Perioperative management - Rectal resection, robot-assisted with total mesorectal excision (TME)

In rectal cancer, curative therapy usually requires not only the resection of the primary tumor in healthy tissue (i.e., with sufficient safety margin) but also the partial or total removal of the mesorectum (PME, TME) and thus the removal of the regional lymphatic drainage area. Only in strictly selected cases is a curative resection possible through local measures.

The indications for robot-assisted deep anterior rectal resection therefore include:

• histologically confirmed malignant neoplasm of the rectum
• endoscopically non-removable or incompletely removable tumor with high-grade intraepithelial neoplasia
• any deeper tumor mass in the rectum with a high suspicion of a malignant process

The indication for the surgical procedure in rectal cancer fundamentally depends on the tumor localization, especially the relations to the dentate line and the levator muscle, the depth of infiltration, and the sphincter function. Whenever possible, sphincter-preserving procedures should be preferred, assessing the long-term quality of life. In cases of poor sphincter function, a permanent colostomy should be preferred instead of a deep anterior resection, which is then performed depending on the safety margin to be achieved from the pelvic floor as rectal extirpation or pelvic floor preserving. If an adequate aboral safety margin cannot be ensured through a low anterior resection of the rectum, the following procedures should be applied depending on the exact height localization and potential infiltration:

• intersphincteric rectal resection
• abdominoperineal rectal extirpation,

In Germany, the recommendations for the treatment of colon and rectal cancer are anchored in the S3 guidelines (S3 Guidelines Colorectal Cancer (Guideline Program Oncology (German Cancer Society, German Cancer Aid, AWMF): S3 Guidelines Colorectal Cancer. Status: 30.11.2017, valid until 29.11.2022, Retrieved on: 14.04.2023)

The following table summarizes the therapeutic concepts depending on the existing tumor situation and spread:

Notes:

• A full wall excision is only sufficient for T1 tumors with a diameter of less than 3 cm with good to moderate differentiation without lymphatic vessel invasion and after R0 resection. However, even here, a higher recurrence risk is to be expected with an overall significantly lower complication rate and better functional results. Technically, transanal microsurgery appears to be advisable.
• UICC II and III situations are usually subjected to a neoadjuvant concept with the operation preceded by radiotherapy or radio-chemotherapy for tumors of the middle and lower thirds. The concept for tumors of the upper third follows that of colon cancer (see contribution to robot-assisted oncological sigmoid resection).
• cT3 tumors of the middle third without lymphatic vessel or vascular invasion and with very limited perirectal fat tissue infiltration in MRI are usually also subjected to primary surgery.
• Complete response: In the (rather rare) cases where no tumor is detectable after neoadjuvant radio-chemotherapy clinically, endoscopically, and through imaging procedures (endosonography and MRI, alternatively possibly also CT), any surgery can be omitted. A prerequisite for a purely observational approach is the thorough explanation to the patient about the still insufficient validation of this approach and the patient's willingness to undergo very close follow-ups for at least 5 years. The optimal design for follow-ups or "watch & wait" is the subject of studies; the following follow-up procedure can be recommended according to an international expert commission: Follow-ups for 5 years after documentation of cCR; for three years every 3 months CEA, then every six months; for two years every 3 months digital-rectal examination, MRI, and endoscopy, then every six months; for 5 years CT thorax/upper abdomen months 6,12,24,36,48,60.

The general contraindications for robotic procedures are based on the general contraindications for minimally invasive procedures. This includes:

• Contraindications for the establishment 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 adhesions (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),
• severe portal hypertension with caput medusae

• Staging
  • Complete colonoscopy 
    • Gold standard in the diagnosis of colorectal carcinoma
    • for localization diagnostics and for histological confirmation and to rule out a second carcinoma (about 5% of cases)
    • If the entire colon is visible during colonoscopy, a CT or MR colonography can be used.
    • After emergency surgery (ileus, tumor perforation, colonoscopy not controllable bleeding): postoperative colonoscopy after anastomosis healing and patient recovery to rule out a synchronous double carcinoma 
  • Histopathological evidence of malignancy
  • CEA

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

•  
  • X-ray of the chest in 2 planes or CT of the chest
  • Ultrasound of the abdomen or CT of the abdomen
  • MRI of the small pelvis 
  • Rectal endosonography
  • If necessary, CEUS (contrast-enhanced ultrasound) in case of suspected hepatic filiation
  • If necessary, MRI of the liver in case of suspected hepatic filiation

Note: Even if a CT of the abdomen or CT of the thorax-abdomen is considered non-mandatory in the S3 guidelines, it is still performed in most clinics. 

• Further preoperative environmental diagnostics
  • Clinical examination
  • Laboratory tests (surgical routine: complete blood count, CRP, electrolytes, blood sugar, coagulation, kidney values, liver values, bilirubin, blood group) + if necessary 2 RBC´s (red blood cell units) depending on clinic standard
  • ECG
  • Pulmonary function diagnostics in case of history
  • Blood gas analysis (BGA) in case of COPD/COLD
  • Cardiac echo with ejection fraction (EF) in case of suspected heart failure

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

• Preoperative preparation on the ward
  • Breathing exercises: from the day of admission for pneumonia prophylaxis
  • Body care: shower on the evening before (antiseptics)
  • Shaving: from nipples to the genitalia
  • Stoma supply: if necessary, mark waterproof
  • Premedication by anesthesia: if no contraindications, always Epiduralcatheter
  • in case of reduced general and physical condition additionally high-calorie enteral nutrition solution (3 days preoperatively)
  • Thrombosis prophylaxis
  • Preoperative bowel preparation: Current data supports anterograde bowel irrigation with synchronous addition of topical oral antibiotics (e.g., 8g Paromomycin on the evening before the surgery).
  • On the morning of the surgery: administration of a double enema.
  • Thrombosis prophylaxis: (usually "Clexane 40"), compression stockings

Caution: Preoperative review and adjustment of therapy with anticoagulants:

•  
  • The perioperative therapy with aspirin can be continued.
  • Clopidogrel (ADP inhibitor) should be paused at least 5 days before surgery.
  • Vitamin K antagonists should be paused for 7-10 days under INR control.
  • DOACs (direct oral anticoagulants) should generally be paused 48 hours preoperatively
  • Always consult with the treating cardiologist if necessary
• Bridging:
  • for Vitamin K antagonists: bridging with short-acting heparins if INR is outside the target range
  • For DOACs, bridging can usually be omitted due to the short half-life. In case of very high closure/insulin risk: bridging under inpatient conditions with UFH and aPTT control
• Preoperative preparation in the OR
  • Insertion of a permanent catheter
  • Epidural placement
  • central-line placement: usually during anesthesia induction.
  • If necessary, arterial access during induction
  • Perioperative antibiotic therapy with e.g. Unacid

Important points of informed consent:

• Indication, planned surgical procedure (including stoma placement), aftercare, possible alternatives
• Bleeding/rebleeding with administration of allogeneic blood
• Drain placement, catheter placement
• Possible necessity for surgical revision due to a complication
• Anastomotic insufficiency with local or generalized peritonitis and sepsis, reoperation, open abdomen treatment, discontinuity resection
• Placement of a protective ileostomy as a fixed part of the surgical planning, e.g., for deep tumors after neoadjuvant therapy
• Possibility/necessity of optional and unplanned stoma placement (protective ileostomy vs. terminal stoma)
• Intra-abdominal abscess formation with the necessity of an interventional or surgical measure
• Wound infection
• Abdominal compartment syndrome
• Incisional hernia/trocar hernia
• Tumor recurrence
• Injury to the ureter, iliac vessels, bladder, spleen, kidney, pancreas, small intestine, other sections of the colon
• Injury to the sphincter apparatus
• Necessity for surgical extension, possibly extirpation
• Conversion to a laparotomy
• Change in bowel habits
• When entering the small pelvis: impotence coeundi in men, fecal incontinence and bladder emptying disorders due to injury of the inferior hypogastric nerves, injury of the internal genitalia in women

• Intubation anesthesia
• Placement PDK (epidural) for postoperative pain therapy and management
• If necessary, TAP Block (Transversus abdominis plane Block): Regional local anesthesia procedure 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 ideally on a large vacuum cushion (on the right side, the cushion supports the rib arch and the iliac crest, so that the weight of the patient in right lateral position does not press on the arm.
• Adduction of both arms (caution: cotton wrapping when attaching with cloth sling)
• Cotton wrapping of the knees and proximal lower legs
• Positioning of the legs in padded "boots"/use of "swan fins" for the legs, so that the legs can be moved separately and sterilely covered if necessary. Alternatively: positioning of the legs in leg shells with fixation of the legs in them
• Legs can be abducted and adducted via the operating table control

Note: The positioning is particularly important due to the docking of the patient to the robotic manipulator. Risk of injury to the abdominal wall if the patient slips.

Caution: Vacuum cushions may have leaks. Check again before sterile covering and repeat this intraoperatively.

• Surgeon at the console ideally also with the possibility to look at the patient and table assistant
• Table assistant to the right of the patient
• Anesthesia at the head of the patient
• Patient card is brought to the patient from the left
• Surgical nurse to the right of the table assistant

Robotic instruments:

• Cardiere or Tip-Up grasping forceps
• bipolar Forceps
• Camera (30°)
• monopolar scissors
• Vessel sealer
• Clip Applier
• Linear stapler

Trocar Robotics:

• Three 8 mm robotic trocars
• One 12 mm robotic trocar
• One 11 mm laparoscopic assistant trocar

Basic instruments:

• 11 scalpel
• Dissection scissors
• Langenbeck hook
• Suction system
• Needle holder
• Thread scissors
• Forceps
• Gauzes, abdominal towels
• Swabs
• Purse-string suture and purse-string clamp
• Suture material for the abdominal fascia in the area of the trocars from 10 mm Vicryl 0 with UCLX needle, for the retrieval incision PDS 0 or PDS 2/0. Subcutis (3-0 multifil, absorbable), Skin (3-0 monofil, absorbable)
• If necessary, Verres needle
• If necessary, Backhaus clamps
• Plaster

Additional instruments

• Gas system for pneumoperitoneum
• Laparoscopic atraumatic bowel grasping forceps
• Laparoscopic stick swab
• Laparoscopic suction-irrigation system
• 29 circular stapler
• Alexis wound retractor size S

Instrument setting with "two left hands"

• Port 1 (8 mm): Cardiere or Tip-Up grasping forceps
• Port 2 (8 mm): bipolar Forceps
• Port 3 (8 mm): Camera
• Port 4 (12 mm): Scissors/Vessel sealer/Clip Applier/Linear stapler

Instrument setting with "two right hands"

• Port 1 (8 mm): bipolar Forceps
• Port 2 (8 mm): Camera
• Port 3 (8 mm): Scissors/Vessel sealer/Clip Applier/Linear stapler
• Port 4 (12 mm): Cardiere or Tip-Up grasping forceps

Additionally:

• Assistant trocar: atraumatic bowel grasping forceps, suction with irrigation, stick swab
• transanal circular stapler

Principle: The postoperative follow-up after colorectal procedures should be embedded in a fast-track concept as "enhanced recovery after surgery" (ERAS). This aims for rapid recovery and reduction of postoperative complications as well as hospital stay.

Key points of the perioperative ERAS concept are:

• preoperative eutrophy and normovolemia with fluid intake up to 2 hours preoperatively,
• modern anesthesia management and use of regional techniques,
• the greatest possible avoidance of drains and invasive accesses,
• the most minimally invasive blood-sparing surgical technique,
• postoperative pain management with reduction of opioid requirement,
• early mobilization,
• early dietary progression as well as
• timely discharge planning using discharge management.

Postoperative measures:

• Monitoring: post OP: recovery room, avoidance of ICU/IMC if medically possible
• Venous accesses: CVC until the 1st post OP day, leave one iv. cannula,
• remove Stomach tube at the end of the Operation
• Foley catheter: removed on the 1st post OP day
• Drainage removal: target drainage by the anastomosis should be removed by the 5th post OP day, quadrant drain (after emergency surgery) should be removed from the 3rd post OP day with volume < 100ml in 24h and clear secretion
• Mobilization: Early mobilization on the evening of the operation. Gradual resumption of physical activity, full weight bearing if symptom-free, e.g. on the operation day in the siesta chair, from the first day standing and walking in the room, from the 2nd post OP day mobilization in the hallway
• Physiotherapy
• Breathing exercises
• Diet progression: sip drinking + yogurt/high-calorie drink solution on the OP day, tea/soup/yogurt + high-calorie drink solution on the 1st post OP day, light full diet from the 2nd post OP day
• Infusion: 500-1000 ml on the first post OP day, thereafter only if oral fluid intake is insufficient
• Antibiotics: single-shot intraoperatively, or according to hospital standards for perioperative bowel decontamination

Note: Consider continuing antibiotics in case of perforated tumor, stool contamination, ileus condition, or general risk factors.

• Bowel regulation/bowel activity: Mg 300 mg 3x/d until the first bowel movement, thereafter macrogol 1-3 sachets/d, from the 3rd day peristalsis should have started, maintain potassium at high normal levels, laxative scheme: 1. tea with laxoberal/dulcolax suppository, 2. Propulsives: MCP / Prostigmin iv, 3. Neostigmine sc or iv, possibly Relistor when administering opioids
• Thrombosis prophylaxis: In the absence of contraindications: for moderate thromboembolic risk (surgical procedure > 30 min duration): low molecular weight heparin in prophylactic (usually "Clexane 40"), possibly in weight- or disposition-risk-adapted dosage until full mobilization is achieved (also after discharge in case of malignancy possibly continue for up to 4 weeks), physical measures, ATS

Note: Pay attention to renal function, HIT II (history, platelet control) when administering heparin.

• Blood work: on the 1st post OP day, and subsequently every 2-3 days with normal course until discharge, immediately in case of 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 removed after 10 days
• postoperative analgesia:

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

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

• PDA (Epiduralcatheter) placed by the pain service of anesthesia- remove on the 3rd – 4th post OP 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 IV bolus, or 1 g as tablet orally or 30-40 drops of Novalgin orally
• Administration of Paracetamol: 1g IV over 15 minutes every 8h, or 1g suppository every 8h rectally (Cave: consider anastomotic height), or 1g as tablets orally

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

• As-needed medication: If VAS >= 4 as needed Piritramid 7.5 mg as IV bolus or SC, or 5 mg Oxigesic acute
• if pain persists post OP >= 4 administration of a prolonged-release opioid (e.g. Targin 10/5 2x/day)

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

Note: Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) as well as to the current guideline for the treatment of acute perioperative and post-traumatic pain and consider the WHO step-by step protocol.

• Discharge: possible from 5th postoperative day
• Sick leave certificate: individual – 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 the further procedure
• Follow-up:
  • For patients with localization of the carcinoma in the upper rectal third, who have not received preoperative radiation or chemoradiation, a procedure analogous to colon carcinoma is recommended in stages II and III. Criteria for adjuvant chemotherapy in stages II and III are compiled in the guideline for colon carcinoma.
  • For tumors in the middle and lower third, if no preoperative radiochemotherapy has occurred and the postoperative stage is UICC II or III, adjuvant chemotherapy analogous to colon carcinoma is also recommended.
  • After neoadjuvant radiochemotherapy adjuvant chemotherapy with optimal fluoropyrimidine regimens should be offered. A good data basis exists, e.g. Capecitabine. Younger patients with an increased recurrence risk (ypStage III) should be advised about the possibility of additional oxaliplatin therapy. The duration of perioperative chemotherapy should add up to about 6 months in total, e.g. through another 5-6 cycles of adjuvant Capecitabine or 8 cycles of FOLFOX.
  • The adjuvant chemotherapy for rectal carcinoma should be started as soon as possible after surgery if indicated.
  • In the overview of Onkopedia the procedure is clearly summarized (Source: Onkopedia).
• Discharge papers: This should contain information about:
  • Diagnosis
  • Therapy
  • Course
  • Histology
  • Comorbidities
  • Current medication on day of discharge
  • Decision of the tumor conference with proposed follow-up treatment
  • Note on informing the patient about the malignancy of the disease and the further course
  • Recommendation for outpatient continuation of VTE prophylaxis
  • Postoperative nutrition (for 4-6 weeks avoid heavy food)
• Rehabilitation: register through the social service
• Cancer registry notification
• Follow-up: