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

Confirmed Malignant Neoplasia

• Histologically confirmed malignant tumor of the right hemicolon, up to the right colonic flexure

Non-Removable Adenoma

• Endoscopically unresectable or incompletely resected adenoma in the right hemicolon, up to the right flexure, with high-grade intraepithelial neoplasia

Suspected Malignancy

• Any tumor-like lesion in the right hemicolon, up to the right flexure, with a high suspicion of malignancy, even if definitive histological confirmation is not possible

Appendiceal and Neuroendocrine Tumors

• Right hemicolectomy is also indicated for appendiceal carcinoma and neuroendocrine tumors of the terminal ileum, colon, and appendix

Therapy Recommendations (Germany)

Therapeutic guidance for colon cancer in Germany is based on the S3 guideline for colorectal cancer treatment.

UICC Staging, TNM Classification and Treatment

Reference

S3 Guideline for Colorectal Cancer:

• (Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Kolorektales Karzinom
• Last update: November 30, 2017 (valid until November 29, 2022)
• Accessed on May 22, 2022

Note on Endoscopic Resection and Surgical Indications

Endoscopic Resection Adequacy:

Endoscopic resection is sufficient if histology confirms an R0 situation in a low-risk pT1 tumor. The following criteria must be met:

• Submucosal infiltration < 1000 μm (sm1 or sm2)
• Low grading (G1 or G2)
• Absence of lymphovascular invasion (L0)

High-Risk Situations:

For high-risk pT1 tumors, a surgical oncological resection is mandatory. This includes removal of the anatomical lymphatic drainage regions.

• Submucosal Infiltration and Lymph Node Metastasis Risk:
  • Tumors with a submucosal penetration depth up to 1000 μm (sm1 and sm2) are associated with lymph node metastases in 0 – 6 % of cases.
  • Tumors with submucosal penetration > 1000 μm (sm3) have a significantly higher risk, with lymph node metastases occurring in approximately 20 % of cases.

The general contraindications for robotic surgery align with those for minimally invasive procedures and include:

Absolute Contraindications:

• Inability to establish pneumoperitoneum due to:
  • Severe systemic illness
  • Manifest ileus with extreme bowel distension
  • Clinical scenarios involving abdominal compartment syndrome
  • Hostile abdomen with massive intra-abdominal adhesions

Relative Contraindications:

Conditions where preoperative optimization may be possible:

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

Staging:

• Complete Colonoscopy:
  • Gold standard for diagnosing colorectal carcinoma
  • Used for localization, histological confirmation, and exclusion of a secondary carcinoma (present in ~5 % of cases)
  • If full visualization of the colon is not possible, complementary CT or MR colonography can be performed
  • After emergency surgery (e.g., for ileus, tumor perforation, or uncontrolled bleeding), postoperative colonoscopy should follow anastomotic healing and patient recovery to exclude synchronous double carcinoma
  • Histopathological Confirmation of Malignancy
• CEA (Carcinoembryonic Antigen):
  • Additional tumor markers such as CA 19-9 and CA 125 are discussed but not recommended in guidelines.

Imaging:

• Chest X-ray in Two Views.
• Abdominal Ultrasound:
  • Consider contrast-enhanced ultrasound (CEUS) if hepatic metastasis is suspected.
  • Consider MRI of the liver in cases of suspected hepatic metastasis.
• CT Scans (Abdomen and Thorax):
  • Although not required per S3 guidelines, CT imaging is commonly performed in clinical practice.
  • Benefits include assessment of hepatic metastases, evaluation of the primary tumor, detection of enlarged lymph nodes, and anatomical relationships of the tumor-bearing colon to adjacent structures.

Additional Preoperative Assessments:

• Clinical Examination
• Laboratory Tests (Routine Pre-Surgical Panel):
  • Complete blood count, CRP, electrolytes, blood glucose, coagulation parameters, renal and liver function tests, bilirubin, blood typing
  • Additional erythrocyte concentrates (e.g., 2 units) as per institutional standards
  • ECG
• Pulmonary Function Testing:
  • For patients with relevant history
• Arterial Blood Gas Analysis (BGA):
  • For patients with COPD/COLD
• Echocardiogram with EF Assessment:
  • If heart failure is suspected

Multidisciplinary Approach

Following completion of diagnostics, treatment begins with a presentation of the case in an interdisciplinary tumor board to determine the optimal therapeutic plan.

On the Ward:

Respiratory Training:

• Begin on the day of admission to prevent pneumonia

Personal Hygiene:

• Shower with antiseptic soap the evening before surgery

Shaving:

• From the nipples to the genital area

Premedication by Anesthesia Team:

• Place an epidural catheter (if no contraindications)

Nutritional Support:

• For patients with reduced general condition (AZ) or nutritional status (EZ), administer high-calorie enteral nutrition solution for 3 days preoperatively

Bowel Preparation:

• Current evidence supports antegrade bowel irrigation with simultaneous administration of topical antibiotics (e.g., Paromomycin 8g)
• On the morning of surgery: administer a double enema

Thrombosis Prophylaxis:

• Administer anticoagulation, typically Clexane 40 mg (low molecular weight heparin)
• Apply anti-thrombosis stockings (AT-Strümpfe)

Adjustment of Anticoagulation Therapy:

• Aspirin:
  • Can generally be continued perioperatively
• Clopidogrel (ADP Inhibitor):
  • Should be paused at least 5 days before surgery
• Vitamin K Antagonists (e.g., Warfarin):
  • Pause for 7–10 days, monitor INR levels, and bridge with low molecular weight heparin (s.c.)
• NOACs (New Oral Anticoagulants):
  • Pause 2–3 days before surgery
• Consultation with Cardiologist:
  • Always confirm perioperative anticoagulation adjustments with the treating cardiologist if necessary

Bridging Considerations:

• For Vitamin K Antagonists:
  • Use short-acting heparins for bridging if INR is outside the therapeutic range
• For NOACs:
  • Bridging is generally unnecessary due to their short half-life
  • For patients at very high thrombotic or embolic risk, consider inpatient bridging with unfractionated heparin (UFH)

In the Operating Room:

• Insertion of Catheters:
  • Insert an indwelling urinary catheter
  • Place an epidural catheter
• Venous Access:
  • Insert a peripheral IV line or, if necessary, a central venous catheter (ZVK) during induction of anesthesia
• Arterial Line:
  • Place during induction if required
• Perioperative Antibiotic Prophylaxis:
  • Administer cefuroxime and metronidazole (Clont)
  • Repeat intraoperatively if surgery exceeds 3 hours

Key Points for Patient Counseling

Indication and Procedure Details:

• Explain the indication for surgery, planned procedure, postoperative care, and alternative treatment options

Risks and Complications:

• Bleeding/Secondary Hemorrhage: Potential need for blood transfusion
• Drain and Catheter Placement: Mention the use of drains and urinary catheters.
• Potential Reoperation: Highlight the possibility of surgical revision due to complications.
• Anastomotic Leakage:
  • Risk of localized or generalized peritonitis, sepsis, and possible need for:
  • Reoperation
  • Open abdomen management
  • Discontinuity resection
  • Stoma formation
• Intra-Abdominal Abscess: May require interventional or surgical management
• Wound Infection
• Dehiscence (Platzbauch)
• Incisional or Trocar Hernia
• Tumor Recurrence
• Injury to Adjacent Structures:
  • Risks to the right ureter, iliac vessels, kidney, pancreas, small intestine, other colonic segments, liver, gallbladder, and stomach
• Extended Surgery: Possibility of needing to expand the planned operation
• Stoma Creation: Temporary or permanent stoma (loop or Hartmann’s)
• Conversion to Laparotomy
• Postoperative Stool Changes: Alterations in bowel habits post-surgery

• General Anesthesia with Intubation (Intubationsnarkose)
• Epidural Catheter (PDK): (PDK)
  • For postoperative pain management and prokinetic effects
• TAP Block (Optional):
  • Transversus Abdominis Plane Block for regional anesthesia of the anterolateral abdominal wall
  • Local anesthetic is injected between the Musculus obliquus internus and Musculus transversus abdominis
• Intravenous Access:
  • Two peripheral IV lines preferred over a central venous catheter (ZVK)
  • Arterial line for patients with cardiac risk factors

Supine Position:

• Use of a vacuum mattress is recommended
• Arms positioned securely
• Padding for extremities and pressure-sensitive areas
• Shoulder and lateral supports to prevent slippage

Before Docking the Robot:

• Position patient in mild Trendelenburg (10°) and slight left lateral tilt (10°).
• Use protective bars to shield the patient’s face from robotic arms.

Special Considerations for Robotic Surgery Positioning

• Importance of Secure Positioning:
  • Proper positioning is crucial to prevent abdominal wall injuries from patient slippage during docking of the robotic manipulator.
• Coupled Operating Tables:
  • With Xi systems, intraoperative position changes are possible without undocking the robot.
  • For systems without this capability, always undock the robot before altering the patient’s position.
• Cave:
  • Vacuum mattresses may have leaks. Check for integrity before sterile draping

Team Positioning:

• Surgeon at the Console: Ideally positioned with a view of both the patient and the table assistant.
• Table Assistant: Positioned to the patient’s left.
• Anesthesia Team: Positioned at the patient’s head.
• Patient Cart: Approached from the patient’s right.
• Surgical Nurse: Positioned to the right of the table assistant.

Robotic Instruments:

• Cardiere or Tip-Up Grasping Forceps
• Bipolar Forceps
• 30° Camera
• Monopolar Scissors
• Vessel Sealer
• Optional: Clip Applier, Linear Stapler

Trocars:

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

Basic Instruments:

• 11-blade scalpel
• Dissecting scissors
• Langenbeck retractors
• Suction system
• Needle holders
• Suture scissors
• Forceps
• Gauzes, abdominal towels, and swabs
• Sutures:
  • Trocar sites ≥10 mm: Vicryl 0 with UCLX needle
  • Extraction incision: PDS 0 or PDS 2/0
  • Subcutaneous tissue: 3-0 braided absorbable
  • Skin: 3-0 monofilament absorbable
  • Veress needle
• Optional: Backhaus clamps, dressings

Additional Instruments:

• Gas system for pneumoperitoneum
• Laparoscopic clip applier (if not using robotic clip applier)
• Laparoscopic atraumatic bowel graspers
• Laparoscopic swab stick
• Laparoscopic suction-irrigation system
• Alexis wound retractor, size S, with cover

Instrument Settings

“Two Left Hands” Configuration (From Start to Transection of Transverse Colon):

• Port 1 (8 mm): Cardiere or Tip-Up Forceps
• Port 2 (8 mm): Bipolar Forceps
• Port 3 (12 mm): Camera or Linear Stapler
• Port 4 (8 mm): Scissors/Vessel Sealer/Needle Holder

“Two Right Hands” Configuration (From Transection of Transverse Colon Onward):

• Port 1 (8 mm): Cardiere or Tip-Up Forceps
• Port 2 (8 mm): Camera
• Port 3 (12 mm): Monopolar Scissors, Linear Stapler
• Port 4 (8 mm): Bipolar Forceps

Assistant Trocar Instruments:

• Atraumatic bowel graspers
• Suction-irrigation device
• Swab sticks
• Optional: Clip applier (if not robotic)

The postoperative care for colorectal procedures should follow an Enhanced Recovery After Surgery (ERAS) protocol to promote rapid recovery, reduce complications, and shorten hospital stays.

Key Elements of ERAS Protocol

• Preoperative Preparation:
  • Ensure normovolemia and eutritional status, with fluid intake allowed up to 2 hours preoperatively
• Anesthesia:
  • Use modern techniques, including regional anesthesia when appropriate
• Minimally Invasive Techniques:
  • Prioritize minimally invasive and blood-conserving surgical methods
• Pain Management:
  • Minimize opioid use for pain control
• Early Mobilization:
  • Encourage movement beginning on the day of surgery
• Early Oral Intake:
  • Start dietary intake as soon as possible
• Streamlined Discharge:
  • Use discharge planning and management tools

Postoperative Measures

Monitoring and Lines:

• Monitoring:
  • First night in an intermediate care unit, then transfer to a standard ward if stable
• Central Venous Catheter (ZVK):
  • Remove by Postoperative Day (POD) 1, leaving one peripheral IV line
• Nasogastric Tube:
  • Remove at the end of the procedure
• Urinary Catheter:
  • Remove by POD 1
• Drains:
  • Anastomotic drains removed by POD 5
  • Quadrant drains (in emergency surgery): Remove by POD 3 if <100 ml/24 h with clear fluid

Mobilization:

• Mobilize on the evening of surgery (e.g., sit in a chair)
• Progress to standing and walking within the room on POD 1
• By POD 2, begin walking in the hallway

Physiotherapy and Breathing Exercises

Diet:

• Day of Surgery: Small sips of fluids and yogurt or high-calorie drinks
• POD 1: Tea, soup, yogurt, and high-calorie drinks
• POD 2: Introduce light solid food

Infusions and Antibiotics:

• Fluids:
  • 500 – 1000 ml on POD 1; switch to oral hydration when adequate intake is achieved
• Antibiotics:
• Single-dose intraoperative prophylaxis (e.g., cefuroxime and metronidazole).
• Extended therapy for cases of perforation, stool contamination, or other risk factors.

Bowel Regulation:

• Magnesium:
  • 300 mg three times daily until first bowel movement
• Laxatives:
  • Macrogol (1–3 sachets/day)
  • By POD 3, ensure bowel movement
  • Use stimulant laxatives (Laxoberal/Dulcolax) as needed
• Prokinetics:
  • MCP or erythromycin (IV), or neostigmine (SC or IV) as last resort

Thrombosis Prophylaxis:

• Anticoagulation:
  • Low molecular weight heparin (e.g., Clexane 40 mg) adjusted for weight and risk
  • Continue prophylaxis until full mobilization; for malignancy, extend up to 4 weeks post-discharge
• Mechanical Measures:
  • Anti-thrombosis stockings (ATS)
• Cave:
  • Monitor renal function and for HIT II during heparin use

Laboratory Testing:

• Check labs on POD 1, then every 2 – 3 days during normal recovery
• CRP is a critical marker for anastomotic insufficiency

Wound Care:

• Change dressings every 2 days; suction dressings every 5 days
• Remove staples/sutures on POD 10 if non-absorbable

Pain Management:

• Baseline Medication:
  • 4x 1 g Novalgin or 3x 1 g Paracetamol (or combination)
  • Administer based on patient factors (e.g., age, allergies, renal function)
• Rescue Medication:
  • If pain ≥4 (VAS):
  • Piritramid 7.5 mg IV/SC or Oxigesic 5 mg oral.
  • For sustained severe pain: Use long-acting opioids (e.g., Targin 10/5 mg twice daily).
  • Before mobilization, administer analgesics 20 minutes in advance if needed.
  • Avoid opioids and NSAIDs as much as possible due to adverse effects on bowel motility and anastomotic healing.

Note: Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) and the current guideline (aktuellen Leitlinie) for the treatment of acute perioperative and post-traumatic pain, and refer to the WHO pain management ladder.

Discharge and Follow-Up:

• Discharge is typically possible by POD 5 if recovery is uneventful.
• Adjust sick leave based on recovery and activity level (e.g., desk work after 3 weeks, physical labor after 4 weeks).
• Case should be reviewed by an interdisciplinary tumor board for further treatment planning.

Adjuvant Therapy for Colorectal Cancer      

• Timing:
  • Adjuvant chemotherapy for colon cancer should be initiated as soon as possible after surgery if indicated
• Indications:
  • According to the AWMF guidelines, adjuvant therapy is recommended from UICC Stage III and can be considered for UICC Stage II
• Risk Factors for Stage II:
• Adjuvant therapy is advised in Stage II for patients with the following risk factors:
  • T4 tumors
  • Tumor perforation or intraoperative rupture
  • Emergency surgery
  • Insufficient lymph node retrieval during surgery
• Microsatellite Instability (MSI):
  • In MSI-high tumors at Stage II, adjuvant therapy should not be performed.
• Stage III Protocols:
• An Oxaliplatin-containing regimen is recommended, such as:
  • FOLFOX4, modified FOLFOX6, or CAPOX/XELOX
• Stage II or Contraindications to Oxaliplatin:
  • A monotherapy with fluoropyrimidines is recommended
• Duration:
  • Low-risk patients (T1-T3, N1): A 3-month course of chemotherapy is recommended
  • High-risk patients (T4 or N2): A 6-month course of chemotherapy should be administered 

Documentation and Rehabilitation

• Discharge Letter: Include diagnosis, treatment, histology, complications, medications, tumor board recommendations, and dietary guidance (e.g., avoid heavy foods for 4–6 weeks).
• Rehabilitation: Arrange via the social service for follow-up care (AHB).
• Cancer Registry Reporting: Ensure reporting to the cancer registry.