General SCOAP Procedures Click here for Bariatric Click

General SCOAP Procedures Click here for: Bariatric Click here for: Appendectomy Click here for: Colon, Rectal & Colorectal Click here for: Small Bowel Obstruction Click here for: Helpful Words Laparoscopic vs. Open Additional Help 1

SCOAP Bariatric Procedures Click here for: Gastric Bypass Click here for: Revision of Gastric Bypass Click here for: Takedown of Vertical Band Click here for: Sleeve Gastrectomy Click here for: Other Bariatric Procedure Click here for: GENERAL SCOAP PROCEDURES SLIDE 2

Gastric Bypasses Proximal gastric bypass is a Roux limb less than, or equal to, 150 cm. BARIATRIC PROCEDURES Krames Stay. Well ~ 780 Township Line Road ~ Yardley, PA 19067 267 -685 -2500 Click here for: Distal gastric bypass is a Roux limb greater than 150 cm PLUS a “common channel” of less than 200 cm. Note: Indicate “other gastric bypass” and specify the Roux length if a Roux limb is greater than 150 cm, but there is no mention of the common channel being less than 200 cm. © Krames Stay. Well. Image reprinted with permission. 3

Revision of Gastric Bypass Revision of Gastric Bypass: Surgical procedure to address failed gastric bypass by addressing gastro-gastric fistula, pouch dilation, anastomotic dilation. Gastro-gastric fistula is a communication between the proximal gastric pouch and the distal gastric remnant. It is a possible complication of gastric bypass. Pouch dilation can occur when the gastric band is too tight. Actions such as vomiting can cause the stomach to slip up through the band, causing the small pouch to dilate. Anastomotic dilation is where the connection between the stomach pouch and the intestine stretches out. Click here for: BARIATRIC PROCEDURES 4

Takedown of Vertical Band Vertical banded gastroplasty (VBG), or stomach stapling, is a restrictive operation for weight control. Both a band staples are used to create a small stomach pouch. The VBG operation is no longer performed. Obstruction with vomiting or weight gain frequently necessitates a takedown or reversal. Click here for: BARIATRIC PROCEDURES © 2013, Web. MD, LLC. All rights reserved. Takedown/reversal may involve removal of the band/staples and conversion to a gastric bypass. 5

Krames Stay. Well ~ 780 Township Line Road ~ Yardley, PA 19067 267 -685 -2500 Sleeve Gastrectomy Sleeve gastrectomy is a surgical removal of a large portion of the stomach, following the greater curve. The open edges are then attached together to form a sleeve, or tube, with a banana shape. The procedure permanently reduces the size of the stomach. © Krames Stay. Well. Image reprinted with permission. There are no anastomoses done with a sleeve gastrectomy. Click here for: BARIATRIC PROCEDURES 6

Other Bariatric Procedure: Biliopancreatic Bypass with Duodenal Switch Krames Stay. Well ~ 780 Township Line Road ~ Yardley, PA 19067 267 -685 -2500 2 part procedure: Part 1: Creation of a gastric sleeve. Part 2: The stomach remains attached to the 1 st segment of the small intestine (duodenum). The duodenum is then separated from the rest of the small intestine. It is attached to the lowest part of the small intestine, bypassing the majority of the 2 nd and 3 rd segments of the small intestine. The small intestine is rerouted. Click here for: BARIATRIC PROCEDURES © Krames Stay. Well. Image reprinted with permission. 7

Appendectomy Click here for: Appendicitis / Appendectomy Procedure Click here for: Appendiceal mass or Cancer Click here for: Appendectomy – Lap. vs. Open Click here for: GENERAL SCOAP PROCEDURES SLIDE 8

Appendectomy is an emergency/urgent procedure to remove an inflamed and/or infected appendix. The appendix can rupture, spilling infectious material into the bloodstream and abdomen, which can be life-threatening. © 1995 - 2012. The Nemours Foundation/Kids. Health ®. Image reprinted with permission. Click here for: APPENDECTOMY MAIN PAGE 9

Appendiceal mass and Cancer An appendiceal mass or phlegmon is most often an infection, treated with antibiotics. Appendiceal cancer is a rare malignancy of the vermiform process/ appendix. Click here for: APPENDECTOMY MAIN PAGE 10

Krames Stay. Well ~ 780 Township Line Road ~ Yardley, PA 19067 267 -685 -2500 Appendectomy – Lap. vs. Open Laparoscopic appendectomy is similar to the open procedure, but instead of one 3 to 5 inch incision (laparotomy), several incisions, each half an inch long, are used (also called minimally invasive surgery). Through these small incisions, the surgeon inserts cameras and small instruments to perform the operation. © Krames Stay. Well. Image reprinted with permission. Click here for: APPENDECTOMY MAIN PAGE 11

SCOAP Colon, Rectal & Colorectal Procedures Colon Rectal Colorectal Click here for: Right/Transverse Hemicolectomy Click here for: Abdominal Perineal Resection (APR) Perineal Proctectomy Click here for: Ileocecectomy Click here for: Proctopexy Click here for: Low Anterior Resection (LAR) Sigmoid Colectomy Stoma Takedown Click here for: Total Abdominal Colectomy (TAC) Ileal Pouch-Anal Anastomosis (IPAA) Additional (or staged) Procedure Pouches (Reservoirs) Ileal Click here for: Left Hemicolectomy Click here for: GENERAL SCOAP PROCEDURES SLIDE Click here for: -ostomies Additional Help 12

Right/Transverse Hemicolectomy A Right/Transverse Hemicolectomy refers to the resection of the ascending colon. This includes the removal of any portion of the colon originating from the terminal ileum, including the cecum, to approximately the mid transverse colon. Other terms used in association with it: ascending colon, cecectomy, hepatic flexure and extended right colectomy. Click here for: COLO-RECTAL PROCEDURES 13

Left Hemicolectomy A Left Hemicolectomy involves removing the descending and/or sigmoid colon. Also included in our definition are any resections done starting from the left side of the transverse colon down through the descending and/or sigmoid colon. For the purposes of SCOAP, the anastomosis will be in the descending or sigmoid colon. Another term used could include the splenic flexure. Click here for: COLO-RECTAL PROCEDURES Image reprinted with permission Cedars-Sinai Health System. 14

Ileocecectomy is the removal of the ileum and part of the colon. This procedure is usually performed in patients with ileal Crohn’s disease. Click here for: COLO-RECTAL PROCEDURES Image reprinted with permission 2018 15

Abdominal-Perineal (APR) Resection Abdomino-perineal Resection (APR) is a procedure that involves removal of the sigmoid, rectum and anus from a combined approach involving an incision in both the abdomen and the perineum. The anus is removed and the opening is sewn shut. APR is usually done for rectal cancer of the last third of the rectum, or Crohn’s disease. Sometimes a plastic surgeon will also be involved to provide a “flap” for the anal closure. This means that the patient will have a permanent colostomy. Sigmoid colostomy Click here for: COLO-RECTAL PROCEDURES Image reprinted with permission from Cynthia Broze and Cedars-Sinai Health System. 16

Image reprinted with permission from Cynthia Broze and Cedars. Sinai Health System. A-P Resection Cont’d. Colostomy Protruding Through Abdomen After AP Resection Click here for: COLO-RECTAL PROCEDURES 17

Perineal Proctectomy is a surgical resection via a perineal incision with partial removal of the rectum and sigmoid and a coloanal anastomosis for prolapse or mass removal from the rectum. A perineal proctectomy is usually done for rectal prolapse, not for cancer. There are two techniques for performing perineal proctectomies: Altemeier Procedure or Delorme. Click here for: COLO-RECTAL PROCEDURES 18

Abdominal Proctectomy is a surgical resection of the rectum through an abdominal incision ONLY. It does not remove the anus or distal rectum. It is frequently associated with a colostomy. However, in some cases, a colo-anal anastomosis can be performed. Click here for: COLO-RECTAL PROCEDURES 19

Total Mesorectal Excision (TME) is a term used to describe the anatomical removal of the rectum including the intact mesentery (fat & lymph nodes) surrounding it. The surgeon or pathologist should describe an intact capsule upon inspection of the specimen. The blue arrow identifies the dentate line, which is where the anoderm transitions to the rectal mucosa. A temporary, or protecting, stoma may be in place for up to a few months after this operation. Reprinted from Max Lahaye, Regina Beets-Tan, Robin Smithuis, and The Radiology Assistant Click here for: COLO-RECTAL PROCEDURES 20

Proctopexy Copyright 2001, Web MD Corporation Proctopexy is a surgical fixation of a prolapsed rectum, also known as rectopexy. Rectal prolapse Rectopexy (laparoscopic or open) is one of the procedures used to repair a rectal prolapse. In this surgery, the rectum is restored to its normal position in the pelvis, so that it no longer prolapses (protrudes) through the anus. Stitches may be used to secure the rectum, often with mesh. Click here for: COLO-RECTAL PROCEDURES 21

Additional (Staged) Procedure A staged procedure may refer to a planned return to the OR during the current admission in cases where the index operation was terminated prematurely due to patient instability. A second operation to complete the procedure would be safer, less morbid, and possibly have a lesser chance of an anastomotic leak. Other staged procedures are planned in the elective setting when protecting loop ileostomies are placed proximal to a high risk anastomosis. Examples of staged procedures: Done in the case of bowel ischemia or necrosis Done when there is so much edema present in the tissues that closure of the incision would in all probability lead to wound dehiscence. Frequently “wound vacs” are placed at this time. Click here for: COLO-RECTAL PROCEDURES 22

Lower Anterior Resection (LAR) A "low anterior resection, " or "LAR" is the removal of a portion of the sigmoid colon WITH a portion of/or the entire rectum. This is formally known as anterior resection/excision of the rectum, sigmoidectomy, or anterior resection (less precise). When a sigmoidectomy is followed by terminal colostomy and closure of the rectal stump, it is called a Hartmann operation. LAR is usually done for rectal cancer. LARs generally give a better quality of life than AP Resections and are the preferred treatment for rectal cancer if surgically feasible. In patients with diverticulitis, LAR is done to diminish the potential for recurrence (the sigmoid has diverticula, the rectum does not). The anastomosis is usually at the recto-sigmoid junction or in the first 2/3 of the rectum. Click here for: COLO-RECTAL PROCEDURES Image reprinted with permission from Cynthia Broze and Cedars-Sinai Health System. 23

Sigmoid Colectomy Removal of the sigmoid colon also called a sigmoid colectomy and is just the removal of the sigmoid colon. Diverticular disease is one of the most common indicators for sigmoid colectomy. The descending colon is then connected to the lower Sigmold colon or rectosigmold junction. Click here for: COLO-RECTAL PROCEDURES Image reprinted with permission from Cynthia Broze and Cedars-Sinai Health System. 24

Total Colectomies Krames Stay. Well ~ 780 Township Line Road ~ Yardley, PA 19067 267 -6852500 Total Abdominal Colectomy (TAC) is the removal of the entire colon (ascending, transverse, descending, and sigmoid). In urgent procedures, a temporary protective ileostomy is frequently done. In some cases the ileum is anastomosed(connected)to the rectum. A TAC is used frequently with ulcerative colitis, Crohn’s disease, or Familial Adenomatous Polyposis. © Krames Stay. Well. Image reprinted with permission. Click here for: COLO-RECTAL PROCEDURES 25

Stoma Takedown Protecting or diverting stomas are placed proximal to high risk anastomosis. They are typically “taken down” after an appropriate convalescence and healing. Stoma Takedown refers to the rejoining or reversal of a temporary/protective stoma and may include a colon resection. Upon completion, bowel continuity is restored. For the purposes of SCOAP, if the procedure is an ileostomy takedown it must have an ileocolonic, ileorectal, or ileoanal anastomosis. After a Hartmann procedure, the stoma is closed with a colorectal anastomosis. SCOAP does not capture ileum to ileum takedowns (loop ileostomy closure). Click here for: COLO-RECTAL PROCEDURES 26

Pouches (Reservoirs) Click here for: About Pouches (Reservoirs) Click here for: Ileoanal Pouch (Reservoir) Surgery Click here for: Ileal Pouch (Reservoir) Types Click here for: COLO-RECTAL PROCEDURES 27

About Pouches (Reservoirs) ileoanal pouch (reservoir) also known as ileal-pouch anal anastomosis (IPAA) A surgical treatment option for chronic ulcerative colitis, colon cancer, and familial polyposis patients who need to have their large intestine (colon) removed. Gives the patient control of bowel movements, and does not require a permanent ileostomy. An internal pouch (reservoir) formed of small intestine. This pouch provides a storage place for stool in the absence of the large intestine. Click here for: COLO-RECTAL PROCEDURES Arrow down for further slides 28

About Pouches, Continued This procedure can be performed in one, two, or three stages, but it is most often done in two stages, usually 2 -3 months apart. Stage 1 removes the entire large bowel and the rectum, but leaves the anal sphincter muscles intact. A reservoir or “pouch” is made out of small intestine and is then connected to the anus. A temporary ileostomy is made. An ileostomy is a surgically created opening between the small bowel and the skin of the abdomen through which stool and gas are passed. This temporary ileostomy diverts the stool, protecting the pouch/reservoir while it heals. In Stage 2, the ileostomy is closed. In a 3 -stage procedure, Stage 1 is an abdominal colectomy. Stage 2 is a ileal J-pouch anal anastomosis. Stage 3 is an ileostomy takedown. Click here for: COLO-RECTAL PROCEDURES Arrow down for further slides 29

Ileoanal Pouch (Reservoir) Surgery Stage 1: Ileoanal Pouch (Reservoir) Surgery 1. Large intestine (colon) is removed 2. Lining of the rectum is removed but the sphincter mechanism is saved A temporary loop ileostomy is created to “detour” the contents of the small intestine so the newly created reservoir may heal. Click here for: COLO-RECTAL PROCEDURES Arrow down for further slides 30

Ileoanal Pouch (Reservoir) Surgery, Continued Stage 2: Gastrointestinal tract AFTER Ileoanal Pouch (Reservoir) Surgery (figure B) 1. Approximately 2 -3 months after the 1 st surgery, the ileostomy is closed. 2. Food now enters the mouth, into the stomach, and through the small intestine into the reservoir. 3. Waste is stored in the reservoir until the need to have a bowel movement. 4. Stool is then passed through the pouch and anus. Click here for: COLO-RECTAL PROCEDURES Arrow down for further slides 31

Ileal Pouch (Reservoir) Types The J, S, and W pouches (reservoirs) are the most commons types of pouches used. Function, capacity, and elasticity vary with design Selection of pouch design depends on factors including: Age Patient size Individual anatomy Click here for: COLO-RECTAL PROCEDURES Arrow down for further slides 32

J Pouch The J pouch (reservoir) is made from 2 side-by-side limbs stapled together to create a J-loop. Click here for: COLO-RECTAL PROCEDURES Reprinted with permission. Copyright © 2012 University of Wisconsin Hospitals and Clinics Authority. Arrow down for further slides 33

S Pouch An S pouch (reservoir) has 3 limbs and a short nipple that serves as the ileal reservoir’s outlet. Reprinted with permission. Copyright © 2012 University of Wisconsin Hospitals and Clinics Authority. Click here for: COLO-RECTAL PROCEDURES Arrow down for further slides 34

W Pouch The W pouch (reservoir) has 4 limbs and looks like 2 Jloops placed side-byside. Reprinted with permission. Copyright © 2012 University of Wisconsin Hospitals and Clinics Authority. Click here for: COLO-RECTAL PROCEDURES 35

Laparoscopic vs. Laparotomy Krames Stay. Well ~ 780 Township Line Road ~ Yardley, PA 19067 267685 -2500 A laparotomy is a surgical incision (open) into the abdominal cavity. Lap-assisted, also known as handassisted procedures, utilize both laparoscopic instrumentation and open techniques. Laparoscopic Surgery (also called minimally invasive surgery) is an surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed for laparotomy. There will always be a small extraction incision. © Krames Stay. Well. Image reprinted with permission. Please note: there are many definitions of minimally invasive surgery and if you have any questions about a case you are abstracting, email Ask. SCOPE@qualityhealth. org Click here for: GENERAL SCOAP PROCEDURES SLIDE 36

Ostomies In an -ostomy, the healthy end of the colon or intestine is sutured to the abdominal wall, creating a stoma through which feces is excreted. An -ostomy is sometimes temporary, in order to give another part of the colon or intestine time to heal. Ascending Colostomy Descending Colostomy Ileostomy Sigmoid Colostomy Reprinted from Duncan Lock, public domain Click here for: GENERAL SCOAP PROCEDURES SLIDE 37

SCOAP Small Bowel Obstruction (SBO) Procedures Click here for: Lysis of adhesions Small Bowel Bypass Click here for: Resection with stoma Click here for: Anti-adhesion barrier placed NOTE: We only include small bowel obstruction cases due to post-op adhesions. Click here for: GENERAL SCOAP PROCEDURES SLIDE 38

Lysis of Adhesions are scars that form within the body, typically after surgery as part of the healing process Lysis refers to separation or cutting of adhesions. Lysis of adhesions is a procedure used to treat intestinal obstruction due to scar tissue related to previous operations. The most common abdominal operations that result in adhesions are gynecologic and gastrointestinal. If adhesions form on the intestines, the tissue is more than likely to get stuck to other tissue, muscle, organ and/or another portion of itself to create a bowel obstruction. Click here for: SBO PROCEDURE SLIDE 39

Small Bowel Bypass The illustration shows a small bowel to transverse colon bypass for treatment of an obstructed terminal ileum due to radiation. Image reprinted with permission One treatment for small bowel obstruction is a small bowel bypass. If the obstructing adhesions are too dense to repair the surgeon may opt to bypass the obstruction by connecting the bowel just proximal to the obstruction to normal decompressed bowel distal to the obstruction. Click here for: SBO PROCEDURE SLIDE 40

Resection with stoma In small bowel resection operation, the small intestine will be clamped above and below the diseased section. This section will be cut free and removed. If there is enough healthy intestine left, the free ends of the intestine may be joined together. Otherwise, a permanent or temporary ileostomy is created. An ileostomy is an opening in the abdomen wall called a stoma. The proximal (upstream) end of the small intestine is attached to the stoma opening in the abdominal wall. Click here for: SBO PROCEDURE SLIDE 41

Anti-adhesion barrier For example, Seprafilm is a mechanical bioresorbable adhesion barrier that is applied to adhesiogenic tissues before surgical closure. It is used to reduce the risk of forming postoperative adhesions in patients undergoing abdominal or pelvic laparotomy. Click here for: SBO PROCEDURE SLIDE 42

Helpful Words Hepatic Flexure – The bend in the ascending to transverse colon that is closest to the liver. Splenic Flexure – The bend in the transverse to descending colon that is closest to the spleen. Suffixes -otomy – “putting a hole in it” (e. g. enterotomy) -ostomy – an artificial stoma or opening into the urinary, gastrointestinal tract (e. g. colostomy, ileostomy) -ectomy – “taking it out” (e. g. colectomy) Click here for: GENERAL SCOAP PROCEDURES SLIDE 43

Additional Help Should you have any additional questions about the General SCOAP collection form or definitions, please contact Ask. SCOAP@qualityhealth. org To ensure HIPAA compliance, when emailing information regarding a case please be careful to redact all patient information. Click here for: GENERAL SCOAP PROCEDURES SLIDE 44