The laparotomy enables the surgeon to view the abdominal cavity in order to see where the perforation has occurred in the bowel. The CT should indicate the site of the perforation and the site for resection. The presence of faecal contamination can preclude anastomosis of the bowel and surgery can be a Hartmann's operation that includes an end-stoma in the form of a colostomy. This type of surgery is intended to be a two-stage procedure, because the colostomy, at a future date, will need to be reversed and the bowel anastomosed. The severity of the condition will frequently determine the type of surgery (Krukowski, 1998). In 2001, a study in Spain of the efficacy of surgical management of acute complications in diverticular disease concluded that resection and intraoperative colonic lavage and primary anastomosis provided an alternative procedure for achieving a one-stage resection (Biondo et al., 2001).
Recent studies in Edinburgh have shown that emergency primary anastomosis in left-sided disease can be performed with a low morbidity and mortality in selected patients, even in the presence of a free perforation with diffuse peritonitis (Zorcolo et al., 2003).
An emergency operation will frequently mean that the patient will have neither counselling from the colorectal nurse specialist about the outcome of the surgery nor the possibility of formation or siting of the colostomy. This
lack of input can lead to postoperative problems in accepting the formation of a colostomy or an inappropriately sited stoma.
The lack of the preoperative counselling aspect can be overcome by the specialist nurse, but in a few cases a more formal counselling route may be necessary, such as a clinical psychologist. In the preoperative scenario a patient can ask questions, look at available literature or even meet a patient with a stoma. But preoperatively, if the patient is very unwell, all of this is irrelevant, because he or she will often say 'Do whatever you want'. It has been proved that a patient who is fully informed of impending stoma surgery will have improved postoperative recovery (White, 1997).
A stoma that has not been appropriately sited preoperatively can lead to problems in the actual management of the stoma (Black, 1994). The stoma, if sited on the operating table, gives a false idea of an ideal position. The table is hard, so creases and folds lie flat, and an assumption of where a patient's waist lies is all supposition by the surgeon. A stoma sited on the operating table is less likely to be in an ideal position and this alone can affect patient acceptance and the ability to cope with a stoma. A stoma that is planned is usually sited by the stoma care nurse specialist and gives the patient a chance to have input into the actual site. There is, however, a necessity to site the stoma within certain parameters (Readding, 2003) (see Chapter 8).
The patient with diverticulitis undergoing surgery is nursed on the colorectal ward and will remain in hospital between 5 and 14 days, depending on the type of surgery and hospital policy. Generally, patients will experience an uneventful postoperative recovery. There are a few patients who will have complications from their surgery, including:
• hospital acquired infection
• wound infection
• paralytic ileus
• bowels not working
• multisystem organ failure.
These complications will be treated in the normal way by the multidisciplinary team. The case history of Jane in Chapter 6 explains how one such complication was dealt with. Most patients will be discharged home with a definite diagnosis of diverticular disease and will not experience any further problems. They will have a routine 6-week follow-up appointment in the outpatient department and then be discharged.
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