Introduction to the Gastrointestinal System. Summary Anatomy & Physiology, Pathology and Operative Considerations for: GI System Breast IVAD Care & Use

Introduction to the Gastrointestinal System

Summary

Anatomy & Physiology, Pathology and Operative Considerations for:

GI System Breast IVAD Care & Use of Endoscopes

Gastrointestinal Definitions

Adhesion- tissue that is normally separate is bound together; produced by inflammation, injury, or intentionally surgically created

Anastomosis- joining of parts to create a union Bile- yellow-green alkaline fluid produced by the liver that aids

in digestion and fat absorption Biliary tract- system of the body involved with bile production,

secretion, and transport Cholangiogram- injection of contrast media into the cystic duct

or a tube placed in the common bile duct to allow visualization of the biliary ductal system

Cholecystitis- inflammation of the gallbladder Cholelithiasis- stones in the gallbladder Colon- large intestines


Diverticula- small pouches in the lining or wall of a canal or organ, most commonly the colon

Dysphagia- difficulty swallowing Fissure- crack or opening Fistula- abnormal passage between two surfaces or two

hollow organs Intussuseption- when part of the upper intestine slips into or

invaginates into a lower portion of the intestine/creates an intestinal obstruction

Meckel’s diverticulum- congenital blind pouch usually associated with the ileum and ileocecal valve

Mucosa- mucous membrane


Peptic ulcer- open lesion in the stomach or duodenum Peritonitis- inflammation of the peritoneal cavity Polyp- growth or tumor with a stalk or pedicle extending from

a mucous membrane Pyloric stenosis- congenital narrowing between the stomach

and duodenum (pyloric orifice) due to thickening of circular muscle surrounding it

Resection- excision of a structure and reconstruction of what remains

Sphincter- ring-like muscle surrounding an orifice Volvulus- twisting or torsion of the intestine causes obstruction

and possible strangulation

General Surgery

Abdominal Wall Abdominal Cavity Abdominal Organs Breast (excluding reconstructive

procedures) Vascular Access (excluding dialysis shunting

access procedures) Can include tracheotomy, thyroidectomy and

parathyroidectomy

Anatomy of the Abdominal Wall

Subcuticular (skin) Subcutaneous (fatty/adipose layer) Anterior fascia (thin or thick membrane over the

muscle) Muscle Posterior fascia (thin or thick membrane under the

muscle) Omentum (lesser and greater) Peritoneum (shiny membrane covering the

abdominal cavity) Contents of abdominal cavity (organs/viscera)

Abdominal Cavity

Diaphragm to pelvic base Pelvic girdle Ribs Vertebrae

Abdominal Surgery Landmarks

Xiphoid process Subcostals Iliac crests Symphysis pubis Umbilicus Linea alba Serve as reference points for incisions and

internal organ access

Abdominal Divisions

Four Quadrants Nine Quadrants

Abdominal Division

Anatomy of the Abdomen RUQ (right upper quadrant) contents: liver gallbladder duodenum head of pancreas right kidney and adrenal part of ascending and transverse colon

Anatomy of Abdomen Continued

LUQ (left upper quadrant) contents: stomach spleen left lobe of liver body of pancreas left kidney and adrenal part of transverse and descending colon


RLQ (right lower quadrant) contents:

cecum

appendix

right ovary and fallopian tube

right ureter

right spermatic cord


LLQ (left lower quadrant) contents:

part of descending colon

sigmoid colon

left ovary and fallopian tube

left ureter

left spermatic cord


Midline of Abdomen:

Aorta

Uterus

Bladder

Digestive TractAlimentary Canal

Mouth to the Anus Mouth>Pharynx>Pharyngoesophageal

Sphincter>Esophagus> Esophagogastric Sphincter>Stomach>Pyloric Sphincter >Duodenum>Jejunum>Ileum>Cecum (appendix)>Ascending Colon>Transverse Colon>Descending Colon>Sigmoid Colon>Rectum>Internal Sphincter>External Sphincter>Anus

Physiology of the Digestive System

Two major parts: GI tract/alimentary Canal

-mouth to anus-about 30 ft long

Accessory Organs-outside of or to side of GI tract, but are connected-teeth, salivary glands, biliary system: liver, gallbladder, pancreas

Physiology of the Digestive System

5 major processes: Ingestion/eating Mechanical and Chemical Digestion Peristalsis Absorption Defecation

Mechanical and Chemical Digestion

Begins in mouth, teeth increases surface area of food to allow enzymes to work on

Tongue pushes food underneath teeth and flips food as a “bolus” to back of throat (oropharynx)

Salivary Glands-primary salivary amylase begins break down of carbohydrates


Esophagus: Begins at oropharynx Mucous allows food to slide down


Stomach 4 areas:1. Cardiac (esophagus ends and cardiac or

esophageal sphincter empties into this region 2. Fundus/fundic area part that is rounded on left

side of body3. Body-main part of stomach4. Pyloric region or antrum=area before pyloric

sphincter which is where the duodenum begins


Rugae (hills and valleys allow stomach to expand 3 basic cell types here that produce:1. Pepsinogen2. HCl3. Mucous HCl acid activates pepsinogen which then becomes pepsin

which begins protein breakdown Vagus nerve stimulates tunica muscularis to create waves in

stomach from bottom up to allow for mixing of HCl and pepsin

Vagus nerve tires easily, production of hormone gastrin by the stomach sustains the action of stomach wave action

Food in stomach 1-6 hours Food broken down into “chyme” (semi-solid or pasty material

Pancreas

Head Body Tail

80% comprised of lobules Lobules consist of exocrine and

endocrine glands


Pancreas Endocrine and exocrine gland

1. Endocrine portion = Islets of Langerhan No ducts, secrete into blood or lymph Secreting portion is Islets of Langerhans 1% of pancreatic mass Receives 25% pancreatic blood supply

Islets of Langerhan

Two cell types: Alpha cells secrete hormone glucagon (↑

blood sugar level) Beta cells secrete hormone insulin (↓ blood

sugar levels) Function maintenance of blood glucose

levels

Exocrine glands

Secrete directly through a duct Called acini Functions: breakdown fats, proteins,

carbohydates and maintain pH pH maintenance prevents excessive

acid production which prevents duodenal ulcers


Pancreas2. Exocrine portion: 1. Produces enzymes: collectively called

pancreatic juices (Trypsin, chymotrysin, carboxypeptidase) break down proteins

2. Pancreatic amylase breaks down carbohydrates

3. Pancreatic lipase breaks down lipids All get to small intestine via pancreatic duct

(Duct of Wirsung) at Ampula of Vater


Liver Functions: Store excessive nutrients Detoxify and filter toxins Regulate nutrient levels Destroy worn out RBCs, WBCs, bacteria Produce heparin, prothrombin, fibrinogen, and

albumin Store fat soluable vitamins (A,D,E,K) Water soluable are excreted Produces bile (function to emulsify lipids)


Gallbladder Stores bile Sphincter of Oddi opens to release bile

into small intestine when lipids are present, otherwise remains closed


Small Intestine Begins at pyloric sphincter, ends at ileocecal valve About 21 feet long Where 90% of digestion and absorption occur Other 10% in stomach and large intestines 3 parts:1. Duodenum-(12 inches long) 2. Jejunum (8 feet long)3. Ileum (12 feet long)


Large intestine Parts of: Ascending, transverse, descending,

sigmoid, rectum Functions: Absorption of water, electrolytes, proteins into

amino acids, and bacterial products Feces formation Food in large intestine 3-10 hours for absorption

purposes Undigested food is expelled via “mass peristaltic

movement” out the anus

Pathology of The Stomach

Ulcers Gastritis Polyps Bezoar (hairball in animals/fiber ball in

humans) Carcinoma Lymphoma (benign or malignant)

Small Intestine

Duodenum Jejunum Ileum

Pathology of the Small Intestine

Ulcer (duodenum most common site) Neoplasm (benign or malignant) Obstruction Crohn’s Disease (Surgical intervention

needed with perforation, abscess or hemorrhagic fistula formation)

Colon Pathology

Appendicitis Adhesions Herniation Polyps Diverticulosis or Diverticulitis Tumor (benign or malignant) Ulcerative Colitis Obstruction Volvulus Intussusception Impaction

Anorectal Pathology

Fistula Fissure Pilonidal Cyst Hemorrhoids

Pathology of the Pancreas

Cyst Tumor (Benign or Malignant) Chronic Pancreatitis Trauma

Spleen

Largest lymphatic mass in body Composed of: 75% red pulp (vascular) 25% white pulp (lymphatic/immune

response) Functions: RBC and Plt storage Excision of renders liver and other

lymphatic tissues to pick up the slack

Pathology of the Spleen

Trauma Hematologic Disorders Tumor (Benign or Malignant) Cyst Splenomegaly

Liver

Largest organ in the body Comprised of 4 lobes Functions: *Bile production *Metabolism of fats, proteins and carbohydrates *Glycogen storage *Storage of fat soluable vitamins (A, D, E, K) and Fe,

Cu *Detoxification *Prothrombin and fibrinogen synthesis

Pathology of the Liver

Carcinoma Trauma FYI: Cirrhosis is related to hepatic cancer Cirrhosis results from hepatitis and

chronic alcohol abuse

Biliary Tract

Gallbladder, cystic duct, common bile duct, and common hepatic duct

Function: transport bile, store bile and release bile into the duodenum

Aids in digestion and absorption of fats Gallbladder divided into fundus, body and Hartman’s pouch Hartman’s pouch: most common site of gallstones (clog and

prevent passage of bile into cystic duct) Sphincter of Oddi: where CBD empties into

duodenum/controls release of bile into duodenum Ampulla or papilla of Vater is an enlarged area where the

duodenum joins CBD

Biliary Pathology

Acute Cholecystitis Cholelithiasis Chronic Cholecystitis Gallbladder calcification Tumor (benign or malignant)

Pre-Operative Testing & Diagnosis

Family History Symptomatic Liver Function Blood Tests Pancreatic Function Blood Tests Barium Studies Endoscopic Studies (Visualization, Biopsy, ERCP

with C-Arm) Ultrasound CT Scan MRI

Medications

Contrast Media (Hypaque) Dye Antibiotic Irrigation Topical Hemostatics Local

Anesthesia

General MAC (IV Sedation) MAC (IV Sedation with Local) Spinal Epidural Local

Instrumentation

Minor tray Major Tray Intestinal Tray Gallbladder Tray Laparoscopic Tray Laparoscopic Accessories Extra Long Instrument Tray Scopes

Equipment

X-Ray Table Laparotomy Endoscopic Tower (video monitor,

insufflation tubing, insufflator, light cord, light source, camera box, camera, scope, scope warmer)

Supplies

Laparotomy Pack Basic Pack Laparotomy Sheet Universal Sheet Minor Basin Set Suture of Surgeon choice Kittners Gloves Blades Cholangiogram Supplies (Sterile specimen cup,

stopcock, IV tubing, 30cc syringes x 2)

Positioning

Supine

trendelenburg

reverse trendelenberg Kraske Lateral

Prepping

Betadine Scrub Betadine Paint Duraprep Alcohol Hibiclens Surgeon Preference

Draping

Towels Stapler or towel clips Optional Ioban or Vi-Drape Laparotomy Sheet Universal Sheet Surgeon Preference

Procedure for Opening Abdominal Cavity

Skin incised Blood vessels cauterized Fascia incised Muscle layers divided or separated Fascia incised Omentum displaced (intestinal bag prn) Peritoneum incised Abdominal cavity contents exposed

Abdominal Incision Type Considerations

Surgeon selects incision that will best expose the structure to be operated on

Surgeon selects incision that will create minimal trauma and post-operative pain

Surgeon selects incision that will allow for wound closure strength as closed by primary wound healing

Abdominal Incision Types

Right Subcostal gallbladder, biliary system Left Subcostal spleen Median Upper Abdominal stomach, duodenum, pancreas Median Lower Abdominal uterus, adnexa (ovaries, fallopian tubes), bladder

Abdominal Incision Types

Right Upper Paramedian stomach, duodenum, pancreas Left Lower Paramedian pelvic structures, colon McBurney appendix Left Oblique Inguinal hernia repair Lower Transverse (Pfannensteil) uterus, ovaries, and fallopian tubes

Dressings

Packing prn 4 x 4s ABD Pad Tape Will vary with Surgeon and Procedure

Drains

Penrose Jackson Pratt Snyder Blake May use grenades or hemovac Varies with Surgeon Preference and

Procedure

Postoperative Care & Considerations

PACU or ICU Minor procedures may D/C to home Possible complications: hemorrhage,

infection, recurrence of pathology, bowel obstruction, wound dehiscence or evisceration, atelectasis>pneumonia,

The Breast

Anatomy of the Breast

Mammary Gland Modified Sweat Glands Anterior to the Pectoralis Major Muscle 15 to 20 lobes Reproductive System (accessory) Secrete milk for infant Functionless in the male Well vascularized

Pathology of the Breast

Abscess Fibroadenoma (benign lesion) Cyst Lump (Benign or Malignant) Mass/Tumor (Benign or Malignant)

Diagnosis R/T Breast

Self-Breast Exam Mammogram Ultrasound Chest X-ray Bone Scan

Surgical Breast Procedures

Biopsy Lumpectomy Segmental Resection Simple Mastectomy (preservation of

pectoralis muscles and axillary nodes) *Modified Radical Mastectomy

(preservation of pectoralis muscles) Radical Mastectomy

Equipment/Instruments/Supplies

Routine (armboards) Minor tray Breast Retractors Extra hemostats Plastic Tray (prn) Laparotomy pack Minor basin set Suture of surgeon choice Blades Gloves Dressing Drain of surgeon choice

Medications & Anesthesia

Local Antibiotic irrigation Dyes: Marking pen Isosulfan Blue (Vital Blue) Technetium

Biopsies will be done under Local General with local anesthesia

Sentinel Nodes

May hear or see “Sentinel node” associated with a breast procedure

This just refers to the first lymph nodes along the lymphatic channel from where the tumor originates

Not in the same place in every patient Helpful in determining extensiveness

of malignancy

Sentinel Node Biopsy

Isosulfan Blue (Vital Blue) “Rule of 5’s” 5ml, 5cm area, 5 sites, 5 minute

massage Remove blue stained nodes Await pathology results May involve further breast or axillary

dissection

Sentinel Node Biopsy

Technetium Injected in nuclear medicine department Is radioactive material “Rule of 6’s” 6ml, 6 sites, 6cm area, 6 minute massage

prior to exploration of nodes Wand passed over that detects “hot” areas Surgeon will mark site with a marking pen

and proceed with dissection of nodes or further intervention

Positioning

Supine Affected arm on armboard

Prep

Performed extensive in event need to extend excision

Anterior chest from neck to umbilicus, upper affected arm to affected axilla

Prep should be gentle particularly if open breast biopsy with needle (wire) localization in place

Draping

Laparotomy sheet or universal drape May use split sheet for affected arm

Dressing/ Drains/Post-op Care

Fluffy dressing Drains of surgeon choice PACU Post-operative complications: Hematoma, hemorrhage, infection,

cellulitis, impaired arm movement, anesthesia of anterior chest wall

Chemotherapy and/or Radiation

Vascular Access Procedures

Vascular Access Procedures

Cannulation of arteries and veins General surgeons primarily will do venous

access procedures (IVAD) Performed percutaneous or via cut-down Indicated for chemotherapy, nutrition (TPN),

blood product infusion, needle phobia, pediatric patients, CVP monitoring needed, exhausted peripheral venous access)

Types: Broviac, Groshong, Hickman, and Port-A-Cath

Complications of IVAD Insertion

Thrombosis Infection Nerve Damage Pneumothorax Hemorrhage due to inadvertent arterial

puncture

Dressing/Postoperative Care

Prior to placing port caps on lumens need to flush ports with 1.5ml to 3ml of Heparin 5,000ut per ml or heparin mixture of surgeon choice (refer to package insert)

Betadine or Neosporin ointment on site where catheter penetrates skin (surgeon preference

2 x 2 (surgeon preference) Tegaderm of appropriate size Surgeon may want you to cover patient with sterile drape until

chest x-ray performed to verify placement and intactness of pleura around lungs

If not, do not breakdown table until line placement verified Carefully remove drapes so as not to dislodge catheter (place

a towel over entire area prior to drape removal)

CARE & HANDLING OF

ENDOSCOPES

Endoscopes

1. Diagnostic 2. Operative (channeled) Rigid Visualization: Direct (0°) Angled (30, 70, 120°) Semi-rigid Flexible Visualization: Panoramic

Two Types of Flexible:1. Fiberoptic Visualization through eyepiece Connect to light source2. Videoscope Visualization on monitor Connect to light source and camera

Diagnostic Endoscopes

Diagnostic purposes (looking around) No operating channels Can be used if more than one port will

be utilized (cholecystectomy, thoracoscopy, etc.) for visualization during utilization of other laparoscopic instrumentation for operative puposes

Operative Endoscopes

Channeled: irrigation, suction, insertion of biopsy forcep or needle, connection of accessory instruments such as cautery or laser

Normally involves one port access (cystoscopy)

Can always use another port

Use & Care of Endoscopes

Light Cords/Source Incandescent first used Problem: patient tissue damage due

to the intense heat that was transferred through the light source and cord


Light Cords/Source Fiberoptics used today “Cold Light” Heat is not transferred through the

scope No patient tissue damage


Light Cords/Source Cord ends DO get HOT Light source should be off prior to connection and

disconnection from the scope Avoid looking into light beam from light source or

cord Light cords may not have universal fitting Are adaptors Light cords usually specifically made to fit the scope Do not bend cord/coil loosely due to multiple glass

fragments (hence fiber optics) contained in the cord


Scopes Should keep scope in a scope warmer until ready to

use on the field to avoid fogging of the scope as a cold scope passing into a warm patient’s body WILL fog

DO NOT place “Operative Scopes” in a scope warmer

Avoid bending the scope where eye piece attaches to scope itself (If loose have poor visibility)

Avoid slamming or scratching the scope


Connection of scope, camera, light cord = “White Balancing” Prior to passing to surgeon for use must white balance the

scope Cannot do this until all parts are connected and all tower

sources are turned on Allowance of camera to pick up white so it will be able to

differentiate primary colors for optimal visualization Hold scope close to a white sponge, lap, towel May be done on the field by pressing balance button on newer

cameras or by the circulator pressing the balance button on the camera box


Cleaning: Keep endoscopic instruments as clean as

possible on the field Post-op clean per manufacturer’s

recommendations with proper enzymatic cleaning agent

Rinse thoroughly with water Dry thoroughly including ports and channels


High-Level Disinfection Intact mucous membranes Esophagoscope, colonoscope,

bronchoscope, laryngoscope, cystoscope

Sterilization Sterile/Intact tissue Vasculature Laparoscope, thoracoscope,

arthroscope, angioscope


High Level Disinfection Gluteraldehyde

FDA: soak 45 minutes

Other: soak 20 minutes

Rinse with sterile water (copious)

*follow institution’s policy

Sterilization Ethylene Oxide Peracetic Acid (Steris)

30 minutes

Should use soon after processed due to poor shelf life

Gastrointestinal Endoscopic Procedures

Anoscopy- examination of the anal mucosa Choledochoscopy- examination of the common bile

duct Colonoscopy- examination of the entire colon Esophagogastroduodenoscopy- (EGD)-

examination of the esophagus, stomach and duodenum

Esophagoscopy- examination of the esophagus Gastroscopy- examination of the stomach Proctoscopy- examination of the rectum Sigmoidoscopy- examination of the sigmoid and

rectum

Summary

Anatomy & Physiology, Pathology and Operative Considerations for:

GI System Breast IVAD Care & Use of Endoscopes

Documents

Introduction to the Gastrointestinal System. Summary Anatomy & Physiology, Pathology and Operative Considerations for: GI System Breast IVAD Care & Use