Perioperative management - Laparoscopic oncological sigmoid resection

• Malignant tumor in the area of the sigmoid colon
• Endoscopically non-resectable polyp in the sigmoid colon with evidence of high-grade intraepithelial neoplasia.
• Presence of a tumorous lesion whose dignity cannot be clearly identified.

In the present case, it is an endoscopically resected polyp with not tumor free margins, a malignant polyp pT1 sm3 R1. In the tumor board, due to the sm3/R1 finding, completion as a laparoscopic-oncological sigmoid resection was recommended.

• General contraindications for laparoscopic procedures (e.g., intolerance to pneumoperitoneum, extreme positioning, or presence of ileus).
• Severe intra-abdominal adhesions
• Generalized peritonitis
• T4 tumor with infiltration of surrounding structures, where resection is not technically feasible laparoscopically.
• Relative contraindications: Severe coagulation disorders (Quick < 50%, PTT > 60 sec., platelets < 50/nl), severe portal hypertension with caput medusae.

• Clinical examination
• Laboratory tests (including tumor markers CEA and CA19-9)
• Complete colonoscopy; if colonoscopy is not possible or cannot be completed: Pneumocolon CT
• Obtaining biopsy samples
• CT of the chest/abdomen
• Possibly MRI of the liver, contrast-enhanced ultrasound of the liver

• 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, NOAC (new oral anticoagulants) at least 3 days preoperatively, bridging with short-acting heparins.
• Preoperative bowel preparation: Current data supports antegrade bowel irrigation with the addition of topical antibiotics.
• Shaving of the abdominal wall
• Marking the optimal location for a potential stoma on the abdominal wall

in the OR:

• Insertion of an indwelling catheter
• Perioperative antibiotic therapy with Unacid

• Bleeding/postoperative bleeding with administration of donor blood and possibly surgical revision
• Anastomotic insufficiency with local or generalized peritonitis and subsequent sepsis, reoperation, discontinuity resection, or creation of a protective ileostomy
• Impotentia coeundi in men, fecal incontinence, and bladder emptying disorders due to injury to the inferior hypogastric nerves
• Intra-abdominal abscess formation
• Injury to the left ureter, iliac vessels, internal genitalia (in women), bladder, spleen, kidney, pancreas
• Creation of a protective ileostomy
• Conversion
• Change in bowel habits
• Trocar hernia
• Risk of injury to the sphincter apparatus by stapler
• Local recurrence