Major Colorectal Surgery

1. Preparation

WHAT IS MAJOR COLORECTAL SURGERY?

Also known as major bowel surgery, colorectal surgery is an umbrella term for a number of operations involving the Colon (large bowel) and rectum (the terminal part of the large bowel). Surgery often involves resecting (removing) all or part of the colon. Sometimes after major surgery the bowel is brought to the surface and a stoma (artificial opening in the abdomen) is created, allowing for faeces to be passed into a bag adhered to the skin. This is termed a colostomy if the colon is involved, and an ileostomy if the ileum (small bowel) is used. This may be a temporary measure, and can be reversed when the bowel has recovered, or it may need to be permanent.

WHY IS IT DONE?

Major Colorectal surgery is usually performed to treat diseases such as cancer, ulcerative colitis, Crohn’s disease, and in some cases diverticulitis. Sometimes major colorectal surgery is needed to treat an acute condition such as a bowel obstruction (blockage) or haemorrhage (uncontrolled bleeding). The reasons for performing surgery and the outcome – whether the disease is cured or the aim is symptom relief – is dependent on the individual condition.

There are several different types of operation that can be classified as colorectal surgery:

Hemicolectomy – can be either left or right, and means approximately half the colon is removed.
Total colectomy – complete removal of the colon
Low Anterior Resection – Removal of the lower part of the colon and the top part of the rectum

Whether or not a stoma needs to be created, temporarily or permanently, depends on individual circumstance.

HOW DO I CHOOSE A SPECIALIST?

Your GP, or the doctor you first consult, will be able to recommend and refer you to a Surgeon who can perform the procedure. They will be termed either a General or Colorectal Sugeon.

You may be happy to accept the advice of your GP with regard to a specialist, or you may like to investigate your choices; either option is safe and valid. In Australia each medical speciality has a governing body to which the consultants belong. These are often good organisations to turn to for information about what you can expect from your medical specialist, and how to locate a specialist in your area. You can access the Royal Australasian College of Surgeons at www.surgeons.org, and the Colorectal Surgical Society of Australasia at www.cssa.org.au.

The list of questions below may help you to better understand your treatment, and if necessary decide on a particular doctor. Practical issues you may also like to consider are what hospital(s) does a particular doctor operate from, and what are their fees. (If you need more information about fee setting and gap arrangements, please refer to our brochure “what you should know before going into hospital”, which is also available on the HCF website)

To access a list of surgeons who participate in HCF’s Medicover no gap arrangement:

Call HCF Member Services on 13 13 34
Visit one of HCF’s customer service branches
Access HCF’s website at www.hcf.com.au / members / find a health professional / find a doctor

Please note: Participation in HCF’s no gap initiatives is at the doctor’s discretion. HCF does not guarantee that every medical service provided by these doctors will be a no gap service. Some doctors who participate in the HCF Medicover No Gap arrangement have chosen not to be listed on the HCF website. Patients are encouraged to confirm with their doctor whether they will support HCF’s no gap initiatives for their treatment.

WHAT SHOULD I ASK MY SPECIALIST?

Make sure you fully understand the procedure that is planned; do not be afraid to ask. It is your right to know all the relevant information, as this is part of informed clinical consent. Your doctor will ask you to sign a consent form.
What are the potential risks and complications associated with the procedure
What is the aim of treatment, and how likely is this to be achieved
In addition to what the procedure involves, you should also ask about:
- Preparation
- Follow up appointments and any further treatment that may be required
Most medication should be continued as usual, but some may interfere with the examination. Your doctor will inform you of the medication you should stop. As a guide, the following medication may require special instruction:
- Aspirin (or any related products),
- Blood thinners (Warfarin, heparin.),
- Arthritis medication,
- Pain medication,
- Insulin.

Don't forget to mention any homeopathic or herbal remedies you are taking, as these can have side effects and interactions too.

WHERE IS IT DONE?

The procedure can only be done in an overnight hospital.

HOW LONG IS THE PROCEDURE?

The time varies enormously depending on the exact nature and extent of your surgery – your time in theatre is likely to be within 2-4 hours.

WHO IS INVOLVED?

The Health professionals involved in the procedure are:

Your surgeon
Assistant Surgeon
Anaesthetist: You will be given a general anaesthetic during the procedure
Specialised Nurses for the procedure and recovery
Physiotherapist
Radiologist
Pathologist

HOW DO I PREPARE FOR SURGERY?

You may be advised to attend a pre-admission clinic at the hospital, where they will run some basic tests to determine your general health and fitness for surgery. These include an ECG (echocardiogram, recording of your heart rhythm), chest x-ray, and blood tests. If you are a smoker and cannot give up completely, giving up in the weeks leading up to your operation may help to reduce the risk of post-operative complications such as chest infection.

If there is a possibility that you may have to have a colostomy or ileostomy performed, most hospitals have a specialist nurse who will help you learn to cope both practically and emotionally with the stoma. You may be introduced to the nurse at the pre-admission so that you can better prepare yourself for this aspect of your procedure.

You may be placed on a restricted diet for several days prior to the procedure and a liquid diet may be necessary a day before the surgery, with nothing by mouth after midnight. The bowel will need to be emptied of stool, therefore you will need to drink a bowel preparation to empty and cleanse the bowel. You may be required to receive an enema. Some oral anti-infectives (neomycin, erythromycin or kanamycin sulfate) may be given to reduce bacteria in the intestine, which will assist in preventing post-operative infection.

Your doctor will have his/her own specific preparation requirements. These instructions should be strictly followed or the procedure may be unsatisfactory and may have to be repeated later.

WHAT DO I TAKE WITH ME TO THE HOSPITAL?

Do not bring any valuables with you – a small amount of change for newspapers etc is all you should need
It’s best not to wear any jewellery (sometimes plain bands are acceptable)
Take comfortable day clothing in addition to nightwear and a gown or robe
Supportive slippers or rubber soled shoes
Bring any medication that you usually take, under most circumstances you may still be able to take these
Any recent, relevant x-rays and scans
You may also wish to bring something to read
Remove all nail polish and do not wear any make-up

2. Costs and Charges

WHAT IS IT GOING TO COST?

Ask your doctor whether he/she will participate in HCF’s no gap arrangement for your surgery so that you do not incur any out of pocket expense. If your doctor does not wish to participate, it is your doctor’s responsibility to fully inform you of your financial liability and any out of pocket expense prior to you consenting to the surgery.

For your information, the average charges for claims paid for Colon Surgery admissions for the financial year 06/07 are provided below:

	On Average
	Charge	Medicare Pays	HCF Pays	³ If your doctor DOES NOT use HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor DOES NOT use HCF’s No Gap Arrangement	⁴ If your doctor USES HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor USES HCF’s No Gap Arrangement
Total Average Hospital Component (accommodation, theatre and hospital related services)	$8,307		$8,109
¹ Medical Services Component
Anaesthetic Services	$1,041	$406	$135	$636	41.0%	$0	59.0%
Assistant in Operations Services	$348	$173	$58	$239	31.1%	$0	68.9%
Colorectal Surgical Services	$1,566	$738	$246	$1,023	35.9%	$0	64.1%
Pathology Services	$680	$443	$148	$150	12.5%	$0	87.5%
Specialist Consultation	$475	$284	$95	$150	11.1%	$0	88.9%
² Total Average Medical Services	$3,779	$1,859	$620	$1,144	61.8%	$0	38.2%
Hospital and Medical Services Average for Colon Surgery Admissions	$12,086	$1,859	$8,729	$1,144	61.8%	$0	⁵ 38.2%

Points to Note:

Charges are based on HCF claims for a sample size of 217 overnight admissions with an average length of stay of 9.2 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation, theatre and hospital related services) – covered under Medicare items 32003 and 32005.
As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation, theatre and hospital related services).

¹These medical services are in-patient services only.

²The medical charges are based on averages and each episode of care is different, i.e.

you may not have all of these medical services, and/or you may also have other medical

services not indicated here e.g. radiology. Therefore, the total average medical service

charge ($3,779) differs from the sum of the individual average charges as shown.

³Doctors who do not use the HCF no-gap arrangement have a higher average out of

pocket charge, as their charges are higher than those doctors who use the no-gap

arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the

average benefits plus the average out of pocket charge you pay will not equate to the

charge as shown in the table.

⁴Doctors’ charges vary so always ask your doctor whether he/she will participate in

HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the

Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered

under the HCF Medicover No Gap arrangement will receive as full payment for

services provided. This also applies to unregistered providers should they charge within

the schedule of benefit listed. This arrangement ensures that our members incur no out of

pocket expense.

⁵This percentage indicates the total coverage of hospital and medical services for all

colon surgery admissions. The percentages shown for each type of medical service are

much higher as they are calculated for those services only and not the entire admission,

which includes all medical services and the hospital services. In an admission you may

have one medical service with an out of pocket expense, which then excludes the whole

admission from being fully covered. Hence the significant difference in percentage for

individual types of medical services as compared to the total admission fully covered.

For your information, the average charges for claims paid for Rectal Surgery admissions for the financial year 06/07 are provided below:

	On Average
	Charge	Medicare Pays	HCF Pays	³ If your doctor DOES NOT use HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor DOES NOT use HCF’s No Gap Arrangement	⁴ If your doctor USES HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor USES HCF’s No Gap Arrangement
Total Average Hospital Component (accommodation, theatre and hospital related services)	$12,539		$12,337
¹ Medical Services Component
Anaesthetic Services	$1,368	$547	$182	$756	38.7%	$0	61.3%
Assistant in Operations Services	$521	$263	$88	$344	30.7%	$0	69.3%
Colorectal Surgical Services	$2,471	$1,152	$384	$1,474	41.6%	$0	58.4%
Pathology Services	$775	$503	$168	$180	15.1%	$0	84.9%
Specialist Consultation	$626	$371	$124	$85	18.9%	$0	81.1%
² Total Average Medical Services	$5,357	$2,613	$871	$1,708	59.7%	$0	40.3%
Hospital and Medical Services Average for Rectal Surgery Admissions	$17,896	$2,613	$13,208	$1,708	59.7%	$0	⁵ 40.3%

Points to Note:

Charges are based on HCF claims for a sample size of 221 overnight admissions with an average length of stay of 12.1 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation, theatre and hospital related services) – covered under Medicare items 32024, 32025 and 32026.
As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation, theatre and hospital related services).

¹These medical services are in-patient services only.

²The medical charges are based on averages and each episode of care is different, i.e.

you may not have all of these medical services, and/or you may also have other medical

services not indicated here e.g. radiology. Therefore, the total average medical service

charge ($5,357) differs from the sum of the individual average charges as shown.

³Doctors who do not use the HCF no-gap arrangement have a higher average out of

pocket charge, as their charges are higher than those doctors who use the no-gap

arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the

average benefits plus the average out of pocket charge you pay will not equate to the

charge as shown in the table.

⁴Doctors’ charges vary so always ask your doctor whether he/she will participate in

HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the

Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered

under the HCF Medicover No Gap arrangement will receive as full payment for

services provided. This also applies to unregistered providers should they charge within

the schedule of benefit listed. This arrangement ensures that our members incur no out of

pocket expense.

⁵This percentage indicates the total coverage of hospital and medical services for all

rectal surgery admissions. The percentages shown for each type of medical service are

much higher as they are calculated for those services only and not the entire admission,

which includes all medical services and the hospital services. In an admission you may

have one medical service with an out of pocket expense, which then excludes the whole

admission from being fully covered. Hence the significant difference in percentage for

individual types of medical services as compared to the total admission fully covered.

2. Day of procedure

WHAT HAPPENS TO ME AT THE HOSPITAL?

You will usually be admitted the day before surgery. When you arrive, the receptionist will do all the paperwork necessary for your stay. Once this is done you will be admitted to the ward, where nurses will show you around and help you settle in. They will also perform some routine tests and observations. Please ensure that you let the staff know of any medication you are taking (including homeopathic and herbal remedies) and any allergies that you may have.

You will have to start your ‘bowel preparation’ the day before theatre. It’s possible you may have a cannula – a small plastic tube – inserted into a vein in your arm or hand, and an intravenous drip started to ensure you stay hydrated during this process.

You will usually be seen by the anaesthetist the night before surgery. In addition to giving the anaesthetic, the anaesthetist is responsible for your overall safety during the procedure, so they will need to examine you, take a full history, and review all your test results. They will also prescribe your post operative analgesia (pain relief medication), so you should discuss all the options with them and make sure you understand the proposed plan.

At some stage before the operation, your surgeon will ask you to sign a form indicating that you understand the procedure and any possible risks, and that you give your consent to the operation. Although you will obviously have discussed this before being admitted to hospital, it’s never too late to ask questions.

Before being taken to theatre, you may be given a medication, a tablet and/or injection to make you slightly drowsy.

WHAT HAPPENS DURING THE OPERATION?

You will be wheeled on a trolley into the anaesthetic room. The first stage of the anaesthetic is to give you sedation through a cannula to make you sleep – you won’t be aware of anything else after this. Once you are asleep, a breathing tube will be placed through the mouth into your throat, a tube will be placed through the nose into the stomach, and a catheter placed in the bladder. You will be attached to sophisticated machines that monitor your vital signs throughout the surgery.

The extent of the resection will depend on the site of the tumour or damage. The usual approach is by an incision that may be up to 40cm long down the centre of your abdomen. The procedure involves the removal (resection) of the damaged part of the intestine and reconnecting or joining (anastomosis) the healthy parts of the intestine. Sometimes, in order to allow the remaining bowel and anastomosis to heal, a stoma is created by bringing either the end of the bowel or a loop of healthy bowel to the surface of the abdomen.

3. Aftercare

WHAT HAPPENS AFTER THEATRE?

Depending on the extent of surgery and your general health, you may be admitted to the intensive care unit after your surgery. This is a precautionary measure only, as the care you receive will be very similar to that which is provided on the surgical ward.

Whether you wake in Intensive Care, or in the recovery unit prior to being transferred back to the ward, you will have frequent monitoring of your blood pressure, pulse, respiration and temperature. You will be wearing an oxygen mask or nasal prongs (small plastic tubes in your nostrils), and will continue to do so usually for several days.You will probably have a drain in your abdomen to ensure any excess fluid is safely removed.

The tube that is passed through your nose into the stomach will remain in place, and will sometimes be secured to low, periodic suction until bowel activity starts up again. You will not be able to eat or drink anything for at least the first couple of days (although you will usually be able to suck ice chips or have very small sips of water). This means that you will have to receive pain medication via an injection, either into the vein or muscle. You will usually receive a strong narcotic such as morphine; often this is delivered via a PCA (patient controlled analgesia) which means you press a button and have a certain amount of control over the amount you receive. This will be fully explained and supervised by the nurses looking after you.

You will be encouraged to be as mobile as possible after your surgery because it helps to accelerate your recovery, and reduces the risk of complications such as chest infections and blood clots in the legs. Because of the incision and possible pain in your abdomen, you may need encouragement to take deep breaths after the operation; the nurses and physiotherapists will help you with exercises that will expand your lungs. You will usually be helped out into a chair, and possibly take a small walk, the morning after your surgery.

You will need to remain on an intravenous drip to keep you hydrated until you are able to eat and drink normally. After any type of bowel surgery the bowel is shocked into immobility, and must be allowed to rest before re-introducing your diet. Some surgeons will wait for signs that the bowel is working again (usually ascertained by listening with a stethoscope for bowel sounds), and some will just wait a few days before allowing gradual resumption of fluids and then food.

If you have had a stoma created, the Stoma therapist (specialist nurse) and the nurses on the ward will care for it initially, and teach you to do the same before you are discharged. Everyone is sensitive to the psychological implications of having a stoma formed, and you will be given help and support to adjust, whether it’s temporary or permanent.

The average length of stay according to our data for all colorectal surgical procedures is 10 days, but this will vary according to the specific nature of your illness and surgery.

Before discharge, ensure you are clear on the following issues:

Any wound care necessary and stoma care if relevant
Any limitations on activity and lifting
Restrictions on driving (its also worth checking with your car insurance company in case they have any restrictions following major surgery)
Symptoms for which you should seek further medical attention
Any changes to your regular medicaton

You will given a follow up appointment to check your progress. You may need to be referred to another specialist such as an oncologist (cancer specialist) for further treatment.

1. Preparation

WHAT IS MAJOR COLORECTAL SURGERY?

WHY IS IT DONE?

There are several different types of operation that can be classified as colorectal surgery:

Hemicolectomy – can be either left or right, and means approximately half the colon is removed.
Total colectomy – complete removal of the colon
Low Anterior Resection – Removal of the lower part of the colon and the top part of the rectum

Whether or not a stoma needs to be created, temporarily or permanently, depends on individual circumstance.

HOW DO I CHOOSE A SPECIALIST?

Your GP, or the doctor you first consult, will be able to recommend and refer you to a Surgeon who can perform the procedure. They will be termed either a General or Colorectal Surgeon.

To access a list of surgeons who participate in HCF’s Medicover no gap arrangement:

Call HCF Member Services on 13 13 34
Visit one of HCF’s customer service branches
Access HCF’s website at www.hcf.com.au / members / find a health professional / find a doctor

WHAT SHOULD I ASK MY SPECIALIST?

Make sure you fully understand the procedure that is planned; do not be afraid to ask. It is your right to know all the relevant information, as this is part of informed clinical consent. Your doctor will ask you to sign a consent form.
What are the potential risks and complications associated with the procedure
What is the aim of treatment, and how likely is this to be achieved
In addition to what the procedure involves, you should also ask about:
- Preparation
- Follow up appointments and any further treatment that may be required
Most medications should be continued as usual, but some may interfere with the examination. Your doctor will inform you of the medications you should stop. As a guide, the following medications may require special instruction:
- Aspirin (or any related products),
- Blood thinners (Warfarin, heparin.),
- Arthritis medications,
- Pain medication,
- Insulin.

Don't forget to mention any homeopathic or herbal remedies you are taking, as these can have side effects and interactions too.

WHERE IS IT DONE?

The procedure can only be done in an overnight hospital.

HOW LONG IS THE PROCEDURE?

The time varies enormously depending on the exact nature and extent of your surgery – your time in theatre is likely to be within 2-4 hours.

WHO IS INVOLVED?

The Health professionals involved in the procedure are:

Your surgeon
Assistant Surgeon
Anaesthetist: You will be given a general anaesthetic during the procedure
Specialised Nurses for the procedure and recovery
Physiotherapist
Radiologist
Pathologist

HOW DO I PREPARE FOR SURGERY?

Your doctor will have his/her own specific preparation requirements. These instructions should be strictly followed or the procedure may be unsatisfactory and may have to be repeated later.

WHAT DO I TAKE WITH ME TO THE HOSPITAL?

Do not bring any valuables with you – a small amount of change for newspapers etc is all you should need
It’s best not to wear any jewellery (sometimes plain bands are acceptable)
Take comfortable day clothing in addition to nightwear and a gown or robe
Supportive slippers or rubber soled shoes
Bring any medication that you usually take, under most circumstances you may still be able to take these
Any recent, relevant x-rays and scans
You may also wish to bring something to read
Remove all nail polish and do not wear any make-up

2. Costs and Charges

WHAT IS IT GOING TO COST?

For your information, the average charges for claims paid for Colon Surgery admissions for the financial year 06/07 are provided below:

	On Average
	Charge	Medicare Pays	HCF Pays	³ If your doctor DOES NOT use HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor DOES NOT use HCF’s No Gap Arrangement	⁴ If your doctor USES HCF’s No Gap Arrangement YOU PAY	% of all admissions where your doctor USES HCF’s No Gap Arrangement
Total Average Hospital Component (accommodation, theatre and hospital related services)	$8,307		$8,109
¹ Medical Services Component
Anaesthetic Services	$1,041	$406	$135	$636	41.0%	$0	59.0%
Assistant in Operations Services	$348	$173	$58	$239	31.1%	$0	68.9%
Colorectal Surgical Services	$1,566	$738	$246	$1,023	35.9%	$0	64.1%
Pathology Services	$680	$443	$148	$150	12.5%	$0	87.5%
Specialist Consultation	$475	$284	$95	$150	11.1%	$0	88.9%
² Total Average Medical Services	$3,779	$1,859	$620	$1,144	61.8%	$0	38.2%
Hospital and Medical Services Average for Colon Surgery Admissions	$12,086	$1,859	$8,729	$1,144	61.8%	$0	⁵ 38.2%

Points to Note:

Charges are based on HCF claims for a sample size of 217 overnight admissions with an average length of stay of 9.2 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation, theatre and hospital related services) – covered under Medicare items 32003 and 32005.
As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation, theatre and hospital related services).