Perioperative management - Laparoscopic colectomy with ileorectostomy

• Prophylactic surgery for familial adenomatous polyposis (FAP) of the colon with manageable involvement of the rectum; this situation is seen particularly in attenuated FAP.
• Multiple carcinomas in the right and left hemicolon; in this case with radical resection of the vessels close to their origin and lymphadenectomy.

General contraindications

• Familial adenomatous polyposis of the colon involving the rectum (restorative proctocolectomy with ileoanal pouch anastomosis)
• Cancer secondary to ulcerative colitis (restorative proctocolectomy with ileoanal pouch anastomosis)

• Limited operability because of severe underlying comorbidity (e.g., severe lung disease, heart failure, liver cirrhosis, unmanageable coagulopathy, etc.) Whether this comorbidity is a contraindication to surgery must be assessed individually for each patient.

Relative contraindications to laparoscopic surgery

• Extensive intraabdominal adhesions

• Generalized peritonitis

• T4 tumor invading surrounding structures or large colon tumor (> 8 cm) of uncertain behavior and not amenable to laparoscopic resection for technical reasons

• Colonic obstruction with massive distension

• Toxic megacolon

• Complete colonoscopy, if necessary, with tattooing for easy intraoperative localizing of polyps and adenomas
• Lab panel: blood count, CRP, coagulation, creatinine, electrolytes, blood group, antibody screening, CEA
• Abdominal ultrasonography, chest X-ray (two views); if necessary, MRI of the liver, contrast enhanced ultrasonography of the liver, and/or CT chest/abdomen

• Orthograde colonic lavage
• Shaving of the abdominal wall
• Marking the best location for a possible stoma on the abdominal wall

In the operating room:

• Placement of indwelling catheter
• Single dose antibiotic ( e.g., cefotaxime + metronidazole)
• Trial positioning after mounting the patient supports on the OR table

General risks

• Bleeding
• Secondary bleeding
• Necessity of blood transfusions with corresponding transfusion risks
• Thromboembolism
• Wound infection
• Abscess
• Injury to adjacent organs/structures (left ureter, iliac vessels, female internal genitalia, bladder, spleen, kidney, pancreas)

Special risks

• Staple line failure with local or generalized peritonitis and subsequent sepsis, reoperation, Hartmann procedure or diverting ileostomy
• Impotentia coeundi in men, fecal incontinence  and impaired bladder voiding due to injury to the inferior hypogastric nerves
• Intraabdominal abscess formation
• Primary diverting ileostomy or primary Hartmann procedure
• Conversion to open surgery
• Changes in stool habits
• Trocar site incisional hernia
• Risk of stapler injury to the sphincter

General anesthesia in pneumoperitoneum

Intraoperative and postoperative analgesia with epidural anesthesia

• Goligher position
• Both arms adducted
• Shoulder supports on both sides
• Check patient positioning before draping

While dissecting the right hemicolon, the surgeon stands to the left of the patient facing the monitor on the patient's right side, the first assistant standing to the right of the surgeon.

From the time of dissecting the left hemicolon (step 7) until the end of the operation, the sides are switched, with a second monitor now positioned on the left side of the patient. Now the first assistant is standing to the left of the surgeon.

The scrub nurse stands between the patient's legs.

• Veress needle

• Gas supply for pneumoperitoneum

• Trocars (in video clip)
  1 Trocar (10 mm) for laparoscope
  1 Working trocar (12 mm)
  1 Working trocar (10 mm)
  3 working trocars (5 mm)

• Linear stapler

• CEA stapler

• Blake drains

Camera system

• ENDOEYE FLEX 3D, this camera system from Olympus features a deflectable tip allowing up to 100° angulation in all four directions. With simple, single-hand operation, this offers not only a frontal view of the tissue of interest, as with conventional laparoscopes, but also a view from other angles and it can even look back on itself. This flexibility of the field of view permits even difficult surgical techniques, as the available space inside the body can be used to the full.

Dissection instrument

• For vessel sealing - in the video the THUNDERBEAT from Olympus with integrated cutting function This innovative tissue management system integrates the simultaneous delivery of bipolar and ultrasound energy. The THUNDERBEAT surgical energy device is available with two handle types and in four working lengths. The system thus ensures reliable vessel sealing up to 7 mm in diameter with only minimal thermal spread. The slim tip design allows precise dissection, and thanks to reduced tissue spatter, surgeons have a better view of their area of interest. The new THUNDERBEAT system is a fast cutting instrument with the usual high level of patient safety.

Postoperative analgesia

• Continue epidural anesthesia until postoperative day 2 to 5

Follow these links to PROSPECT (Procedures Specific Postoperative Pain Management) Or the current German guideline: Guidelines on treatment of acute perioperative and posttraumatic pain.

Postoperative management:

• Remove Foley catheter on day of surgery if possible
• If used, remove abdominal drain between postoperative day 1 and 2
• If non-absorbable sutures were used, remove skin sutures around postoperative day 10.

Deep venous thrombosis prophylaxis:

Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 minutes) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached. Note: Renal function, HIT II (history, platelet check).

This link will provide you with the current German Guideline on Thromboembolism Prophylaxis

Ambulation

• Immediate ambulation
• Phased return to full physical activity

Physical therapy

• Possibly prophylactic respiratory therapy for pneumonia

Diet

• Day of surgery: Sipping only
• Postoperative day 1: Tea, soup, yogurt
• Starting postoperative day 2: Light food and return to unrestricted diet

Bowel movement:

• If necessary, laxatives may have to be started on postoperative day 2
• In case of intestinal paralysis, 3 × 1 mg neostigmine (slowly over about 2 hours; CAUTION off-label-use) and 3 x 10 mg metoclopramide as short infusions each.

Discharge

• Possible from postoperative day 4

Work disability

Depending on patient occupation between 3 and 6 weeks