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