Perioperative management - Laparoscopic colectomy with ileorectostomy - general and visceral surgery
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Indications
- 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.
Contraindications
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
Preoperative diagnostic work-up
- 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
Special preparation
- 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
Informed consent
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
Anesthesia
Patient positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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