Perioperative management - Right hemicolectomy, laparoscopically assisted

• Adenocarcinoma of the cecum and ascending colon
• Carcinoid of the appendix, if an appendectomy is not oncologically sufficient

• Adenocarcinoma of the right colonic flexure
• Familial adenomatous polyposis (restorative proctocolectomy with ileoanal pouch anastomosis)
• Cancers on the basis of ulcerative colitis (restorative proctocolectomy with ileoanal pouch anastomosis)

• Complete colonoscopy with biopsies for histological confirmation, preferably with ink marking for easy intraoperative localization.
• Laboratory: CBC, CRP, coagulation, creatinine, electrolytes, blood type, antibody screening test, CEA
• Abdominal ultrasound, chest X-ray in 2 planes, possibly liver MRI, contrast-enhanced liver ultrasound and/or CT of the thorax/abdomen

• generally unnecessary, but
• in case of suspected infiltration of the ureter by the tumor or involvement by the peritumoral inflammatory reaction, placement of a right-sided ureteral stent!

General Risks:

• Bleeding
• Rebleeding
• Thrombosis
• Embolism
• Wound infection

Specific Risks:

• Injury to the right ureter
• Injury to the duodenum
• Postoperative anastomotic insufficiency
• Scar and trocar hernia
• Anastomotic stenosis

• Intubation anesthesia and – if possible
• thoracic epidural catheter
• Normothermia (warming the patient)

• Supine position
• Both arms positioned alongside
• Shoulder supports and/or
• Vacuum mattress

• Surgeon on the patient's left
• 1st Assistant on the patient's left and to the right of the surgeon
• Instrumenting OR nurse on the patient's left, at the foot of the surgeon

• Laparoscopy tower, preferably in HD
• Laparoscopic instrument basic tray
• Laparoscopic sealing instrument based on diathermy (e.g., LigaSure™) or ultrasound (e.g., Harmonic Ace®)
• LaproClip™
• Laparoscopic irrigation suction device
• Ring drape (e.g., 7 cm; adjusted to tumor size)

Postoperative Analgesia:
adequate pain management; for more severe pain, additional analgesics; or follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) or follow the link to the current guideline Treatment of acute perioperative and post-traumatic pain.Medical Follow-up:
regular laboratory checks; if inserted – removal of abdominal drainage between the 1st and 2nd postoperative day; if non-absorbable – removal of skin suture material around the 12th postoperative day
Thrombosis Prophylaxis:
in the absence of contraindications, due to the high risk of thromboembolism, low molecular weight heparin should be administered in a prophylactic dose, possibly adjusted to the risk of disposition, for at least 2, possibly up to 6 weeks. Note: renal function, HIT II (history, platelet control). Follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).Mobilization:
immediate mobilization; gradual resumption of physical activity until full load.
Physiotherapy:
physiotherapy and breathing exercises
Dietary Progression:
in the absence of atony, nausea, and vomiting, start with drinking and, for example, two yogurts on the day of surgery; if tolerated, immediate dietary progression to desired diet.
Bowel Regulation:
if necessary, laxatives from the 2nd day; in case of intestinal paralysis, 3×1 mg neostigmine (slowly over about 2 hours; CAVE off-label use) and 3x 10 mg metoclopramide each as IV contraindication.
Incapacity for Work:
individually depending on the surgical indication (underlying disease) and the profession practiced between 3 and 6 weeks.