Perioperative management - Left hemicolectomy, open, curative

• Colon carcinoma of the descending colon
• Endoscopically non-(completely) resectable polyp with evidence of high-grade intraepithelial neoplasia.
• Presence of a tumorous change whose dignity cannot be clearly determined.
• Stenoses of other genesis, e.g., in Crohn's disease

In the present case, it is a clinically T3 carcinoma just below the left flexure without evidence of distant metastasis in the liver or lung. For this reason, indication for left hemicolectomy. The middle colic artery will not be resected due to the patient's advanced age and the tumor's distant location.

• Severe comorbidity

Limited operability, e.g., due to severe lung disease, heart failure, liver cirrhosis, etc.; whether this comorbidity constitutes a contraindication to surgery must be assessed individually.

• Primary tumor that does not cause symptoms in the case of unresectable metastasis. In this case, initiation of systemic therapy is recommended.

Colon Carcinoma:

• Clinical examination
• Laboratory tests (including tumor markers CEA and CA19-9)
• Complete colonoscopy; if colonoscopy is not possible or cannot be completed due to a stenosis: Pneumocolon CT or repeat colonoscopy 3-6 months postoperatively.
• Biopsies for histological confirmation
• CT thorax/abdomen
• Possibly MRI liver, contrast-enhanced ultrasound liver

Crohn's Disease:

• A Sellink MRI examination is useful to exclude Crohn's involvement with stenoses in the small intestine.

• For carcinomas with an increased risk of recurrence, a recommendation for neoadjuvant systemic therapy is emerging.
• In the case of distant metastases, an interdisciplinary tumor board decides on further therapy.
• Perioperative antibiotic prophylaxis, e.g., with a second or third-generation cephalosporin combined with metronidazole (effective against anaerobes)
• Review of anticoagulant therapy: Perioperative therapy with aspirin can be continued. Clopidogrel (ADP inhibitor) should be paused at least 5 days prior. Vitamin K antagonists should be paused 7 days, NOACs (new oral anticoagulants) at least 3 days preoperatively, bridging with short-acting heparins.
• Preoperative bowel preparation: Current data supports anterograde bowel lavage with the addition of topical antibiotics. See also
• Shaving of the abdominal wall
• Insertion of an indwelling catheter

The most important aspects

• Anastomotic insufficiency
• Septic complications such as intra-abdominal abscess and wound infections
• Injury to the spleen and pancreas
• Injury to the left ureter

Other standard points of clarification are

• Thrombosis and embolism
• Necessary blood transfusions
• Postoperative bleeding
• Incisional hernia

The left hemicolectomy is usually always performed under

• general anesthesia. In the case of a conventional approach with laparotomy, it is advisable to place a
• epidural catheter for intraoperative anesthesia management and postoperative pain therapy. In the case of laparoscopic surgery, this measure can be omitted.

• Lithotomy position
  Advantage: if, depending on the variable tumor location, a sigmoid resection is performed or the sigmoid is resected, making an anastomosis to the upper rectum necessary. Here, both the preparation and, in the case of a stapler anastomosis, the positioning in the lithotomy position are extremely helpful.
• Abduction of both arms

Note: if the patient is operated on laparoscopically, it is advisable to position the right arm, as the camera assistant must stand very cranially next to the patient.

• Surgeon to the right of the patient
• First assistant opposite him on the left side
• Second assistant between the patient's legs
• Surgical nurse to the left of the first assistant
• Instrument table over the patient's left leg

The laparotomy is performed with a scalpel, and further incision of the abdominal wall is done using monopolar diathermy. The abdomen is kept open with a retractor system, with both costal arches being elevated cranially/ventrally using hook systems. The dissection is carried out with monopolar diathermy and scissors, with vessel transections between ligatures using absorbable sutures of size 3/0 braided. Intestinal anastomosis end-to-end is also performed with absorbable suture material 3/0, either continuously extramucosal or in single button suture technique.

Postoperative Analgesia:

Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management)
Follow the link here to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up:

Early removal of intraoperatively placed drains. Regular wound checks, if not absorbable – removal of skin sutures around the 12th postoperative day.

In case of recurrent vomiting, insertion of a nasogastric tube for decompression of the gastrointestinal tract and aspiration prophylaxis.

7 days after inadequate food intake, parenteral caloric nutrition with 25-30 kcal/kg body weight (Protein:Fat:Carbohydrates – 20:30:50) should be started.

Follow-up: In stages II and III, regular follow-up examinations are indicated. In UICC Stage I, colonoscopies are sufficient as follow-up to detect secondary tumors.

Thrombosis Prophylaxis:

In the absence of contraindications, due to the high risk of thromboembolism, low molecular weight heparin should be used in prophylactic, possibly disposition risk-adapted dosing, in addition to physical measures. Note: Renal function, HIT II (history, platelet monitoring). Follow the link here to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization:

Immediate mobilization is aimed for, on the evening of the day of surgery, at the latest on the morning of the following day.

Physical Therapy:

No specific physical therapy required, possibly support for patients with, e.g., pulmonary impairment.

Dietary Progression:

The nasogastric tube should be removed on the day of surgery, and the patient can drink on the same day post-surgery. In most clinics, it is customary to provide easily digestible food on the 1st postoperative day, such as soups. On the 2nd and 3rd days, a quick progression to solid food is possible, initially given in relatively small portions.

Bowel Regulation:

Physiologically, a postoperative ileus occurs after left-sided open hemicolectomy, lasting about 2–3 days. From this point, the bowel can be stimulated with various medications. 

From the 3rd-4th postoperative day, if no spontaneous bowel movement has occurred by then, administration of an oral laxative. In case of bowel paralysis, 3×1 mg Neostigmine (slowly over about 2 hours; CAVE off-label use) and 3 x 10 mg Metoclopramide each as KI i.v..

Incapacity for Work:

Individually depending on the surgical indication (underlying disease) and the profession practiced, between 4 and 6 weeks; not foreseeable in advanced tumors.