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

• Intubation anesthesia with capnoperitoneum
• Placement of epidural catheter for postoperative pain therapy
• Alternatively, intraoperative spinal anesthesia
• or TAP Block (Transversus abdominis plane block: Regional local anesthesia technique of the anterolateral abdominal wall, where the local anesthetic is injected between the internal oblique muscle and the transversus abdominis muscle.)
• A central line is omitted. Patients receive two peripheral lines and, in the presence of cardiac risk factors, an arterial line.

• French positioning on the vacuum mattress, i.e., supine position with horizontal abduction of the legs
• left arm abducted

• Surgeon on the right side of the patient
• 1st assistant towards the head on the same side
• 2nd assistant opposite the surgeon
• Surgical nurse at the foot of the surgeon

Basic Instruments for Laparoscopy:

• Scalpel No. 11
• Dissection Scissors
• Langenbeck Retractor
• Suction System
• Needle Holder
• Suture Scissors
• Forceps
• Gas System for Pneumoperitoneum
• Camera System (30-degree optics)
• Backhaus Clamps
• Gauzes, Abdominal Towels
• Swabs
• Tobacco Pouch Suture and Tobacco Pouch Clamp
• Suture Material for the Abdominal Wall Fascia in the Area of the Camera Trocars or the 12mm Trocar Vicryl 0, for the Extraction Incision PDS 0. Subcutis (3-0 braided, absorbable), Skin (3-0 monofilament, absorbable), Colon (4-0 monofilament, absorbable).
• Plaster

Trocars:

• Hasson Trocar 10mm
• 2 Working Trocars 5mm
• 1 Working Trocar for Linear Stapler 12mm

Additional Instruments:

• 2 Atraumatic Bowel Graspers
• Electric Curved Scissors
• Bipolar Dissection Instrument
• Swab Stick
• Suction-Irrigation System
• Linear Stapler (60mm, blue cartridge)
• 29mm Circular Stapler
• Clamp for the Spike of the Stapling Device (Head Grasper)
• Clip Applier with Titanium Clips
• Alexis Wound Retractor Size S
• Suture Catcher for Closure of the 12mm Abdominal Wall Incision

Postoperative Analgesia:

Postoperatively, patients receive non-opioids regularly, opioids only as needed. 
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:

The urinary catheter is removed in the OR, allowing early mobilization of patients (in the evening on the day of surgery). A central line is avoided.
Monitoring in the recovery room immediately postoperatively, then transfer to the general ward.

Thrombosis Prophylaxis:

In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30 min duration), in addition to physical measures, low molecular weight heparin should be administered prophylactically, possibly in a weight- or risk-adapted dosage until full mobilization is achieved.
Note: Renal function, HIT II (history, platelet monitoring)
Follow the link here to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization:

Early mobilization on the evening of the operation. Gradual resumption of physical activity, full weight-bearing if pain-free.

Physiotherapy:

Breathing exercises

Diet Progression:

Drinking on the day of surgery, soup, yogurt from day 1, light diet from day 2

Bowel Regulation:

Stimulation of bowel activity with parasympathomimetics (e.g., Neostigmine sc. 2x/d)

Discharge:

From the 4th postoperative day; sick leave individually – according to the degree of convalescence

Interdisciplinary Tumor Board to determine further procedures