease, it is important to note, among other things, that the likelihood of developing colon cancer increases with increasing duration of disease (>10 years) and involvement of the entire colon, and in this context requires special surgical measures. After these brief explanations of this disease, the surgical measure in particular will be discussed here.

Exemplary for the spirit of optimism in abdominal surgery under these new conditions is the work of the surgeon Professor Ulrich Kroenlein, who worked and taught at the University Hospital Zurich since 1881. He translated the new hygiene ideas into measures in the hospital by having floors tiled, wooden bedsteads removed, and a new operating room built in the form of an amphitheater (student classroom). Kroenlein was one of the first surgeons to operate on acute appendicitis and was involved in the treatment of purulent peritonitis, a complication that occurs particularly after intestinal injuries.

In order to avoid such peritonitis caused by bad intestinal sutures (anastomosis), two other famous surgeons at that time were struggling to find new suturing techniques in intestinal surgery, Theodor Kocher and Vincenz Czerny. “Intestinal resection has become an extraordinarily important and relatively frequent surgical procedure, by the correct performance of which the surgeon can preserve many a life otherwise irrecoverably lost.” Writes Theodor Kocher in 1894, introducing his continuous intestinal suture (Boschung U.: Milestones in the history of intestinal anastomosis. Swiss Surg 2003; 9: 99-104). For example, as early as 1907, Sir Ernest Miles performed the first radical abdominoperineal resection for rectal carcinoma, a major procedure in which the colon and rectum were completely removed.

For the removal of the diverticulum-bearing portion of the sigmoid loop, the results were particularly good when preoperative lavage of the bowel, consistent antibiotic administration, and new suturing techniques were introduced with today’s modern suture materials. A major step towards low complication rates, short hospital stays and good postoperative results has been achieved by the recently introduced minimally invasive laparoscopic sigmoid resection. Together with the concept of “fast track” surgery (gentle, low impact surgery for patients), sigmoid resection for diverticular disease has now become a safe surgery with low complication rates.

Colonoscopy with tissue sampling and bacteriology may help confirm the diagnosis, and an x-ray of the bowel with water-soluble contrast may show altered bowel wall structure. Because, no sign, no symptom on its own is conclusive for ulcerative colitis, only the synopsis of all examination results can yield the correct diagnosis, since there are also other inflammatory bowel diseases that cause similar complaints.

The acute onset of the disease, as well as recurrent relapses, may be associated with certain complications, although rarely. Acute distension of the colon (toxic megacolon), significant bleeding in the area of ulceration, abscess formation, and/or rupture of the bowel wall may occur, and surgeon intervention may be urgently required.

The surgical treatment procedure is continence-preserving proctocolectomy with J-pouch placement. Patients with long-standing ulcerative colitis are regularly colonoscoped, as this condition is associated with an increased likelihood of developing carcinoma. If carcinoma is diagnosed, the entire colon must be removed because there is a risk that a tumor could also develop in another location over time. If the colon (including the rectum) is removed as a whole, as is done in a proctocolectomy, the patient lacks the part of the intestine that thickens the liquid food pulp, but also the rectal ampulla as a stool reservoir. The rectal ampulla and the anus, with its special musculature, are intricately coordinated and together form the anatomical unit that allows humans to have fecal continence. For many years, patients who had undergone proctocolectomy therefore had to be provided with an artificial small bowel outlet (ileostoma).

The ileostomy is used to drain stool and gas from a section of the small intestine through the abdominal wall into a pouch. In the meantime, however, there is a surgical procedure which aims to form a “stool reservoir” from a loop of small intestine (J-pouch), so that the patient can still defecate via the anus. This procedure assumes that the affected patient has no anal disease and the sphincter muscle is functioning well. Nevertheless, this operation is a major surgical procedure, and pouching has advantages and disadvantages that need to be explained very carefully in advance. This will be discussed again in the last chapter.

An open proctocolectomy requires a large incision from the breastbone to the pubic hairline. Then the abdominal wall is cut in layers until the abdominal cavity is opened. The surgeon first palpates all organs, such as the liver, spleen and stomach, by hand to see if there are enlarged lymph nodes and metastases. Then he looks for the ascending colon on the right side and the “caecum” and detaches both from the abdominal wall. The entire colon frame is subsequently mobilized. The transverse colon is carefully pushed off the peritoneum, the suspensory ligaments are cut from the transverse portion to the stomach, and the descending colon in the left lower abdomen is also detached from the peritoneum. In the area of the cecum, the small intestine is cut with a stapler. The blood vessels leading to the sections of the colon that will later be omitted are visualized and interrupted, and the colon is further mobilized to the sigmoid loop.

During this phase of the operation, the surgeon also repeatedly checks that the ureters on both sides remain uninjured. The rectum is carefully detached from the pelvic tissues as it progresses, almost to the anus. The surgeon now checks whether the length of the small intestine loop reaches the lowest section of the rectum so that the new reservoir can later be connected without tension. The surgery is now continued from the anus. Approximately one to two centimeters from the anus, the mucosa of the rectum is peeled off, but the muscular sheath of the rectum remains. The colon and rectum, which have already been mobilized, are placed at the point where the mucosa was exfoliated.

The reservoir (pouch) is then formed from the lower loops of small bowel by folding the end of the small bowel over in a J-shape and suturing the walls that touch each other in the process. Personally, I construct each pouch with single button seams so that the seam stretches well. I consider staple sewing equipment to be unsuitable here. Then the small bowel reservoir is gently pulled down towards the anus and sutured in the sphincter muscle area in the muscular layer and mucosal layer of the rectum. In the area of the tip of the J-shaped pouch, an opening of one and a half centimeters is cut and sutured to the layers of the anus rectum.

To initially relieve the anastomosis in front of the anus, the surgeon creates a temporary ileostomy in the area of the right lower abdomen. For this purpose, a small, round skin incision is made, the abdominal wall is carefully opened at this point, a piece of small intestine is pulled through this opening in front of the abdominal wall, the intestine is opened and finally sutured into the skin. The intestinal contents can then empty into a bag through this opening over the next few months, so that the newly created reservoir is still protected and all sutures can heal. A thorough check for blood dryness, insertion of two drains, and layer-by-layer closure of the abdominal wall is performed.

The ileostomy will relieve and protect the suture site in the rectum for two to three months. It is then repositioned in a further operation. During this procedure, the small intestine is carefully removed from the abdominal wall and mobilized The “stoma-bearing” portion of the small intestine is removed and rejoined. During this surgery, the surgeon will assess, from the anus, the suture site in the rectum and the condition of the reservoir, and make any corrections. After repositioning of the ileostomy, the patient will initially have frequent defecation via the reservoir (approximately 10 to 12 times per day). However, this high frequency usually reduces to four to six times per day after a few months.

At this point, it is necessary to mention a complication of pouchitis, which must always be mentioned and explained when considering performing such an operation: Pouchitis, a non-specific inflammation of the small intestinal reservoir, the cause of which is still not fully understood. Is it a bacterial infection? Is it the continuation of colitis in the small intestine? Or are there certain metabolic changes in the intestinal mucosa? About 40% of pouch wearers experience such reservoir inflammation once, some more than once. Antibiotic therapy is usually successful in combating this condition, although it is not known for certain whether bacteria are actually causing this inflammation. Only very rarely does this complication take a chronic course, ultimately requiring removal of the pouch. Half of the patients with pouching never experience inflammation in the reservoir or experience only very minimal inflammation, so it appears that individual factors may play a role in the development of such a complication.

In 1844, the first anesthesia with nitrous oxide was performed by Horace Wells, and in 1901, Karl Landsteiner discovered the blood groups of humans. This opened up the possibility for the first time to perform blood transfusions during major surgical operations and to successfully treat hemorrhage shock. The greatest achievement, however, was Ignatz Philipp Semmelweiss’ realization that wound infections, which were usually fatal at the time, especially puerperal fever, were caused by poor hygiene of hands and instruments. Until then, thorough hand disinfection was completely unknown in hospitals. One “carried”, without knowing it, the bacteria from one patient to another. Unfortunately, Semmelweiss was too far ahead of his time, so his appeals for hand disinfection with carbolic acid, despite proven efficacy by Luis Pasteur, the famous discoverer of the bacteria, were not taken seriously at first. It was the surgeon Joseph Lister in Glasgow who heard Semmelweiss’ ideas and successfully implemented them in his clinic in 1867: Before operations, the surgeons’ hands were washed with carbolic soap, and a carbolic solution was atomized over the surgical area during the operation. This significantly reduced the number of fatal complications after surgery.

In the course of this knowledge, operating rooms were then created that could only be entered with a hood and mouth guard, so that the first major abdominal surgical procedures, which were then also performed aseptically, were more successful from 1880. Exemplary for the “spirit of optimism” in abdominal surgery under these “new” conditions is the work of the surgeon Professor Ulrich Kroenlein, who worked and taught at the University Hospital Zurich since 1881. He translated the new “hygiene ideas” into measures in the hospital by having floors tiled, wooden bedsteads removed, and a new operating room built in the form of an amphitheater (student classroom). Kroenlein was one of the first surgeons to treat acute peritonitis and was involved in the treatment of purulent peritonitis following intestinal injuries.

To avoid such peritonitis caused by poor intestinal sutures (anastomoses), two other famous surgeons at that time were struggling to find new suturing techniques in intestinal surgery, Theodor Kocher and Vinzenz Czerny. “Intestinal resection has become an extraordinarily important and relatively frequent surgical procedure, by the correct performance of which the surgeon can preserve many a life otherwise irrecoverably lost,” wrote Theodor Kocher in 1894, introducing his continuous intestinal suture (Boschung U. Milestones in the history of intestinal anastomosis. Swiss Surg 2003; 9: 99-104). For example, as early as 1907, Sir Ernest Miles performed the first radical abdominoperineal resection for rectal carcinoma, a major procedure in which the colon and rectum were completely removed.

Gas and stool occlusion, an important function of the anal canal and anus, is achieved through
a multilayered and complexly arranged outer muscle cuff that extends to the anus,
a cushion-like “corpus cavernosum” of small veins and arteries, which lies on both sides under the mucosa in the anal canal and allows fine regulation, and a zone lying just in front of the anus, in which longitudinally running folds of the mucosa form pocket-like structures, which represent a kind of “valve function”.

The actual defecation is activated by a complicated control circuit, which in turn is so controlled by the touch and stretch stimuli from the rectum that each person usually has a bowel movement only once a day. However, stool frequency is very individual and subject to wide variation.

Classification of hemorrhoids by severity is done as follows:

Grade 1
An enlargement and thickening of the corpus cavernosum occurs as a result of the blood backing up in the cushion-like vascular plexus.

Grade 2
The soft, greatly enlarged tissue area protrudes pedunculated into the anal canal, occasionally also to the anus. The typical hemorrhoidal knot has formed.

Grade 3
Hemorrhoidal nodes are typically permanently located in front of the anus.

After proper storage, the anal skin is inspected first. Here it is important for the examiner to see if there are any skin changes, redness, and eczematous or inflammatory conditions in the area. The patient should push to provoke anal prolapse, rectal prolapse or hemorrhoids. These diseases can be identified based on their typical shape. Then the doctor will gently palpate the rectum with the index finger to get an indication of the elasticity of the external and internal sphincter. Subsequently, the rectum is also palpated.

Hemorrhoidal nodes cannot be palpated. They are only blood-filled vessels, which immediately empty on pressure and can be “moved” in the soft mucosa. However, the palpating finger senses mucosal tears, tumors, strictures, or irregular contours of the anus. At the end of the examination, the size of the prostate is palpated through the mucosa in men and the cervix of the uterus is assessed in women. The exact pressure of the anal muscular apparatus can be measured accurately with special fine pressure probes. This measurement is important in cases of additional fissures or anal incontinence.

The hemorrhoidal nodes themselves, their grading, and their position in the anal canal at 3, 7, and 11 o’clock can be more accurately assessed only with the aid of a proctoscope. This is a tubular instrument, open at the front and beveled, about five centimeters long with a light source, which is carefully advanced into the rectum. This usually does not cause pain in the patient, but does cause an uncomfortable feeling of pressure in the bowel. With this instrument, the anal canal can be seen well and especially hemorrhoids and fistulas can be assessed well.

The rectoscope is a 20-centimeter-long instrument that can be used to view the last approximately 20 centimeters of the rectum. In order to see the entire inner part of the intestine, air must be blown in for this purpose. If the examinations with these two instruments are unremarkable and if there is only the slightest indication of perianal blood loss (blood loss via the rectum) in the patient’s medical history, the physician should also arrange for a colonoscopy in order to exclude a carcinoma located higher up in the intestine in any case. Colonoscopy is performed by gastrointestinal specialists (gastroenterologists) using a flexible instrument about two meters long, which can be used to mirror the entire colon.

• Sclerotherapy of the enlarged vascular cushion by injection of a special fluid (sclerotherapy).
• Ligation of hemorrhoids with a rubber ligature. In this procedure, the hemorrhoids are cut off from the blood supply with a tight rubber band at the base and sclerosed.
• Laser treatment, in which the internal hemorrhoids are sclerosed by direct contact with a special laser device

• Excision of the hemorrhoidal knot according to Milligan-Morgan or Ferguson
• Cutting out according to “Longo” using a special clamp seam cutter.

As in the other parts of the colon, adenocarcinoma (lat. adeno = originating from glandular cells) is the most common malignant tumor. The shape that the tumor takes in the intestine can also vary: it can be pedunculated, crater-shaped and grow diffusely, or it can constrict the intestinal clearing in a ring shape. Depending on the manifestation, the early symptoms that may be associated with this tumor are very different.

The causes of the development of these malignant tumors are not precisely known. Genetic, but also nutritional factors such as a high fat content in the diet, are discussed. Some risk factors are well established. These include certain pre-existing intestinal conditions such as ulcerative colitis, Crohn’s disease, or familial polyposis coli. The latter is considered a precancerous condition (tumor precursor), since here the many growths of the intestinal mucosa (polyps) become malignant after a certain time. A known family history of malignant colorectal tumors in the immediate family also increases the likelihood of developing such a tumor.

Tumor disease may also be associated with weight loss and physical limitation. In some cases, acute intestinal obstruction (ileus) may occur. This is characterized by an absence of wind and stool discharge, usually lasting for days, and increasing pain, beginning with colic and later becoming permanent.

Then the doctor will examine the abdomen and feel if there is any hyperinflation, if there is any palpable tumor, and if there are any additional other conditions such as hernias (breaks) of the abdominal wall. Since the majority of malignant colon tumors are found in the rectum, a digital examination of the rectum by the physician is an important part of the diagnostic process. The rectum is palpated with a finger through the anus, the sphincter function is checked and the prostate gland is examined for irregularities in men. A laboratory test is then performed to rule out anemia, to assess other important organ functions, and to collect tumor markers typical of this type of tumor.

If the suspicion of rectal cancer has been confirmed by then, an additional colonoscopy (Fig. 3) must be performed to obtain tissue samples from all suspicious areas of the mucosa.

Furthermore, an ultrasound examination of the abdomen will be performed to evaluate the liver (metastases), gallbladder, bile ducts, pancreas and kidneys. Depending on the location and size of the tumor as well as other concomitant diseases of the patient, additional special examinations may be necessary, such as a CT scan, an MRI (Fig. 4), an endosonography of the rectum (the exact location of the tumor is very important for surgical planning), a cardiac ultrasound scan or a lung function diagnosis.

Prior to surgery, bowel irrigation is performed to prevent infection from germs when the bowel segment is removed and rejoined. For this reason, each patient receives an antibiotic before surgery, which is passed on for several days after surgery in some cases. The aim of the operation is to remove the section of intestine with the tumor as well as the associated lymph nodes and to reunite the colon areas. The curative therapy of rectal carcinoma is performed by a so-called anterior (front) rectal resection. The abdominal cavity is accessed through a mid-abdominal incision (Fig. 5) or laparoscopically.

The surgeon then turns to the lower abdomen and locates the tumor-bearing section of bowel. From the preliminary examinations, he knows at what height the tumor can be found. This knowledge is very important in rectal tumors because the distance from the tumor to the anus plays a major role in surgical planning, and especially in creating the anastomosis (reunion) in this area.

In order to remove a section of bowel in the rectal area, the preceding section must be detached from the substrate and mobilized. In the case of malignant tumors, the associated lymph nodes on the large vessels are visited and removed. The vessels originating from the center of the abdomen in the suspensory ligaments of the intestinal segments (mesenteries) are shown centrally and set off (Fig. 6). This radically removes the entire drainage area of the lymph, including the lymphatic channels and the lymph nodes. This step is important in the case of tumor disease. The number of lymph nodes found and affected by the tumor is crucial for possible chemotherapy after surgery. The rectum is then mobilized, with the surgeon being careful not to injure either ureter.

The rectum lies in a mantle of fatty tissue (mesorectum), in which the vessels and lymphatic channels run. The mesorectum is removed to eliminate any metastases that may be present. This modern surgical method (TME – Total Mesorectal Excision) was introduced in 1985 by Professor Bill Heald. The nerves that are important for male potency and that run close to the place where the rectum has to be removed can practically always be preserved thanks to this technique.

The next step is to restore the continuity of the intestine. Clamp sutures are used for this purpose. They allow anastomosis (reunion) of the bowel even a few centimeters from the anus (Fig. 7).

A measure which unfortunately sometimes cannot be avoided in intestinal surgery, but which can become a severe psychological burden for the patient, is the creation of an artificial bowel outlet (anus praeter). It is used to drain stool and gas from a section of bowel outward through the abdominal wall into a bag. Depending on whether a small bowel or large bowel section is being passed out, it is referred to as an ileostomy or colostomy. A stoma may be created as a short-term measure with the goal of restoring bowel continuity after a few months by repositioning, or it may be a permanent expulsion.

1. Impending intestinal obstruction due to an unresectable tumor,
2. very deep tumors close to the sphincter muscle, in which the sphincter muscle must also be removed …
3. … to protect an anastomosis until it has healed.

This can be a painful phase, as the intestine is still partially overinflated and resumes its activity only slowly, often accompanied by cramps. Gradually, food intake continues to build via soup and pureed food. Patients are closely supervised by the physiotherapy staff in order to avoid possible complications caused by temporarily limited mobility. If drains (tubes to drain wound secretions) were placed in the abdominal cavity during surgery, they will be removed after a few days.

All tissues removed during the operation are sent to the pathologist for fine tissue examination. This describes the tumor, the incision margins and the lymph nodes and thus determines the tumor stage. As soon as we receive the results of the examination, we discuss the findings and possible consequences with the patient, if desired together with family members.

After major abdominal surgery, the body needs some time to convalesce. For this reason, most of our patients like to take advantage of the possibility of direct rehabilitation following their hospital stay. Their planning takes place during the inpatient stay.

The individual follow-up of each patient is carried out according to the tumor stage. Tumor markers are checked at certain intervals, and an ultrasound or CT scan of the abdomen and colonoscopy are performed to make sure that no metastases have occurred or that no new tumor has developed.