introduction to the gastrointestinal system. summary anatomy & physiology, pathology and...
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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
Gastrointestinal Definitions
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
Gastrointestinal Definitions
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
Anatomy of Abdomen Continued
RLQ (right lower quadrant) contents:
cecum
appendix
right ovary and fallopian tube
right ureter
right spermatic cord
Anatomy of Abdomen Continued
LLQ (left lower quadrant) contents:
part of descending colon
sigmoid colon
left ovary and fallopian tube
left ureter
left spermatic cord
Anatomy of Abdomen Continued
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
Mechanical and Chemical Digestion
Esophagus: Begins at oropharynx Mucous allows food to slide down
Mechanical and Chemical Digestion
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
Mechanical and Chemical Digestion
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
Mechanical and Chemical Digestion
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
Mechanical and Chemical Digestion
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
Mechanical and Chemical Digestion
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)
Mechanical and Chemical Digestion
Gallbladder Stores bile Sphincter of Oddi opens to release bile
into small intestine when lipids are present, otherwise remains closed
Mechanical and Chemical Digestion
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)
Mechanical and Chemical Digestion
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
Use & Care of Endoscopes
Light Cords/Source Fiberoptics used today “Cold Light” Heat is not transferred through the
scope No patient tissue damage
Use & Care of Endoscopes
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
Use & Care of Endoscopes
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
Use & Care of Endoscopes
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
Use & Care of Endoscopes
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
Use & Care of Endoscopes
High-Level Disinfection Intact mucous membranes Esophagoscope, colonoscope,
bronchoscope, laryngoscope, cystoscope
Sterilization Sterile/Intact tissue Vasculature Laparoscope, thoracoscope,
arthroscope, angioscope
Use & Care of Endoscopes
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
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