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