Complications - Right Hemicolectomy, Robot-Assisted, with Complete Mesocolic Excision (CME) and UFA (Uncinatus First Approach) (Critical View Concept (CV))

• Intraoperative complications arise from unintended injury to anatomically adjacent structures.
• The frequency generally ranges between 2 and 12% for colon procedures.

Caution: Known risk factors for intraoperative injury to adjacent structures include:

• Obesity
• Previous surgeries
• Adhesive abdomen
• Emergency procedure
• T4 tumor or extensive accompanying inflammation

Small bowel injury:

• Frequency 1-3%, necessary adhesiolysis increases the risk to 4-13%
• Possible injury patterns:
  • Superficial serosal injuries
  • Transmural lesions of the intestinal wall
  • Thermal damage to the intestinal wall using bipolar scissors or ultrasonic dissector, especially in the area of the left flexure.
  • Mesenteric tears with subsequent ischemia of the dependent intestinal segment
  • Injury from trocar placement, Veress needle
     
• Prevention:
  • In recurrent procedures, incision as far as possible outside the scar
  • Open insertion of the first trocar after previous surgeries
  • Grasping the intestine as much as possible in the area of the taeniae or appendices epiploicae only with atraumatic forceps under vision.
  • No blind coagulations, careful, targeted preparation under vision
  • Caution: Even ultrasonic scissors and bipolar sealing devices can cause thermal damage several seconds after active use.
     
• Approach upon recognition:
  • Robotic suturing for serosal lesions and smaller defects
  • For larger defects >1/2 of the circumference or near-mesenteric lesions: robotically assisted resection and anastomosis

Pancreatic injury

• Injury mechanism: During central preparation of the vessels near the pancreatic head, injury can occur in the process.
• Approach upon recognition:
  • For bleeding, coagulation with bipolar current (bipolar forceps), possibly using a hemostatic agent (Tachosil, Flowseal, etc.) or fibrin glue.
  • For parenchymal injuries, drainage is recommended to divert secretions in case of a pancreatic fistula and prevent postoperative complications.

Ureteral injury

• Injury mechanism: During mobilization of the right hemicolon from the retroperitoneum, due to its close anatomical relationship, ureteral injury can occur. This includes sharp partial or complete transections as well as electrical injuries.
• Prevention:
  • Preservation of Gerota's fascia
  • Secure identification of the ureter
  • Use of ICG (Indocyanine Green) for better visualization

Caution with previous surgeries and inflammation- or tumor-related adhesions (large tumors with organ-overlapping growth) with disruption of anatomical layers: preoperative stenting of the ureter may be considered to facilitate its identification.

• Intraoperative diagnostics
  • Visual examination
• Therapy
  • Stenting and suturing/possibly anastomosis for short-segment injuries

Note: For superficial injuries, robotic suturing or possibly anastomosis can be performed; alternatively, a small laparotomy directly over the injury site can be performed to suture the ureter openly. In any case, the placement of a ureteral stent is indicated.

• Extensive injuries with substance loss or partial resections require complex urological reconstructions (diversion, contralateral implantation, psoas hitch procedure).

Intraoperative bleeding

• Risk factors:
  • Obesity
  • Altered anatomy due to previous surgeries, inflammation, and tumors
  • Emergency procedures
• Symptoms/Clinical presentation: Depending on the size of the injured vessel and the associated blood loss, ranging from intraoperatively inconspicuous courses to acute shock symptoms (hemorrhagic shock) are possible.
• Diagnostics: Intraoperative visual identification of the bleeding source
• Prevention:
  • Identification of surgery- or patient-related risk factors for bleeding complications
  • Use of ICG for identification of vascular structures
• Therapy
  • Temporary bleeding control through compression with laparoscopic/robotic atraumatic instruments
  • Informing the surgical team and anesthesia
  • Creating the best possible material and personnel situation surgically (vascular surgeon, second experienced surgeon) as well as anesthesiologically (senior physician, blood units, volume, etc.) Transfusion if transfusion criteria are met
• Surgical tactics
  • Injury to muscular or epigastric vessels in the abdominal wall during trocar placement: compression, possibly over a filled bladder catheter. U-sutures above and below the trocar insertion site. In case of doubt, enlargement of the incision site and direct suturing, especially in obese abdominal walls.
  • Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and possibly clipping.
  • For injuries to large vessels (e.g., aorta, vena cava), immediate laparotomy is indicated. Informing anesthesia and providing blood units, possibly involving a vascular surgeon and preparing a vascular tray, creating anatomical overview, repairing the vessel defect.

Caution: Uncontrolled use of the suction device, especially in venous injuries, can significantly but almost imperceptibly increase blood loss. Therefore, compression until readiness for intervention is established and only then targeted use of the suction device for injury management.

Intraoperative anastomotic leakage

• Diagnostics: Visual inspection of the anastomosis
• Therapy: If the leak test is conspicuous, an attempt can be made to suture a small and easily accessible insufficiency. In case of doubt, re-establishment of the anastomosis should be performed.

Prevention of Postoperative Complications

• The ERAS (Enhanced Recovery After Surgery) concept and fast-track surgery aim to accelerate postoperative recovery, reduce hospital length of stay, and decrease the frequency and severity of postoperative complications.

• The focus is primarily on reducing postoperative pain, postoperative ileus with nausea and vomiting, bowel dysfunction, and infections. In elective colon surgery, studies have shown a reduction in complications of up to 40%.

Anastomotic Leakage

(occurs in approximately 1–8% of elective right hemicolectomies)

Definition:

An insufficiency of the suture line between two intestinal segments, resulting in the leakage of intraluminal fluid and/or air. Anastomotic leakage is the most serious complication following colon cancer resection.

Significance:

It is the most frequent cause of postoperative sepsis after colon procedures and is associated with high morbidity and mortality.

Prevention:

• Tension-free anastomosis

• Optimal anastomotic technique

• Sufficient perfusion of bowel ends

• Intraoperative leak testing

• Perioperative restrictive fluid administration

Note:

Indocyanine green (ICG) fluorescence angiography is used to assess perfusion of the bowel ends intended for anastomosis, aiming to reduce the risk of leakage.

Clinical presentation (day 4–10 postoperative):

Varies depending on the extent and location of leakage — ranging from asymptomatic to septic shock.

• Abdominal pain

• Peritonitis

• Inflammatory markers (especially increasing CRP)

• Postoperative fever

• Sepsis and signs of shock

• Bowel obstruction or paralytic ileus

• Discolored or feculent drainage fluid

• General clinical deterioration

Note:

A low CRP between postoperative days 3 and 5 has a high negative predictive value. CRP > 170 mg/L (normal < 5 mg/L) is suspicious in the appropriate clinical context.

Diagnostics:

• Laboratory: CRP, leukocytosis, ± IL-6, PCT, drain fluid analysis

• Ultrasound, ± ultrasound-guided fluid aspiration

• Contrast-enhanced CT: extraluminal contrast or free/localized air

• Endoscopy

• Diagnostic laparoscopy

Caution:

Any deviation from an expected postoperative course should raise suspicion for an anastomotic leak. If suspected, prompt endoscopy (flexible) and/or contrast-enhanced CT with rectal contrast is indicated.

Therapy:

• Conservative management:

In selected cases of micro-leakage without contrast extravasation and in clinically stable patients under close monitoring.

• Broad-spectrum antibiotics (e.g., piperacillin/tazobactam, meropenem)

• Restricted oral intake or elemental diet (if no diverting stoma is in place)

• IV fluids

• Parenteral nutrition if needed

• Serial clinical reassessment

• Interventional:

• Endoscopic clipping, if appropriate

• Surgical:

Indicated in cases of clinical deterioration, septic presentation, or undrained leakage.

• Oversewing of minor defects + drainage

• Reanastomosis in defects > 25% of circumference + drainage

• Consider diverting stoma

• In extensive cases: take down of anastomosis and creation of Hartmann’s procedure + drainage

• ICU care including sepsis management, broad-spectrum antibiotics for secondary peritonitis, fluid and electrolyte resuscitation, and organ support if needed

Intraoperatively Missed Bowel Injury

Clinical signs:

May resemble anastomotic leakage, often with an insidious onset.

• Abnormal drain fluid

• High inflammatory markers

• Abdominal pain

• Sepsis

Prevention:

• Visualized trocar placement

• Use of atraumatic instruments

• Precise dissection under direct vision

• Careful instrument insertion and withdrawal

• Avoid grasping bowel unless at taeniae or appendices epiploicae

• Avoid jerky manipulations

• Full bowel inspection after extensive adhesiolysis

Diagnostics:

• Contrast-enhanced CT: extraluminal contrast and/or free air

Therapy:

• Surgical revision with oversewing or segmental resection and re-anastomosis

Intraabdominal Abscess

Incidence: 1–12%

Diagnostics: Ultrasound or CT

Therapy:

• Small, asymptomatic abscesses may be observed

• Caution: Abscesses may be indirect signs of an anastomotic leak—must be ruled out

• Abscesses with infection signs should be drained (ultrasound or CT-guided depending on location and expertise)

• In cases of progressive sepsis, surgical source control is mandatory alongside supportive ICU care

Postoperative Ileus

Incidence: up to 25%

Prevention: ERAS protocol with early mobilization and early oral intake

Therapy (stepwise):

• Chewing gum

• Laxatives

• Metoclopramide / erythromycin

• Neostigmine

• Methylnaltrexone (if opioid-induced)

• Diluted contrast medium

Postoperative Bleeding

Incidence: 0.5–3%

Management:

• Minor rectal bleeding is common postoperatively

• Significant or fresh rectal bleeding warrants endoscopic evaluation

• Bleeding at the anastomosis site should be treated endoscopically (clips); surgery is rarely needed

• Monitor hemoglobin and coagulation status

• Drain-site bleeding also requires evaluation; management depends on clinical condition and bleeding volume — blood transfusion or surgical revision may be indicated

Anastomotic Stricture

Clinical signs:

• Irregular bowel habits

• Paradoxical diarrhea

• Subileus symptoms

• Abdominal pain

Therapy:

• Initial: Endoscopic dilation

• If unsuccessful: Surgical revision

Incisional or Trocar Hernia

Incidence: 5–16%, typically at extraction sites or trocar ports

Therapy:

• Surgical repair no earlier than 6 months post-op, mesh-based approach recommended

Intraoperatively Missed Ureteral Injury

Symptoms:

• Nonspecific

• Flank pain

• ± Fever, sepsis

• Decreased urine output in large leaks

• Hydronephrosis in case of ligation

• Hematuria (note: mild hematuria may occur with indwelling stents)

Caution:

Clear fluid via drains combined with reduced urine output is a red flag.

Diagnostics:

• Creatinine in drain fluid

• Serum renal function

• Ultrasound

• CT urography, IVU

Therapy:

• Minor superficial injuries: minimally invasive suturing

• Larger injuries: limited laparotomy for open repair

• Ureteral stenting is mandatory

• Extensive damage may require complex urologic reconstruction (e.g., ureteral reimplantation, psoas hitch)

Wound Dehiscence / Fascial Insufficiency at Extraction Site

Incidence: After minimally invasive surgery

Types:

• Incomplete: intact skin

• Complete: exposed bowel or omentum

Timing: Typically days 3–9 postop

Diagnosis:

• Persistent wound secretion

• Visible bowel loops (clinical exam)

• Ultrasound

Therapy:

• Surgical revision to rule out intraabdominal pathology

• Fascial closure with slowly absorbable continuous suture (SL:WL ratio >4:1), ± onlay mesh

Caution:

Fascial dehiscence may indicate underlying intraabdominal complications such as anastomotic leakage.

Wound Infection

Incidence: 4–30%, depending on definition and follow-up time

CDC Classification:

• A1: Superficial (skin/subcutis)

• A2: Deep (fascia/muscle)

• A3: Organ/space infection

Prevention:

• Prophylactic antibiotics ≤30 min before incision

• Repeat after 4 h for longer surgeries

• Continue in contaminated wounds

• First dressing change after 48 h

• Avoid intraoperative hypothermia

Therapy:

• Open the wound widely

• Irrigate with sterile saline

• Culture swab and empirical antibiotics targeting E. coli and S. aureus

• Debridement if needed

• Vacuum therapy (NPWT) for large/deep wounds

General Medical Complications:

• Thrombosis / embolism

• Pneumonia

• Cardiac events

• Urinary tract infections

• Stroke