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