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Clark D. Gerhart, MD, FACS
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Laparoscopic Colon Surgery

About the Colon

The colon is a part of the digestive tract, also called the GI (gastrointestinal) tract, where food is processed to rid the body of waste. Food travels down the esophagus, through the stomach, and into the small intestine, the longest section of the digestive tract, which is joined to the large intestine. The large intestine, called the colon, absorbs water and nutrients from food and stores waste matter. The colon consists of four sections: ascending colon, transverse colon, descending colon and sigmoid colon.

Colon Disease

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Conditions of the colon vary by severity; some cause mild irritation and others can be life-threatening. Four common types of colon disease are the development of polyps, Crohn’s disease, ulcerative colitis and diverticular disease.

Noncancerous Polyps

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According the American Society of Colon and Rectal Surgeons (ASCRS), polyps are one of the most common conditions affecting the colon and rectum. They occur in 15 to 20 percent of adults. Polyps are mushroom-shaped abnormal growths that line the large intestine and protrude into the intestinal canal. Though most polyps are noncancerous, over time they can become cancerous and invade the colon wall and blood vessels, eventually spreading to other parts of the body. Ninety percent of colon and rectal cancers occur from polyps that are initially noncancerous. Therefore, rectal polyps are usually removed after being discovered.

Diagnosis
Polyps can be diagnosed either by examining the colon lining or by x-ray. Screening methods include:

Sigmoidoscopy (Rigid and Flexible)
An examination of the rectum and lower colon using a lighted instrument (about the thickness of a finger) called a sigmoidoscope. A video camera is connected to the sigmoidoscope for better viewing. A rigid sigmoidoscopy allows doctors to examine the lower six to eight inches of the colon; a flexible sigmoidoscopy, the lower one fourth to one third of the colon. However, doctors are only able to see less than half of the colon.

Colonoscopy
Colonoscopy is an examination of the rectum and entire colon using a lighted instrument called a colonoscope, a longer version of a sigmoidoscope. The colonoscope is connected to a video camera for closer examination. Sometimes doctors are able to remove polyps during this procedure or a sigmoidoscopy.

Barium Enema
The procedure is also called a double contrast barium enema. Patients are given barium sulfate (a chalky substance) inserted through a small tube in the anus to fill and open up the colon. Once the barium is spread throughout the colon, patients are placed on an x-ray table for examination.

Treatment
There is no way to tell if a polyp will become cancerous. To be safe, doctors remove polyps for testing. The majority of polyps can be removed with a wire loop, and small polyps can be destroyed just by touching them with an electrical current. Removing larger polyps may require surgery.

After polyps are removed, recurrence is unusual, though new polyps develop in at least 30 percent of people who previously had them. Regular examinations by physicians trained to treat colon and rectum disease are recommended.

Crohn's Disease

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Crohn’s disease is a chronic inflammation of the digestive tract most commonly affecting the last part of the small intestine and/or large intestine, the colon. The disease can occur anywhere in the digestive tract and may recur over the course of a lifetime. People may have long periods of remission that can last for years. However, there is no way to predict when remission may occur and there is no known cure for the disease.

Symptoms may include cramping, abdominal pain, diarrhea, fever, weight loss, bloating, anal pain or drainage, skin lesions, rectal abscess, fissure and joint pain. Not all patients experience all of these symptoms and some may have none.

Diagnosis
Doctors perform physical examinations and review family histories to diagnose Crohn’s disease. Tests may include a barium enema, x-ray of the upper and lower part of the intestinal tract, or sigmoidoscopy or colonoscopy.

Treatment
Initial treatment usually involves medication to relieve symptoms. The most common prescription drugs are corticosteroids, such as prednisone and methylprednisolone, and various anti-inflammatory agents.

Surgery is eventually required in up to three-fourths of all Crohn’s patients.¹ The most common surgical procedure is the removal of the diseased portion of the bowel. Surgery may be recommended for advanced or complicated cases of the disease. Complications include perforation of the intestine, blockage of the bowel, or significant bleeding. Although surgery cannot cure Crohn’s disease, most patients do not require additional operations or prescribed medications.

Ulcerative Colitis

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Approximately 500,000 Americans are affected by ulcerative colitis, predominantly under the age of 30.¹ Ulcerative colitis is an inflammation that affects the innermost lining (mucosa) of the colon and rectum. The most serious complication of ulcerative colitis is toxic megacolon, which paralyzes the colon, preventing bowel movement.

Symptoms may include rectal bleeding, abdominal pain, bloating, constipation or diarrhea, weight loss or fevers. Diagnosis can be made by a sigmoidoscopy or colonoscopy, examinations of the colon with a lighted instrument inserted through the anus.

Treatment
Anti-inflammatory drugs are usually the first step in the treatment of ulcerative colitis. They include: sulfasalazine, mesalamine, balsalazide, corticosteroids. In some cases, drug therapy can lead to long-term remission.

Surgery is necessary for patients who have life-threatening complications including massive bleeding, perforation, or infection. The standard operation for ulcerative colitis is the removal of the entire colon, rectum and anus, called a proctocolectomy.

Diverticular Disease

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Diverticular disease affects about 50 percent of Americans by age 60 and nearly all by age 80.¹ Diverticulosis is the presence of pockets, called diverticula, in the colon wall. Diverticulitis is inflammation or infection of these pockets.

Symptoms of diverticular disease include abdominal pain, diarrhea, cramps, alteration of bowel habit and rectal bleeding. However, symptoms occur in a small percentage of patients and are sometimes difficult to distinguish from irritable bowel syndrome.

Treatment
Eating a low-fiber diet may cause diverticulosis because it increases pressure inside the colon and causes constipation. For many people, eating a high-fiber diet that includes whole grains, fruits and vegetables is the only treatment necessary.

Diverticulitis needs to be managed carefully. Severe cases require hospitalization. Treatments include oral antibiotics, dietary restrictions and possibly stool softeners. Surgery is required only when complications recur or people have severe attacks with little response to medication. Surgery involves removing part of the colon, usually the sigmoid colon, and reattaching the remaining part of the colon to the rectum. Normal bowel function resumes in about three weeks.

Traditional Open Surgery

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Severe complications from Crohn’s disease, ulcerative colitis and diverticular disease require open surgery for whole or partial colon removal. Surgeons make an incision up to 16 inches long from the upper to lower abdomen to view the colon and remove diseased portions. Patients often face a long and painful recovery due to large incisions, resulting in hospital stays of at least a week and recovery time ranging from six to eight weeks.

Hand-assisted Laparoscopic Surgery (HALS)

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The LAP DISC, a ringlike device, allows surgeons to enter their hand into the abdomen to reach the colon through an incision no larger than their glove size, to help guide laparoscopic instruments, including a miniature camera. The LAP DISC gives the surgeon the feel, maneuverability and hand assistance he or she gets in open surgery, but without the 16-inch-long incision in the abdomen that is typically required in traditional colon surgery.

Surgeons create a small incision, approximately 3 to 4 inches long (no larger than the surgeon’s glove) in the patient’s abdomen. Three other small abdominal punctures are also made for a laparoscope (telescope connected to a video camera) and other instruments. The smaller incisions mean patients can leave the hospital in a few days, experience less pain and return to normal activity in about a week, as compared to six to eight weeks in open surgery.

1. American Society of Colon and Rectal Surgeons (ASCRS) Web site: http://www.fascrs.org.

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