Perioperative management - Sigmoid resection, oncological, robotically assisted with medial-to-lateral approach

• Histologically confirmed malignant neoplasm of the middle and distal third of the sigmoid colon
• Endoscopically non-resectable or incompletely resectable adenoma in the sigmoid colon with high-grade intraepithelial neoplasia
• Any tumorous mass in the sigmoid colon with a high suspicion of a malignant process even if clear 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 Carcinoma (Guideline Program Oncology (German Cancer Society, German Cancer Aid, AWMF): S3 Guideline Colorectal Carcinoma. Status: 30.11.2017. valid until 29.11.2022, accessed on: 22.05.2022)

Note:

Endoscopic resection is sufficient if histology confirms an R0 situation in 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.

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

• 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
  • Severe 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), 
• pronounced portal hypertension with caput medusae

• Staging
  • Complete Colonoscopy
    •  Gold standard in the diagnosis of colorectal carcinoma
    • 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 as a supplement 
    • 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 guideline  

• 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 evaluation of the spatial relationship of the tumor-bearing colon to other structures, such as the ureters and their course.

• Further Preoperative Environmental 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 history indicates
  • 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 carcinoma begins with presentation in an interdisciplinary tumor conference to determine further action. 

• Preoperative Preparation on the Ward
  • Breathing exercises: from the day of admission for pneumonia prophylaxis
  • Personal hygiene: shower the evening before (antiseptics)
  • Shaving: from nipples to genital area
  • 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.
  • On the morning of the surgery, double enema.
  • Thrombosis prophylaxis (usually "Clexane 40"), compression stockings

Note: Preoperative review 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.
• DOAC (direct oral anticoagulants) should be paused 2-3 days preoperatively
• Always if necessary after consultation with the treating cardiologist

Bridging:

• For vitamin K antagonists, bridging with short-acting heparins if INR is outside the target range
• For DOACs, due to the short half-life, bridging can usually be omitted. In case of very high risk of closure/insult: bridging under inpatient conditions with UFH
• Preoperative Preparation in the OR
  • Insertion of a urinary catheter
  • Epidural catheter placement
  • Central venous catheter placement: usually during anesthesia induction.
  • Possibly arterial access during induction
  • Perioperative antibiotics with, e.g., Unacid

Important Points of Information:

• Indication, planned surgical procedure, postoperative care, possible alternatives
• Bleeding/postoperative bleeding with administration of donor blood
• Drain insertion, catheter insertion
• Possible necessity for surgical revision due to a complication
• Anastomotic leakage with local 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
• 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 for 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 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 ideally on a large vacuum cushion (on the right side, the cushion supports the rib cage and the iliac crest, so that the patient's weight in the right lateral position does not press on the arm.
• Adduction 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"/use of "swan-fins" for the legs, so that the legs can be moved separately and covered sterilely if necessary. Alternatively: Positioning of the legs in leg shells with fixation of the legs in them
• Legs can be angled and adjusted via the operating table control

Note: Positioning is of particular importance due to the docking of the patient to the robot's manipulator. Risk of injury to the abdominal wall if the patient slips.

Caution: Vacuum cushions may have leaks. Check again before sterile draping.

• Surgeon at the console ideally also with the ability to look at the patient and table assistant
• Table assistant on the right side of the patient
• Anesthesiologist at the head of the patient
• Patient card is brought to the patient from the left
• OR/scrub nurse to the right of the table assistant

Robotic Instruments:

• Cardiere or Tip-Up Grasper, 
• bipolar Forceps, 
• Camera (30°), 
• monopolar Scissors, 
• Vesselsealer,
• Clip Applier, 
• Linear Stapler

Robotic Trocars:

• Three 8 mm Robotic Trocars
• One 12 mm Robotic Trocar
• One 11 mm laparoscopic assistant trocar

Basic Instruments:

• 11 Scalpel
• Dissection Scissors
• Langenbeck Retractor
• Suction System
• Needle Holder
• Suture Scissors
• Tweezers
• Gauzes, 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 retrieval incision PDS 0 or PDS 2/0. Subcutis (3-0 braided, absorbable), Skin (3-0 monofilament, absorbable)
• If necessary, Veress Needle
• If necessary, Backhaus Clamps
• Plaster

Additional 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

Instrument Setting for "Two Left Hands"

Port 1 (8 mm): Cardiere or Tip-Up Grasper

Port 2 (8 mm): bipolar Forceps

Port 3 (8 mm): Camera

Port 4 (12 mm): Scissors/Vesselsealer/Clip Applier/Linear Stapler

Instrument Setting for "Two Right Hands"

Port 1 (8 mm): bipolar Forceps

Port 2 (8 mm): Camera

Port 3 (8 mm): Scissors/Vesselsealer/Clip Applier/Linear Stapler

Port 4 (12 mm): Cardiere or Tip-Up Grasper

Additionally:

Assistant trocar: atraumatic bowel graspers, suction with irrigation, swab on a stick

Circular stapler per anal

Note: Postoperative care 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 and hospital stay.

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 accesses as much as possible, 

·      Minimally invasive blood-sparing surgical techniques, 

·      Postoperative pain management with reduction of 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 1st post-op day, leave one cannula, 

·      Nasogastric tube removed at the end of the operation

·      Urinary catheter: removed by 1st post-op day

·      Drain removal: Target drain at the anastomosis removed by the 5th post-op day at the latest, quadrant drain (after emergency surgery) removed from the 3rd post-op 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 pain-free, e.g., on the day of operation in the siesta chair, standing and walking in the room from the first day, mobilization in the corridor from the 2nd post-op day

·      Physiotherapy

·      Breathing exercises

·      Nutritional build-up: Sip drinking + yogurt/high-calorie drink on the day of operation, tea/soup/yogurt + high-calorie drink 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, then only if oral fluid intake is insufficient

·      Antibiotics: Single-shot intraop, or according to clinic standard for perioperative bowel decontamination

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

·      Bowel regulation/activity: Mg 300 mg 3x/d until first bowel movement, then macrogol 1-3 sachets/d, peristalsis should have started by the 3rd day, maintain high-normal potassium, laxative regimen: 1. Tea with Laxoberal/Dulcolax suppository, 2. Prokinetics: MCP / Prostigmin i.v., 3. Neostigmine s.c. or i.v., if necessary, Relistor when opioids are given

·      Thrombosis prophylaxis: In the absence of contraindications: for moderate thromboembolic risk (surgical procedure > 30 min duration): low molecular weight heparin in prophylactic dose (usually "Clexane 40"), possibly adapted to weight or disposition risk until full mobilization is achieved (also after discharge in case of malignancy possibly continue for up to 4 weeks), physical measures, ATS 

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

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

·      Blood works: on the 1st post-op 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

·      Clips/sutures: if not absorbable, removed 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 (numerical rating scale 0–10), the VAS (visual analog scale), or the VRS (verbal rating scale).

Caution: Aim to minimize the use 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 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 i.v. infusion, or 1 g as oral tablet or 30-40 drops 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 oral tablets

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. infusion 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, an as-needed medication should be given 20 minutes before mobilization.

 Note: Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline for the treatment of acute perioperative and post-traumatic pain and consider the WHO stepwise approach.

• Discharge: From the 5th postoperative day onwards
• Sick note: Individually – depending on the degree of recovery and type of work, e.g., office work after 3 weeks post-op, physical work after 4 weeks post-op 
• Interdisciplinary tumor board to determine further procedures
• 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 performed from UICC stage III and can be performed from UICC stage II. 
  • Certain risk constellations are defined in which 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.
• Medical report: The medical report should include information on: diagnosis, therapy, course, histology, comorbidities, current medication, tumor board decision with intended follow-up treatment, note on informing the patient about the malignancy of the disease and further procedure, continuation of VTE prophylaxis, postoperative nutrition (avoid heavy food for 4-6 weeks)
• Rehabilitation: Register through the social service
• Cancer registry notification

Checklist Xi Sigmoid Resection up to Docking

• Incision in the left upper abdomen, insertion of the Veress needle
• Pneumoperitoneum
• Marking the line and points for trocars
• Insertion of 4 Xi trocars 8 cm apart
• Insertion of the camera manually after inserting the first trocar and insertion of the others under vision
• Camera trocar 12 mm with reducer sleeve at the 3 or possibly 4
• Assistant trocar right mid-abdomen
• Positioning: 10° Trendelenburg, 10° tilt right
• Dock camera arm + insert camera
• Targeting
• Dock 3 additional arms
• Arms always a fist-width apart
• Check the remote center
• Insertion of instruments and introduction into target anatomy (1: left cranial: tip up, 2: bipolar forceps, 4: right caudal monopolar scissors/vessel sealer, 3: camera/stapler
• Burping
• Switch to the console