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