Perioperative management - Left hemicolectomy, ArtiSential-assisted

• histologically confirmed malignant neoplasm of the descending colon
• adenoma in the descending colon that cannot be removed endoscopically or completely, with high-grade intraepithelial neoplasia
• any tumorous mass in the descending colon with a high suspicion of a malignant process even if definitive histological confirmation is not achieved

In Germany, the recommendations for the treatment of colon cancer are anchored in the S3 guideline. 

Source: S3 Guideline Colorectal Cancer (Guideline Program Oncology (German Cancer Society, German Cancer Aid, AWMF): S3 Guideline Colorectal Cancer. Long version 2.1 Status: January 2019, AWMF Registry Number: 021/007OL. Valid until 29.11.2022, Retrieved on: 22.11.2022)

Note:

Endoscopic resection is sufficient if an R0 situation is confirmed in histology for a low-risk pT1 tumor (submucosal infiltration < 1000 μm, grading G1 or G2, absence of lymphatic invasion (L0). In high-risk situations, a surgical oncological resection with removal of the anatomical lymphatic drainage areas must be performed.

A penetration depth into the submucosa up to 1000μm (sm1 and sm2) is associated with lymph node metastasis in 0–6% of patients. In sm3 tumors (>1000μm submucosal invasion), this rate is already 20% of cases. 

The general contraindications for the minimally invasive approach include:

• Contraindications for the creation of a pneumoperitoneum, e.g., 
  • due to severe systemic disease, 
  • or a manifest ileus with massive bowel distension
  • all clinical situations with an abdominal compartment syndrome
  • Massive adhesion abdomen (hostile abdomen)

Additionally, relative contraindications should be considered, where preoperative optimization may be possible, such as:

• Severe coagulation disorders (Quick < 50%, PTT > 60 sec., platelets < 50/nl), 
• pronounced portal hypertension with caput medusae

Staging

• Complete Colonoscopy
  •  Gold standard in the diagnosis of colorectal cancer
  • for localization diagnostics and histological confirmation and to exclude a second carcinoma (approximately 5% of cases)
  • If the entire colon is not visible colonoscopically, a CT or MR colonography can be used additionally
  • After emergency surgery (ileus, tumor perforation, colonoscopically uncontrollable bleeding): postoperative colonoscopy after anastomosis healing and patient recovery to exclude a synchronous double carcinoma
• Histopathological proof of malignancy
• CEA

Note: Other tumor markers such as CA 19-9, CA 125 are discussed, but without positive endorsement from the guidelines

• Chest X-ray in 2 planes
• Ultrasound of the abdomen
• Possibly CEUS (contrast-enhanced ultrasound) in case of suspected hepatic metastasis
• Possibly MRI liver in case of suspected hepatic metastasis

Note: Even though the S3 guideline considers a CT abdomen or CT thorax-abdomen as not necessary, it is performed in most clinics. It serves not only for the detection of hepatic metastases but also for the assessment of the primary tumor, possibly enlarged lymph nodes, and the assessment of the spatial relationship of the tumor-bearing colon to other structures, such as the ureters and their course.

Further Preoperative Surrounding Diagnostics

• Clinical examination
• Laboratory tests (surgical routine: CBC, CRP, electrolytes, blood sugar, coagulation, kidney function, liver function, bilirubin, blood type) + possibly 2 RBC units depending on clinic standard
• ECG
• Pulmonary function diagnostics if indicated by history
• ABG in COPD/COLD
• Cardiac echo with EF in case of suspected heart failure

Caution: After diagnostics are completed, the therapeutic phase of each colorectal cancer begins with presentation in an interdisciplinary tumor conference to determine the further course of action. 

• Preoperative Preparation on the Ward
  • Respiratory training: from the day of admission for pneumonia prophylaxis
  • Body care: shower the evening before (antiseptics)
  • Shaving: nipples to including genitals
  • AP care: if necessary, mark waterproof
  • Premedication by anesthesia: if no contraindication, always epidural catheter
  • In case of reduced general condition and nutritional status, additionally high-calorie enteral nutrition solution
  • (3 days preoperatively)
  • Thrombosis prophylaxis
  • Preoperative bowel preparation: Current data suggests anterograde bowel irrigation with synchronous administration of topical antibiotics (e.g., 8g Paromomycin orally at 8 PM on the pre-op day)
  • On the morning of the surgery: enema
  • Thrombosis prophylaxis (usually "Clexane 40"), compression stockings

Note: Preoperative checking and adjustment 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 7-10 days under INR control.
  • Vitamin K antagonists: Bridging with short-acting heparins if INR is outside the target range
  • DOAC (direct oral anticoagulants) should be paused 2-3 days preoperatively. Due to the short half-life of DOACs, bridging is generally not necessary. In cases of very high closure/insult risk: bridging under inpatient conditions with UFH
  • Always if necessary after consultation with the treating cardiologist
• Preoperative Preparation in the OR
  • Insertion of an indwelling catheter
  • Epidural catheter placement
  • Central venous catheter placement: usually during anesthesia induction.
  • Possibly artery during induction
  • Perioperative antibiotics with e.g., Unacid

Important points of informed consent:

• Indication, planned surgical procedure, postoperative care, possible alternatives
• Bleeding/postoperative bleeding with the administration of donor blood
• Drain insertion, catheter insertion
• Possible necessity of surgical revision due to a complication
• Anastomotic leakage with localized or generalized peritonitis and resulting sepsis, reoperation, open abdomen treatment, discontinuity resection, creation of a protective ileostomy, 
• Intra-abdominal abscess formation requiring interventional or surgical measures
• Wound infection
• Wound dehiscence
• Incisional hernia/trocar hernia
• Tumor recurrence
• Injury to the left ureter, iliac vessels, bladder, spleen, kidney, pancreas, small intestine, other sections of the colon
• Injury to the sphincter apparatus by the stapler
• Necessity of surgical extension
• Possibility/necessity of creating a stoma (protective ileostomy vs. end stoma as a "worst-case scenario")
• Conversion to a laparotomy 
• Change in bowel habits
• When entering the small pelvis: impotence in men, fecal incontinence and bladder emptying disorders due to injury to the inferior hypogastric nerves, injury to the internal genitalia in women

• Intubation anesthesia
• Placement of epidural catheter for postoperative pain therapy
• Possibly TAP block (Transversus abdominis plane block): Regional local anesthesia technique of the anterolateral abdominal wall: the local anesthetic is injected between the internal oblique muscle and the transversus abdominis muscle.
• two peripheral accesses with avoidance of a central venous catheter (preferred)
• in case of cardiac risk factors: arterial access

• Lithotomy position (French Position) ideally on a large vacuum cushion (on the right side, the cushion supports the rib cage and iliac crest, so the patient's weight in right lateral position does not press on the arm.
• Positioning of both arms (note: cotton wrapping when positioning with a cloth sling)
• Cotton wrapping of the knees and proximal lower legs
• Positioning of the legs in padded "boots" so that the legs can be moved separately and covered sterilely if necessary. Alternatively: Positioning of the legs in leg holders with fixation of the legs in these
• Legs can be angled and adjusted via the operating table control

Note: The positioning of the patient is of particular importance; positioning injuries should be avoided as much as possible. The patient must also be carefully secured against slipping during position changes and sometimes extreme positions.

Tip: Always perform a trial positioning, including the extreme positions to be performed in the operation, before washing.

Caution: Vacuum cushions can have leaks. Check again before sterile covering.

• Surgeon on the right side of the patient, can switch between the patient's legs during mobilization
• 1st assistant towards the head on the same side
• Instrumenting OR nurse at the foot of the surgeon

Special Instruments:

• Livsmed Artisential Bipolar Articulating Forceps
• Livsmed Artisential Monopolar Articulating Spatula
• Ethicon Enseal Articulating Tissue Sealer (G2 articulating tissue sealer)

ArtiSential™ instruments feature a double-jointed instrument tip and an ergonomic handle that facilitates movements and offers 7 degrees of freedom. Both vertical and horizontal movements are possible with ArtiSential™, perfectly synchronized with the user's hand.

By combining articulation with tactile feedback, ArtiSential™ laparoscopic instruments provide surgeons who require precise access for a range of surgical steps with full mobility and degrees of freedom.

Laparoscopic Instruments:

• Gas system for pneumoperitoneum
• Laparoscopic Atraumatic Bowel Grasper
• Laparoscopic Swab on a Stick
• Laparoscopic Suction-Irrigation System
• 29 Circular Stapler
• Alexis Wound Retractor Size S
• Camera (30°)
• Monopolar Scissors
• Clip Applier
• Linear Stapler (60mm, blue cartridge)
• 29 mm Circular Stapler

Basic Instruments:

• 11 Scalpel
• Dissection Scissors
• Langenbeck Retractor
• Suction System
• Needle Holder
• Suture Scissors
• Forceps
• Compresses, Abdominal Towels
• Swabs
• Tobacco Pouch Suture and Tobacco Pouch Clamp
• Suture material for the abdominal wall fascia in the area of trocars from 10 mm Vicryl 0 with UCLX needle, for the extraction incision PDS 0 or PDS 2/0. Subcutis (3-0 braided, absorbable), Skin (3-0 monofilament, absorbable)
• Possibly Veress Needle
• Possibly Backhaus Clamps
• Plaster

Trocars:

• One 10 mm Camera Trocar Infraumbilical (1)
• One 8 mm Trocar in the Right Upper Abdomen (2)
• Two 12 mm Trocars in the Right/Left Lower Abdomen (3), (4)
• One 5mm Assistant Trocar in the Epigastrium (5)

Instrument Setting:

• Port 1 (10 mm): Camera
• Port 2 (8 mm): Artisential Bipolar Forceps
• Port 3 (12 mm) Right LB: Artisential Monopolar Spatula (medial-to-lateral approach + TME)
• Port 4 (12 mm) Left LB: Artisential Monopolar Spatula (Mobilization of the Left Flexure)
• Port 5 (5mm): Assistant: Atraumatic Bowel Grasper
• Peranal: Circular Stapler

Note: Postoperative care following colorectal procedures should be integrated into a fast-track concept known as "enhanced recovery after surgery" (ERAS). This aims for rapid recovery and reduction of postoperative complications as well as hospital stay duration.

Key points of the perioperative ERAS concept are:

·       Preoperative eutrophy and normovolemia with fluid intake up to 2 hours preoperatively,

·       Contemporary anesthesia management and use of regional techniques,

·       Avoidance of drains and invasive access as much as possible,

·       Minimally invasive blood-sparing surgical technique,

·       Postoperative pain management with reduced opioid requirement,

·       Early mobilization,

·       Early nutritional build-up and

·       Timely discharge planning using discharge management

Postoperative Measures:

• Monitoring: post-op: recovery room, avoid ICU/IMC if medically possible
• Venous access: Central venous catheter removed by the 1st postoperative day, leave one cannula,
• Nasogastric tube removed at the end of the operation
• Urinary catheter: removed by the 1st postoperative day
• Drain removal: Target drain at the anastomosis removed by the 5th postoperative day at the latest, quadrant drain (after emergency surgery) removed from the 3rd postoperative day if volume < 100ml over 24h and clear secretion
• Mobilization: Early mobilization on the evening of the operation. Gradual resumption of physical activity, full load if symptom-free, e.g., on the day of the operation in the siesta chair, standing and walking in the room from the first day, mobilization in the corridor from the 2nd postoperative day
• Physical therapy
• Breathing exercises
• Nutritional build-up: Sip drinking + yogurt/high-calorie drink on the day of the operation, tea/soup/yogurt + high-calorie drink on the 1st postoperative day, light full diet from the 2nd postoperative day
• Infusion: 500-1000 ml on the first postoperative day, thereafter only if oral fluid intake is insufficient
• Antibiotics: Single-shot intraoperatively, or according to house standard for perioperative bowel decontamination

Note: Consider continuing antibiotics for perforated tumor, fecal contamination, ileus condition, or general risk factors.

• Bowel regulation/bowel activity: Mg 300 mg 3x/day until first bowel movement, then Macrogol 1-3 sachets/day, peristalsis should have started by the 3rd day, maintain potassium at high normal, laxative regimen: 1. Tea with Laxoberal/Dulcolax suppository, 2. Prokinetics: MCP / Prostigmin i.v., 3. Neostigmine s.c. or i.v., if necessary Relistor with opioid administration
• Thrombosis prophylaxis: In the absence of contraindications: for moderate thromboembolism risk (surgical procedure > 30 min duration): low molecular weight heparin prophylactically (usually "Clexane 40"), possibly in weight- or disposition risk-adapted dosage until full mobilization is achieved (also after discharge for malignancy possibly continue up to 4 weeks), physical measures, compression stockings

Note: Follow the link to the current guideline for the prophylaxis of venous thromboembolism (VTE).Prophylaxis of venous thromboembolism (VTE)

Caution: When administering heparin, consider: renal function, HIT II (history, platelet control)

• Laboratory: on the 1st postoperative day, and then every 2-3 days with normal progress until discharge, immediately if clinical deterioration

Note:CRP as an important marker for anastomotic insufficiency

• Dressing every 2 days, with cutaneous suction dressing every 5 days
• Staples/sutures: if not absorbable, remove after 10 days
• Postoperative analgesia

Note:Various scales are available for quantifying postoperative pain, allowing the patient to determine their own pain level multiple times a day, such as the NRS (numeric rating scale 0–10), the VAS (visual analog scale), or the VRS (verbal rating scale).

Caution: Aim for the greatest possible avoidance of opioids and NSAIDs (adverse effects on bowel motility and anastomotic healing)

• Epidural catheter removed by the pain service of anesthesia on the 3rd – 4th postoperative day
• Basic medication: Oral analgesia: 4x1g Novalgin/3x1 g Paracetamol, also combinable, e.g., fixed Novalgin and as needed Paracetamol up to 3x/day
• Administration of Novalgin: 1g Novalgin in 100 ml NaCl solution over 10 minutes as i.v., or 1 g as a tablet orally or 30-40 drops of Novalgin orally
• Administration of Paracetamol: 1g i.v. over 15 minutes every 8h, or 1g suppository every 8h rectally (Caution: consider anastomosis height), or 1g as tablets orally

Caution: The basic medication should be tailored to the patient (age, allergies, renal function).

• As-needed medication: For VAS >= 4 as needed Piritramid 7.5 mg as i.v. or s.c., or 5 mg Oxigesic acute
• If pain persists post-op >= 4, administration of a sustained-release opioid (e.g., Targin 10/5 2x/day)

Note: If pain occurs only during mobilization, as-needed medication should be given 20 minutes before mobilization.

Note: Follow the link toPROSPECT (Procedures Specific Postoperative Pain Management) and to thecurrent guideline for the treatment of acute perioperative and post-traumatic pain and consider the WHO step scheme.

• Discharge: From the 5th postoperative day
• Incapacity for work: Individually determined – according to the degree of recovery and the type of activity, e.g., office work after 3 weeks post-op, physical work after 4 weeks post-op
• Interdisciplinary tumor board to determine further procedure
• Follow-up treatment:
  • Adjuvant chemotherapy for colon cancer should be started as soon as possible after successful surgery if indicated.
  • According to the AWMF guideline, adjuvant therapy should be conducted from UICC stage III and can be conducted from UICC stage II.
  • Certain risk constellations are defined where adjuvant therapy should also be performed in stage II. These include: T4, tumor perforation/intraoperative tear, emergency surgery, too few lymph nodes.
  • In stage II with microsatellite instability, adjuvant therapy should be omitted.
  • In stage III, an oxaliplatin-containing adjuvant therapy should be used (FOLFOX4, mod. FOLFOX6, CAPOX/XELOX)
  • In stage II and with contraindications to oxaliplatin, monotherapy with fluoropyrimidines is recommended.
  • For low risk (T1-T3, N1), a three-month duration is recommended.
  • For high risk (T4 or N2), therapy should be conducted over 6 months.
• Discharge letter: The discharge letter should contain information on: diagnosis, therapy, course, histology, comorbidities, current medication, tumor board decision with intended follow-up treatment, note on patient education about the malignancy of the disease and further procedure, continuation of VTE prophylaxis, postoperative nutrition (avoid heavy food for 4-6 weeks)
• Rehabilitation treatment (AHB): Register through the social service
• Cancer registry notification