Colorectal Surgery
Andrew A. Shelton MD1
Carlos E. Pineda MD1
Mark Lane Welton MD1
Clifford A. Schmiesing MD2
Alimorad G. Djalali MD2
1SURGEONS
2ANESTHESIOLOGISTS
ENHANCED RECOVERY AFTER SURGERY (ERAS)
Fast-track, or enhanced recovery programs after elective surgery incorporate a variety of evidence-based interventions in an attempt to maintain normal physiologic function, enhance recovery, and prevent or minimize postoperative complications. These interventions encompass all phases of a patient’s perioperative care from the preoperative phase, to the intraoperative phase, and to the postoperative phase. These programs are being increasingly used in the perioperative management of patients with colorectal conditions. The anesthesiologist is responsible for three key elements in affecting outcomes after surgery: stress reactions to the surgery, fluid therapy, and analgesia. Common components of ERAS programs are noted below.
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Several studies have demonstrated that the ERAS programs compared with traditional postoperative care are associated with earlier recovery and discharge after colorectal surgery with decreased morbidity.
Suggested Readings
1. Gustafsson UO, Scott MJ, Schwenk W, et al: Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013; 37(2):259-84.
2. Lassen K, Soop M, Nygren J, et al: Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009; 144(10):961-9.
3. Rossi G, Vaccarezza H, Vaccaro CA, et al: Two-day hospital stay after laparoscopic colorectal surgery under an Enhanced Recovery after Surgery (ERAS) pathway. World J Surg 2013; 37(10):2483-9.
LAPAROSCOPIC COLORECTAL SURGERY
Laparoscopic surgery has changed the face of general surgery with the widespread use of laparoscopic cholecystectomy, appendectomy, and other surgical procedures. Although across the country many colorectal procedures continue to be done in the standard open fashion, laparoscopic techniques are being used more and more for procedures on the colon and rectum. All of the following procedures can be done, and have been done, laparoscopically. Advantages to the patient include smaller incisions, less postop discomfort, a decreased in-hospital stay, decreased wound-related complications with early return to work and normal activity. Steep positional changes are often used
to facilitate retraction of the small bowel out of the operative field. The patient is often placed on a beanbag to prevent movement. The term laparoscopic-assisted is more appropriate for colorectal procedures because the colon often is mobilized laparoscopically. A small incision is then made, through which the bowel is exteriorized, the mesentery is divided, and an anastomosis is created. “Hand-assisted” laparoscopy involves placement of a hand-port through a 5-10 cm incision. The abdominal cavity is then insufflated as in standard laparoscopy, but the surgeon’s hand is used alongside the other laparoscopic instruments. Laparoscopic techniques continue to advance with the development of single-incision laparoscopic surgery (SILS) for resection of the colon and rectum; natural orifice transluminal endoscopic surgery (NOTES) techniques in which the resected specimen is removed from a natural orifice such as the vagina; and the use of the da Vinci robot for the laparoscopic treatment of rectal cancer.
to facilitate retraction of the small bowel out of the operative field. The patient is often placed on a beanbag to prevent movement. The term laparoscopic-assisted is more appropriate for colorectal procedures because the colon often is mobilized laparoscopically. A small incision is then made, through which the bowel is exteriorized, the mesentery is divided, and an anastomosis is created. “Hand-assisted” laparoscopy involves placement of a hand-port through a 5-10 cm incision. The abdominal cavity is then insufflated as in standard laparoscopy, but the surgeon’s hand is used alongside the other laparoscopic instruments. Laparoscopic techniques continue to advance with the development of single-incision laparoscopic surgery (SILS) for resection of the colon and rectum; natural orifice transluminal endoscopic surgery (NOTES) techniques in which the resected specimen is removed from a natural orifice such as the vagina; and the use of the da Vinci robot for the laparoscopic treatment of rectal cancer.
Laparoscopic resections of the colon or rectum are done using a pneumoperitoneum with its associated physiologic changes. Laparoscopic surgery involves the insufflation of carbon dioxide into the peritoneal cavity at a rate of 4-6 L/min to a pressure of 15-20 mm Hg. The raised intraabdominal pressure (IAP) and the effects of carbon dioxide can cause changes in the physiology of the respiratory and cardiovascular systems. Increased IAP affects venous return, systemic vascular resistance, and myocardial function. Pneumoperitoneum also results in cephalad shift of the diaphragm, decreasing the functional residual capacity, possibly to values less than the closing volume. This can result in airway collapse, atelectasis V/Q mismatch, potential hypoxemia, and hypercarbia.
Because of the inability to use retractors as in open surgery, retraction of the bowel out of the operating field is usually accomplished through changes in the patient’s position on the operating table, frequently in steep degrees of Trendelenburg position. Because of this, the patient must be secured to the operating table. These position changes can further affect the cardiovascular and respiratory systems in addition to those caused by the pneumoperitoneum itself.
An important consideration for any laparoscopic procedure is that the surgeon might need to convert to an open laparotomy. This may occur in a secondary fashion for failure to progress or in an emergent fashion for technical difficulties.
Suggested Readings
1. Bonjer HJ, Hop WC, Nelson H, et al: Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 2007; 142(3):298-303.
2. Dwivedi A, Chahin F, Agrawal S, et al: Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease. Dis Colon Rect 2002; 45(10):1309-14; discussion 1314-5.
3. Favuzza J, Delaney CP: Outcomes of discharge after elective laparoscopic colorectal surgery with transversus abdominis plane blocks and enhanced recovery pathway. J Am Coll Surg 2013; 217(3):503-6.
4. Gordon PH, Nivatvongs S, eds: Principles and Practice of Surgery of Colon, Rectum, and Anus, 3rd edition. Informa Healthcare, New York: 2007.
5. Keshava A, Young CJ, Richardson GL, et al: A historical comparison of single incision and conventional multiport laparoscopic right hemicolectomy. Colorectal Dis 2013; 15(10):e618-22.
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7. Nishimura A, Kawahara M, Honda K, et al: Totally laparoscopic anterior resection with transvaginal assistance and transvaginal specimen extraction: a technique for natural orifice surgery combined with reduced-port surgery. Surg Endosc 2013; 27(12):4734-40.
8. Perrin M, Fletcher A: Laparoscopic abdominal surgery: continuing education in anesthesia, critical care, and pain. 2004; 4(4):107-10.
9. Scheidbach H, Schneider C, Konradt J, et al: Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum. Surg Endo 2002; 16(1):7-13.
TOTAL PROCTOCOLECTOMY
SURGICAL CONSIDERATIONSDescription: A total proctocolectomy involves the removal of the entire colon, rectum, and anus (Fig. 7.4-1). Indications for this operation include ulcerative colitis (UC), Crohn’s disease (CD), and familial adenomatous polyposis (FAP). Inflammatory bowel disease (IBD) can be diagnosed at any age, but there are peaks in diagnosis in the teens and twenties and the sixties and seventies. The most common indication for total proctocolectomy in the setting of UC
or CD is intractable symptoms despite maximal medical therapy. Patients are commonly chronically or acutely ill and may be malnourished or anemic. They are often on immunosuppressive drugs such as corticosteroids, 6-mercaptopurine or azathioprine, or biologic inhibitors of tumor necrosis factor alpha such as infliximab, adalimumab, or certolizumab. These medications all predispose these patients to an increased risk of postoperative infections and complications due to poor wound healing. Another important indication for proctocolectomy in patients with UC is the presence of dysplasia or cancer.
or CD is intractable symptoms despite maximal medical therapy. Patients are commonly chronically or acutely ill and may be malnourished or anemic. They are often on immunosuppressive drugs such as corticosteroids, 6-mercaptopurine or azathioprine, or biologic inhibitors of tumor necrosis factor alpha such as infliximab, adalimumab, or certolizumab. These medications all predispose these patients to an increased risk of postoperative infections and complications due to poor wound healing. Another important indication for proctocolectomy in patients with UC is the presence of dysplasia or cancer.
 Figure 7.4-1. Anatomy of the colon. (Reproduced with permission from Hardy JD: Hardy’s Textbook of Surgery, 2nd edition. JB Lippincott, Baltimore: 1988.) |
FAP is an autosomal-dominant disease resulting in hereditary colon cancer. Patients develop hundreds to thousands of adenomatous polyps throughout their colon and rectum, as well as elsewhere in the GI tract. Colorectal cancer is inevitable unless proctocolectomy is performed. This is typically done in the late teens or twenties. In contrast to patients with CD or UC, patients with FAP are usually healthy without other medical comorbidities.
Sequential compression stockings are used for thromboprophylaxis. Patients with CD and UC are at ↑ risk for the development of DVT and should be given subcutaneous unfractionated heparin or low-molecular-weight heparin. Patients taking chronic corticosteroids are given stress-dose steroids before the procedure. Broad-spectrum antibiotics covering gram-negative rods and anaerobes are given prior to the incision.
Total proctocolectomy with end ileostomy, total proctocolectomy with continent ileostomy (Koch pouch), and restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) all involve complete removal of the colon and rectum, down to the level of the pelvic floor or levator ani muscles. They differ in the fate of the anal canal, creation of a stoma, or construction of an anastomosis. The patient is placed in a lithotomy position in padded Allen stirrups. A Foley catheter is placed. If the procedure is done using laparoscopic techniques, a small incision is made in the periumbilical region, the suprapubic region, or as a Pfannenstiel incision to extract the specimen. If done as an open procedure, it is commonly performed through a midline incision. The abdomen is explored for evidence of unexpected malignancy or, in the case of FAP, for desmoid tumors. The right colon
is mobilized first, and then the small bowel mesentery is mobilized to allow for creation of an ileostomy. The transverse colon may be mobilized by separating it from the greater omentum, or the greater omentum may be resected along with the specimen. The sigmoid and descending colon are mobilized, and the splenic flexure is taken down. The ileum is then divided flush with the cecum, and the vessels in the colon mesentery are ligated. At this point, the entire abdominal colon has been resected. An avascular fascial envelope surrounds the rectum and its mesentery, the mesorectum. It is possible to circumferentially dissect the rectum down to the level of the pelvic floor without ligating any vessels. There may be significant blood loss if an inadvertent injury to the spleen occurs during mobilization of the splenic flexure. Massive blood loss may occur if the presacral venous plexus is entered during posterior rectal mobilization.
is mobilized first, and then the small bowel mesentery is mobilized to allow for creation of an ileostomy. The transverse colon may be mobilized by separating it from the greater omentum, or the greater omentum may be resected along with the specimen. The sigmoid and descending colon are mobilized, and the splenic flexure is taken down. The ileum is then divided flush with the cecum, and the vessels in the colon mesentery are ligated. At this point, the entire abdominal colon has been resected. An avascular fascial envelope surrounds the rectum and its mesentery, the mesorectum. It is possible to circumferentially dissect the rectum down to the level of the pelvic floor without ligating any vessels. There may be significant blood loss if an inadvertent injury to the spleen occurs during mobilization of the splenic flexure. Massive blood loss may occur if the presacral venous plexus is entered during posterior rectal mobilization.
Total proctocolectomy with ileostomy: For patients with CD, elderly patients with UC, or FAP patients with low rectal cancer, complete removal of the colon, rectum, and anus is the procedure of choice. After completing the abdominal mobilization of the colon and rectum, the perineal phase of the operation begins. Ideally, two teams of surgeons participate in the operation simultaneously. The abdominal surgeon can create the ileostomy and close the abdomen, while the perineal surgeon finishes removal of the rectum and anus. A circumferential incision is made at the anal verge, and the intersphincteric plane is identified. The dissection proceeds cephalad until the abdominal dissection is encountered, and the specimen is removed. The levator ani muscle, external anal sphincter, and skin are closed. While this is being done, the abdominal surgeon makes a circular incision over the previously marked ileostomy site. A muscle-splitting incision is carried through the rectus fascia. The terminal ileum is then brought through this site. After the fascia and skin are closed, the ileostomy is matured. Some surgeons prefer to do the perineal phase of a proctocolectomy in the prone jackknife position. In this case, after completing the abdominal phase of the operation, the abdomen is closed, the stoma is matured, and the patient is flipped prone to finish the procedure.
Total proctocolectomy with continent ileostomy (Koch Pouch): Because of frequent complications and the development of alternative procedures (see below) this procedure has been largely abandoned
Restorative proctocolectomy with ileal J pouch anal anastomosis (IPAA): IPAA is the procedure most performed for patients with FAP and UC. In this operation, the colon and rectum are removed, down to the level of the pelvic floor; however, the anal canal and anal sphincter complex are preserved. The rectum is stapled and divided at the level of the surgical anal canal, ˜1-1.5 cm above the dentate line. An ileal reservoir is constructed by anastomosing the distal 30 cm of ileum in a side-to-side fashion, creating a J pouch. The apex of the pouch is then anastomosed to the anal canal using a circular stapling device. Rarely, a hand-sewn anastomosis is created. A temporary diverting loop ileostomy may or may not be created, depending on the clinical situation.
▪ SUMMARY OF PROCEDURES
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▪ PATIENT POPULATION CHARACTERISTICS
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ANESTHETIC CONSIDERATIONSSee Anesthetic Considerations for Large Bowel Surgery, p. 546.
Suggested Readings
1. Bertario L, Arrigoni A, Astel H, et al: Recommendations for clinical management of familial adenomatous polyposis. Tumori 1997; 83(5):800-3.
2. Ghosh S, Shand A, Ferguson A: Ulcerative colitis. BMJ 2000; 320(7242):1119-23.
3. Gordon PH, Nivatvongs S, eds: Principles and Practice of Surgery of Colon, Rectum, and Anus, 3rd edition. Informa Healthcare, New York: 2007.
4. Guy TS, Williams NN, Rosato EF: Crohn’s disease of the colon. Surg Clin North Am 2001; 81(1):159-68, ix.
5. Katz JA: Medical and surgical management of severe colitis. Sem Gastrointest Dis 2002; 11(1):18-32.
6. King JE, Dozois RR, Lindor NM, et al: Care of patients and their families with familial adenomatous polyposis. Mayo Clin Proc 2000; 75(1):57-67.
7. Litle VR, Barbour S, Schrock TR, et al: The continent ileostomy: long-term durability and patient satisfaction. J Gastrointest Surg 1999; 3(6):625-32.
8. Metcalf AM: Elective and emergent operative management of ulcerative colitis. Surg Clin North Am 2007; 87(3):633-41.
9. Michelassi F, Hurst R: Restorative proctocolectomy with J-pouch ileoanal anastomosis. Arch Surg 2000; 135(3):347-53.
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11. Schiessling S, Leowardi C, Kienle P, et al: Laparoscopic versus conventional ileoanal pouch procedure in patients undergoing elective restorative proctocolectomy (LapConPouch Trial)—a randomized controlled trial. Langenbecks Arch Surg 2013; 398(6):807-16.
12. Sica GS, Biancone L: Surgery for inflammatory bowel disease in the era of laparoscopy. World J Gastroenterol 2013; 19(16):2445-8.
13. Wolff BG, Garcia-Aguilar J, Roberts PL, et al, eds: The ASCRS Textbook of Colon and Rectal Surgery. Springer Science-Business Media, New York: 2007.
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