Colon Resection

Colon resections (colectomies) are performed to treat and prevent diseases and conditions that affect the colon, such as colon cancer (see the image below). Colectomies are usually performed by general surgeons or colorectal surgeons. (See Benign or Malignant: Can You Identify These Colonic Lesions?, a Critical Images slideshow, to help identify the features of benign lesions as well as those with malignant potential.)

For a better understanding of colon resections, it is important to have a thorough understanding of the terminology regarding these procedures.

A colectomy is a surgical procedure in which all or part of the large intestine is resected. The large intestine is the part of the alimentary tract that consists of the cecum, the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum. For purposes of simplicity, the term colon is often used to refer to any of the components of the large intestine, save the rectum.

A colectomy that involves removing the entire colon is called a total colectomy. If most of the colon is removed, the procedure is called a subtotal colectomy. When a segment of the colon is removed, the procedure may be called a segmental colectomy, and it may be labeled a right or left colectomy (or hemicolectomy) to differentiate the right and left halves of the large intestine.

If the prefix "procto-" precedes the term colectomy (ie, proctocolectomy), the procedure involves the removal of the rectum in addition to the colon. Removal of only the rectum is referred to as a proctectomy.

Other terms used include low anterior resection (LAR), which classically refers to removal of the sigmoid colon and upper rectum and derives its name from the fact that the dissection is below the anterior reflection of the peritoneal lining. Although the rectum is anatomically distinct from the colon, many pathologic conditions and procedures related to the colon also involve the rectum. For this reason, surgical procedures involving the rectum (eg, abdominoperineal resection [APR]) have also been included in this article.

Colectomies are performed to treat and prevent diseases and conditions that affect the colon.

The American Society of Colon and Rectal Surgeons (ASCRS) has issued practice parameters that discuss the use of colectomy in colon cancer,[1] rectal cancer,[2] ulcerative colitis,[3]  Crohn disease,[4] left-side colonic diverticulitis,[5]  Lynch syndrome,[6] and inherited polyposis syndromes.[7]

Some of the most common indications for colon resection are discussed below.

Colorectal cancer

Colorectal cancer has a lifetime incidence of 6% and is the second leading cause of cancer death in the United States. It affects slightly more men than women and is curable with surgery if caught early. A colectomy for colon cancer requires removal of the tumor-affected portion of the colon and/or rectum and adequate margins, as well as the blood supply to that segment. In the vast majority of cases, primary anastomosis is performed.

In a study that included 5139 patients, Birkett et al evaluated the benefit of elective primary colon resection (ePCR) in patients with asymptomatic colon tumors and stage IV colon cancer with liver metastases,[8]  excluding those who underwent emergency colectomy or liver-based therapy. The rate of ePCR decreased significantly over time, from 84% in 2000 to 52% in 2011. Multivariate analysis indicated that older patients and patients from rural areas were more likely to undergo ePCR, as were whites as compared with African Americans. The odds of PCR were 25% higher in high-poverty areas than in low-poverty areas.  PCR was associated with a significant survival benefit.

Cecum and ascending colon cancer

Treatment for cecum and ascending colon cancer is a right hemicolectomy, which involves removing the distal 5 cm of the terminal ileum, the cecum, the ascending colon, the hepatic flexure, the first third of the transverse colon, and associated fat and lymph nodes. By convention, the dissection includes the right branch of the middle colic artery.

Transverse colon cancer

The treatment of transverse colon cancer is controversial and depends on the location of the cancer. For proximal transverse tumors and midtransverse tumors, the authors perform a right hemicolectomy. Similarly, for distal transverse tumors, even at the splenic flexure, the authors often perform an extended right colectomy. Because the cancer cells drain proximally, it is important to remove the lymph node basin proximal to the tumor. The distal margin of resection in an extended right hemicolectomy is the proximal descending colon.

Takedown and resection of the splenic flexure is followed by an anastomosis between the ileum and the upper descending colon, with the distal limb of the anastomosis dependent on blood supply from the left colic artery. The key point is takedown and resection of the splenic flexure. It is not advisable to make an anastomosis in the region of the splenic flexure, because this region is a watershed zone. Once the middle colic artery is divided, the splenic flexure becomes entirely reliant on blood supply from the inferior mesenteric artery (IMA).

One type of operation described is a limited transverse colectomy. In this procedure, only the part of the transverse colon containing the lesion is resected, followed by anastomosis of the remaining ends. This operation would be feasible for midtransverse cancers that are strictly limited to the transverse colon (ie, the cancer does not involve either flexure). However, if too much of the transverse colon is resected, tension may prevent a safe anastomosis, necessitating mobilization of both the hepatic and the splenic flexure. In such cases, it is better to perform an extended right colectomy.

Descending colon cancer

The treatment required for descending colon cancer is a left hemicolectomy, with takedown of the splenic flexure, followed by anastomosis of the transverse colon to the upper sigmoid. Depending on the extent of the cancer, the sigmoid colon may also be resected, in which case the transverse colon would be anastomosed to the rectum.

Sigmoid colon cancer

Treatment for sigmoid colon cancer is resection of the sigmoid colon, with the descending colon anastomosed to the upper rectum.

Rectal cancer

The type of resection for rectal cancer depends on the exact location of the cancer. The two common surgical options for treating rectal cancer are LAR and APR.

If the cancer is located in the upper rectum, the cancer-affected portion of the rectum is removed, along with surrounding lymph nodes, as long as a 5-cm distal mucosal margin can be obtained. The colon is then joined to the rectal stump. A circumferential dissection that includes the fascial envelope around the rectum, termed a total mesorectal excision (TME), is imperative.

If the cancer is in the middle to lower rectum and complete TME is performed, only a 2-cm distal margin is needed. These margins are important: If the tumor is too low and a margin cannot be obtained, the sphincter complex must be removed, which requires a permanent colostomy (termed an APR).

Other terminology used includes coloanal anastomosis, intersphincteric dissection, and colonic pouches. When the entire rectum must be removed for cancer clearance, the descending colon can be sewn to the anal sphincter complex at the dentate or pectinate line; this is termed a coloanal anastomosis. If the cancer is very low, the authors often remove the internal sphincter with the specimen to obtain a better margin; this is known as an intersphincteric dissection.

The rectum acts as a reservoir for feces. When a portion of the rectum is removed, a rectal stump shorter than 6 cm may lead to problems with both continence and evacuation. Rectal stumps that are longer than 12 cm do not significantly alter function.

In cases of an LAR in which less than 6 cm of rectal stump remains, the surgeon may create a colonic pouch, often called a J pouch or coloplasty, so that the patient may achieve better continence postoperatively. A pouch is an extra reservoir to help store stool. This reservoir is created by stapling or sewing loops of colon together to make a pouch and then attaching the pouch to the anus.

Studies have shown that colonic pouches are superior to coloanal anastomosis in that a J pouch results in a decreased anastomotic leak rate, a better continence rate, better control of urgency, better control of flatus, and fewer stools per day.[9]

Colonic diverticular disease

Not all cases of diverticulosis necessitate colon resection. In fact, diverticulosis is usually asymptomatic and is often an incidental finding on screening colonoscopies or diagnostic laparoscopies. However, when diverticulosis is complicated by diverticulitis or if it presents with massive bleeding, a colon resection may be required.

Diverticulosis

Mucosal and submucosal outpouchings in the colon are called diverticula. They are false diverticula and are a phenomenon of a diet low in complex carbohydrates and dietary fiber. By age 70 years, more than 50% of people in the United States have colonic diverticulosis.

In general, the only operative indication for surgery in diverticulosis is for hemorrhage. Diverticulosis may cause a massive lower gastrointestinal (GI) bleed, and if this cannot be controlled with endoscopy or interventional radiology, surgery may be required. If the area of the bleed is localized with angiography, a segmental resection corresponding to the bleeding may be performed. In an unstable patient or one who has been transfused with more than 10 units of blood upon hospital admission or more than 6 units of blood in 24 hours or is hemodynamically unstable, an emergency subtotal colectomy may be required.

Diverticulitis

Diverticulitis is a perforation of a diverticulum. Diverticulosis does not always result in diverticulitis. Furthermore, not all cases of diverticulitis warrant colon resection. Acute uncomplicated diverticulitis can often be treated successfully with bowel rest and antibiotics alone. The decision to undergo surgical intervention is made on a case-by-case basis.[10]

The indication for colon resection is recurrent attacks or complicated diverticulitis, which is characterized by perforation, obstruction, abscess, or fistula. In general, the authors try to convert an emergency procedure into an elective one. In a case of a free perforation with feculent peritonitis, a Hartmann procedure is often performed, which involves resection of the inflamed segment of large bowel followed by an end colostomy and a stapled rectal stump. The colostomy can then be reversed 3-6 months postoperatively.

Trauma

Bowel perforation is a medical emergency that necessitates immediate surgical intervention. In addition to occurring as a consequence of penetrating injuries such as stabbing or gunshot wounds, bowel perforation can occur as a complication of colonoscopy or other procedures. Bowel perforation can even result from blunt trauma.[11]

Bowel perforation does not always call for a colectomy. If the lesion is small enough, a primary repair can be performed. Factors that may preclude primary repair include severely inflamed tissues, feculent peritonitis, distal obstruction, presence of a foreign body or tumor, and an impaired blood supply.

Inflammatory bowel disease

Ulcerative colitis

Total proctocolectomy is the only curative treatment for ulcerative colitis. It is indicated when medical management fails or is intolerable owing to the side effects of the medication. In addition, surgical treatment is indicated in patients who develop dysplasia or colon cancer. Surgery alleviates symptoms and eliminates the risk of colonic adenocarcinoma.[12] As in LAR, a J pouch is made (in this case with small intestine) to improve the patients' quality of life postoperatively by restoring intestinal continuity.

Crohn disease

There is no cure for Crohn disease. Although colectomy does not cure Crohn disease, it is indicated for refractory Crohn colitis, colonic strictures, or fistulas that affect the overall well-being of the patient. It is imperative that as much of the small intestine is preserved as possible. Patients with Crohn disease are often young and will likely require additional surgeries at later stages of life.

Bowel infarction

The colon is supplied by the superior mesenteric artery (SMA) and the IMA. A compromise of blood supply to the colon results in ischemic colitis that can progress to bowel infarction if left untreated. Infarction can result from an occlusive embolus in one of the arteries that supplies the colon or from the vasoconstrictive effects of strong vasopressors. An infarcted bowel can rapidly develop into a perforated bowel. Therefore, bowel infarction or colon ischemia is a surgical emergency.

Slow-transit constipation

Colonic inertia, a very specific form of slow-transit constipation, may be treated with subtotal colectomy. Surgery is advised when diagnostic tests such as a sitz marker study reveal profound dysmotility of the colon. Medical measures (eg, fiber supplementation, stool softeners, laxatives, enemas, rectal suppositories, and biofeedback) should be tried first. In addition, the surgeon should also evaluate the patient for obstructive defecation and pelvic floor dysfunction as part of the preoperative workup.

Obstructive defecation, whether due to muscle dysfunction or a rectocele, may coexist with a transit abnormality. If the patient has both, the obstructive defecation should ideally be resolved before surgery, but if it cannot be resolved, the surgeon may still proceed with colectomy. If a colon resection is to be performed, a subtotal colectomy with an ileorectal anastomosis is the procedure of choice.

There is some controversy in this area. Many surgeons believe that leaving some of the distal sigmoid colon may help prevent debilitating diarrhea. Partial colon resection has met with very limited success in the past and has been abandoned by the overwhelming majority of surgeons.[13] Preoperatively, the surgeon should obtain objective documentation of slow colonic transit by ordering a colon transit study. Tests such as anorectal manometry, electromyography (EMG), and defecography are useful in assessing for obstructive causes.

The surgeon should also be wary of patients who have adult-onset constipation. Both iatrogenic (eg, narcotic use, medicinal side effects) and psychological causes of constipation (eg, voluntarily withholding stools out of fear of pain or fear of public restrooms) should be ruled out. Colectomies should be performed only in psychologically stable patients with an identifiable physiologic abnormality.

Polyposis syndromes

Familial adenomatous polyposis

Patients with familial adenomatous polyposis (FAP) develop hundreds to thousands of noncancerous polyps in the colon as early as their teenage years.[7] These polyps are premalignant and will develop into cancer. The average age at which an individual with FAP develops colon cancer is 39 years.[14] Thus, these patients may choose to undergo prophylactic colectomy.

Hereditary nonpolyposis colorectal cancer

Like FAP, hereditary nonpolyposis colorectal cancer (HNPCC) is an inherited colorectal cancer syndrome.[7] Although patients with HNPCC do not develop as large a number of polyps as those with FAP do, they have an 80% lifetime incidence of colorectal cancer.[15] Surgical resection of the entire colon is the only definitive way of preventing colon cancer. Thus, patients with HNPCC may choose to undergo prophylactic total colectomy or proctocolectomy.

Colectomy has no absolute contraindications, though the overall medical status of the patient and the indication for surgery should be evaluated on a case-by-case basis.

A patient with severe cardiac disease who has a large polyp in the cecum that is not amenable to colonoscopic removal is a classically difficult case. The physician has to weigh the risks and benefits of the surgical procedure against the projected outcomes of inaction. A patient with severe cardiac disease or one who cannot tolerate anesthesia may not be a candidate for surgery. It should be routine practice to discuss the potential outcomes with the patient and his or her family.

In terms of approach, laparoscopic colectomy has some relative contraindications. Intra-abdominal adhesions or scar tissue from previous abdominal surgical procedures may preclude a laparoscopic approach. In addition, a phlegmon due to perforated diverticulitis would make laparoscopic colectomy difficult to perform.

As for all laparoscopic abdominal operations, inability of the patient to tolerate insufflation is a contraindication for laparoscopic colon resection. Therefore, preoperative pulmonary function studies are prudent in patients suspected of having breathing difficulties.

The surgeon should also note whether the patient has a bleeding disorder or liver disease. Portal hypertension, though not an absolute contraindication, can result in massive hemorrhage intraoperatively, a dangerous and challenging situation to control even in the best of circumstances.

Finally, if a 15-cm tumor must be extracted or if a tumor is invading abdominal wall muscle of pelvic attachments, the decision whether to perform laparoscopy may depend on the individual surgeon’s skillset.

Complication prevention

Perioperative complications due to colon resections may include wound infection, pelvic abscess formation, anastomotic leakage, bleeding, or injury to other organs/structures. The surgical-site infection (SSI) rate at the authors’ institution as per the National Surgical Quality Improvement Program for colon resections is 6%, and the anastomotic leak rate is 2%. The incidence in the literature ranges from 4% to 38%. The rate of the other complications is less than 2%.

To prevent complications, prophylactic antibiotics should be administered within 30 minutes of incision. Suggested antibiotic regimens for colectomy include the following:

• Cefazolin 1 or 2 g plus metronidazole 500 mg
• Ertapenem injection 1 g
• Levofloxacin 500 mg plus metronidazole 500 mg (if the patient is allergic to penicillin)

In addition, the authors prescribe a Nichol preparation the night before surgery, which consists of an erythromycin base and neomycin (1 g each at 5:00 PM, 6:00 PM, and 9:00 PM). Mechanical bowel preparation is used for left, sigmoid, and rectal resections.

To reduce the risk of infection after surgery, the authors irrigate the rectum with dilute povidone-iodine before performing left and sigmoid colectomies, as well as proctectomies.[16]

To prevent deep venous thrombosis (DVT), all patients should have sequential compression devices and receive heparin or low-molecular-weight heparin (LMWH) subcutaneously within 2 hours of surgery.

Outcomes after colon resection are excellent. The average length of stay at the authors’ institution is in the range of 4-5 days. As mentioned above, it is imperative to try to maintain low SSI rates by using appropriate technique and maintaining an attention to detail. Specific outcomes are based on the indication for surgery. For example, the recurrence rate after an attack of diverticulitis is less than 5%. The cancer recurrence rate is based on the final pathologic stage of the cancer.

The Clinical Outcomes of Surgical Therapy (COST)[17] and Colon Cancer Laparoscopic or Open Resection (COLOR)[18] trials found laparoscopic surgery for colon cancer to be as effective as open colectomy in preventing recurrence and death from cancer. Clinical trials also found there to be no significant increased risk of seeding tumor at port sites or spreading tumor by laparoscopic colectomy.

With respect to transverse colon cancer, which was excluded from the COST study, Agarwal et al compared laparoscopic colectomy with open colectomy for stage I-III adenocarcinoma.[19]  They found complication rate and severity, 5-year survival, and disease-free survival (DFS) to be similar in the two groups, and they found the laparoscopic approach to be superior in terms of short-term recovery and lymph node harvesting.

Reports from developing countries are also showing laparoscopic surgery to have advantages over open surgery.[20]  In a case-matched analysis, Ammori et al compared laparoscopic and open right colonic resection in 69 patients with colon cancer who were comparable with respect to age, sex, size of tumor, preoperative serum albumin level, and hemoglobin level. Patients in the laparoscopic surgery group had less blood loss (50 vs 100 mL) and a shorter hospital stay (4.1 vs 6 d) but a longer operating time (200 vs 140 min). The rates of severe complications, reoperations, readmissions, and death were comparable between the two groups.

In a multicenter retrospective comparative analysis, Giordano et al compared robotic with laparoscopic sigmoid dissection in 336 patients.[21]   All of the surgeons involved had an experience of more than 50 cases using each approach annually. Propensity score matching was used to make the baseline characteristics and surgical risk factors comparable between the two groups. The laparoscopic group had a shorter operating time, whereas the robotic group had less blood loss and a shorter time to first flatus. Postoperative complication rates tended to be lower in the robotic group (5.1% vs 8.6%). Readmission and reoperation rates were lower in the robotic group (4% vs 8% and 0.5% vs 5.1%, respectively).

Apurinic/apyrimidinic endonuclease 1 (APE1) is an important enzyme involved in the base excision repair pathway. Song et al determined the expression level of APE1 protein and its correlation with oncologic outcomes in patients with stage III colon cancer who had received oxaliplatin-based chemotherapy.[22] Patients with a higher expression of APE1 had a poorer prognosis than those with low expression. The authors concluded that APE1 can be used as a marker for prognosis in colon cancer patients treated with oxaliplatin-based chemotherapy.

In patients who have colon cancer with synchronous liver metastasis, treatment can be challenging, and multidisciplinary assessment is often needed. Neoadjuvant therapy is frequently employed; however, it is not clear whether this affects postoperative outcomes in patients whose colon cancer and liver metastasis are resected simultaneously. In a study that included 1006 patients who underwent simultaneous colectomy and liver operations, Mankarious et al found that neoadjuvant therapy was not associated with postoperative anastomotic leaks or serious complications.[23]  

Most current clinical practice guidelines recommend resection of at least 12 regional lymph nodes to obtain a satisfactory yield for colon cancer. Reports have shown lymph node yield (LNY) to increase from 14.91 to 21.30 over the past 20 years; however, it is unclear whether this is beneficial. In a study of 285 patients who underwent right hemicolectomy for right-side colon cancer, Hwang et al studied the impact of LNY lower than 25 and LNY of 25 or greater on survival.[24]  Primary endpoints included 5-year and 10-year survival, including DFS and overall survival (OS). Survival outcomes were not significantly different between the two groups. 

Fuchs et al described the outcomes of transanal hybrid colon resection (ta-CR), a NOTES (natural orifice transluminal endoscopic surgery) hybrid technique in which the transanal route was used for access, in 82 patients who had rectal prolapse, slow transit obstructive defecation, or chronic sigmoid diverticulitis.[25]  One patient had an intraoperative complication (rectal tear) that required intervention. Four patients had postoperative leakage (three of them managed laparoscopically and the fourth with open revision). The Gastrointestinal Quality of Life Index (GIQLI) improved significantly, from 89 preoperatively to 119 postoperatively.

In a systematic review and network meta-analysis of 48 trials (40 nonrandomized, 8 randomized), Tan et al reported the 5-year OS and DFS of several treatment strategies for acute left colonic obstruction.[26]  They found that 5-year OS and DFS were better in patients undergoing colonic stent–bridge to surgery (CS-BTS) and decompressing stoma–bridge to surgery (DS-BTS) than in those undergoing emergency surgery (ES). They also found that the 5-year OS was significantly better with DS-BTS than with CS-BTS. Transanal colorectal tube–bridge to surgery (TCT-BTS), CS-BTS, and ES had similar long-term survival rates.

The following are links to patient education resources:

• Drexel University College of Medicine, Division of Colorectal Surgery
• Susan Cohan Colon Cancer Foundation
• Crohn's and Colitis Foundation of America
• STOP Colon/Rectal Cancer Foundation
• American Society of Colon and Rectal Surgeons
• United Ostomy Association
• Wound Ostomy Continence (WOC) Nursing

Elements of informed consent

The authors discuss the risks, benefits, and alternatives of the planned procedure with every patient. The perioperative outcomes are also discussed, as well as the disease-specific outcomes.

Nutritional status is important, in that the morbidity increases in patients who are malnourished. If a preoperative albumin level is lower than 3 g/dL, supplemental nutrition is prescribed, and if feasible, the surgery is delayed. Anemia is also important to note preoperatively. The authors routinely prescribe supplemental ferrous sulfate for anemic patients.

Patients with a history of pelvic phlegmon, those undergoing repeat rectal surgery (eg, for recurrent cancer or Crohn disease), and those with a history of distant radiation therapy receive ureteral stents. Whether routine ureteral stenting is warranted is a matter of debate.[27] The authors do not believe in routine stenting and encourage surgeons to use their judgment to determine whether stents are needed for specific individual cases.

Standard surgical instruments are required for colon resections. In addition to the standard abdominal tray, abdominal retractors and stapling devices are also often used. The classic abdominal-wall retractors include a Buchwalter and a Balfour. These stretch the abdominal wall to allow exposure of the abdominal cavity.

Intestinal staplers are also commonly used. There are linear cutting staplers, circular staplers, and staplers that simply staple an end of intestine. Laparoscopic staplers are also available.

Energy devices can be used to facilitate coagulation of blood vessels and dissection. Regardless of the energy source, the goals of using energy devices are to quickly coagulate tissue, to minimize the risk of arcing current and injuring other structures, and to have a small diameter of thermal spread. Common instruments include the LigaSure from Covidien and the Harmonic and Enseal from Ethicon Endosurgery.

If laparoscopic colectomy is to be performed, atraumatic bowel graspers, a 30° laparoscope, and a wound protractor for specimen extraction are needed. Robotic colectomy has also become more commonplace, and robotic techniques have become part of the minimally invasive approach to colectomy.

Classic bowel preparation is becoming controversial. Traditionally, on the day before surgery, patients should drink only clear liquids. Patients should be on nil per os (NPO) status past midnight, except for medications. Polyethylene glycol may be given as a bowel preparation. The authors also prescribe neomycin and erythromycin (Nichols preparation) in order to decrease the intraluminal bacterial counts preoperatively in combination with the mechanical bowel preparation (MBP).

The authors’ current practice is as follows: No dietary changes are required the day before surgery for a right colectomy, and no bowel preparation is needed. For left colectomy, sigmoid colectomy, or low anterior resection (LAR), MBP is prescribed in conjunction with a Nichols preparation. In the operating room after induction, rectal irrigation is performed with dilute povidone-iodine in saline via a mushroom catheter and cystoscopy tubing. The lower colon and rectum must be thoroughly cleansed and emptied just before the start of surgery because the rectum is accessed to perform the anastomosis.

In January 2019, the American Society of Colon and Rectal Surgeons (ASCRS) issued the following recommendations for bowel preparation in elective colon and rectal surgery[28] :

• MBP combined with preoperative oral antibiotics is typically recommended for elective colorectal resections
• Preoperative MBP alone, without oral antibiotics, is generally not recommended for patients undergoing elective colorectal surgery
• Preoperative oral antibiotics alone, without MBP, are generally not recommended for patients undergoing elective colorectal surgery
• Preoperative enemas alone, without MBP and oral antibiotics, are generally not recommended for patients undergoing elective colorectal surgery

Enhanced recovery after surgery (ERAS) protocols have become mainstream and have been shown to decrease length of stay. ERAS protocols vary from one institution to another, but in general, their hallmarks include the following[29] :

• Multimodal pain management to decrease the use of narcotics, including transversus abdominis anesthetic blocks
• Goal-directed fluid therapy intraoperatively using monitors such as the Flotrac (Edwards Lifesciences)
• Preoperative carbohydrate loading
• Postoperative early ambulation

Many medications used to treat pain after surgery (eg, acetaminophen, oxycodone, and hydromorphone) are narcotics or opiates. When opiates bind to opiate receptors (eg, mu and delta) on gut smooth muscle, gastrointestinal (GI) motility is decreased. Alvimopan, acting as a mu opioid receptor antagonist, blocks the GI effect of opiates.

Alvimopan is a US Food and Drug Administration (FDA)-approved medication that decreases the length of postoperative ileus after bowel resection, thereby helping the bowel recover more quickly after bowel surgery and allowing the patient to resume eating solid foods and having regular bowel movements. It is usually taken once before surgery and twice a day after surgery for up to 7 days or until hospital discharge.

Efficacy trials have shown that in comparison with placebo, alvimopan reduces postoperative morbidity and lowers the incidence of prolonged hospital stay or readmission. One study showed that alvimopan decreased the length of hospital stay by 18 hours, as measured by time to discharge orders being written.[30]

The authors have added gabapentin and intravenous (IV) acetaminophen to their pain regimen to decrease narcotic dependence.

Preoperative IV antibiotics are given as per the Surgical Care Improvement Project (SCIP) guidelines. The authors also administer heparin subcutaneously (5000 U) 1 hour prior to surgery to aid in the prevention of deep vein thrombosis (DVT).

Anesthesia

Colectomies are usually performed with general anesthesia. Patients undergoing general anesthesia require intubation because the diaphragm is paralyzed. General anesthesia is the preferred method for performing colectomies because it paralyzes the abdominal-wall musculature, facilitating exposure and retraction of tissue.

An alternative method of anesthesia for performing colectomies is combined spinal-epidural anesthesia. This method may be appropriate for patients with conditions that cause breathing difficulties, such as severe kyphosis, chronic obstructive pulmonary disease (COPD), or restrictive lung diseases. In such patients, the concern of general anesthesia is the possibility of further respiratory failure that might result in prolonged intensive care management and mechanical ventilation.[31, 32]

Combined spinal-epidural anesthesia allows the patient to remain awake and unintubated throughout the entire procedure while eliminating sensation from the field of surgical operation. The fact that the diaphragm is not paralyzed in spinal-epidural anesthesia can be a disadvantage in laparoscopic cases. The pressure exerted on the diaphragm by insufflation can cause great discomfort to the patient. If this discomfort were to become intolerable, the procedure would have to be converted to an open procedure.

Positioning

The patient's arms should be tucked in when possible. For left colectomy, sigmoid colectomy, and LAR, the patient is placed in the lithotomy position. Depending on the surgeon's preference and the patient's body habitus, the Lloyd-Davies position may be used.

The Lloyd-Davies position is a modified lithotomy position with 30° of Trendelenburg and the hips flexed at 15°. The advantage of this position is that it provides good exposure for operations in the pelvic area. The disadvantage is that the Trendelenburg position could cause limb ischemia, especially in procedures lasting longer than 5 hours, followed by an increased risk of lower-limb compartment syndrome during the reperfusion period.[33]

For right colectomy and abdominoperineal resection (APR), the authors place the patient in the supine position. For APR, after completing the mobilization of the rectum and creating the colostomy, the authors close the abdomen and place the patient in the prone jackknife position and complete the operation. The exposure from the prone position warrants the time taken to reposition the patient.

For pelvic surgery, it is imperative that patient is secured so that he or she does not slide off the bed toward anesthesia while in the Trendelenburg position. The authors use a beanbag and padded foam on the mattress to add friction. The authors also tape the patient's chest for laparoscopic cases; tilting the patient may be required to facilitate exposure.

Wound and stoma care

Wounds and stomas must be examined daily. Both the intactness of the stoma and the output from it must be monitored. If stoma output exceeds 2 L/day, it may be necessary to start loperamide. Like patients with high-output enterocutaneous fistulas, patients with high-output stomas are at risk for electrolyte imbalance and dehydration. Therefore, losses may have to be replaced with IV fluids.

Drains

Abdominal drains and subcutaneous drains are placed to bulb suction. Patients who develop deep pelvic abscesses postoperatively may require drain tube placement by interventional radiology. Drains may be removed in a few days when the output has markedly decreased.

Antibiotics

Antibiotics can be discontinued within 24 hours of surgery unless gross spillage or purulence was encountered during the procedure.

Venous thromboembolism prophylaxis

Unless contraindicated, patients should be continued postoperatively on heparin 5000 units subcutaneously three times a day or low-molecular-weight heparin (LMWH) daily. Patients should also wear sequential compression devices while in bed.

Diet

The authors believe that nasogastric and orogastric tubes need not be kept in place postoperatively and thus should be removed immediately at the end of the case. However, a nasogastric tube may have to be inserted if postoperative ileus develops. A nasogastric tube does not shorten the duration of postoperative ileus but does relieve the symptoms of nausea, vomiting, and bloating.

On the day of surgery, the patient may be started on sips of clear liquids. The diet is advanced as tolerated. The surgeon should use his or her clinical judgment to determine when to discontinue IV fluids.

Activity

The patient should sit up in a chair for all meals.

The head of the patient’s bed should be elevated 30° or higher.

Although data have suggested that relief of bloating and cramps after ambulation may be more perceived than real,[34]  it is the authors' perspective that ambulation at least does no harm and is a form of venous thromboembolism (VTE) prophylaxis and that patients should be aggressively ambulated.

Respiratory

As with all surgical procedures, incentive spirometry is key to preventing atelectasis and its attendant pneumonia. Incentive spirometry should be practiced at least 10 times every hour. Oxygen therapy can be weaned to room air starting the morning after surgery.

Foley catheters

In most cases, indwelling urinary catheters can be removed the day after the procedure. However, for patients who have undergone LAR, APR, or ileal pouch–anal anastomosis (IPAA), the urinary catheter ought not to be discontinued until at least postoperative day 2. The reason why these patients need additional time for indwelling catheterization is that these operations are more likely to disrupt the autonomic nerves that innervate the pelvic viscera.[35]

If a patient is unable to void 6 hours after urinary catheter removal, bladder ultrasonography must be performed immediately. An estimated urine volume of 200 mL or greater would be grounds for recatheterization, via either a Foley or a straight catheter. In some instances, urinary retention may present as overflow incontinence. Patients with diabetes or benign prostatic hyperplasia are especially prone to overflow incontinence, the former because of autonomic neuropathy and the latter owing to mechanical obstruction of outflow from the bladder.

Overflow incontinence typically presents as a constant dribbling of urine or frequent urination of small amounts. In such cases, the patient may still be discharged from the hospital but with a Foley catheter left in place and a urine bag attached to the leg. Thorough evaluation of the patient's ability to empty the bladder, along with assistance from a urologist, is essential to the patient's postoperative progress.

Laboratory studies

Daily laboratory studies are usually not necessary unless justified by the patient’s clinical condition (eg, high-output stoma).

Blood transfusion

The authors consider a blood transfusion for patients with a hemoglobin level lower than 7 g/dL or those with symptoms of anemia (eg, fatigue, pale skin, tachycardia, dizziness, cold extremities).

Ostomy management

Patients with colostomy need enterostomal nursing care and education on how to take care of the stoma at home. Many patients benefit from a home visit by a nurse. The operation performed and the type of ostomy created dictate when and how the patient can have sex—for example, whether a gay man can engage in receptive anal intercourse (RAI). Such issues are sensitive ones that patients might be reluctant to raise but that nevertheless should be addressed by either the surgeon or the enterostomal therapy nurse.

Diversion colitis

Diversion colitis is an inflammatory process that occurs in segments of bowel that have been "diverted" from the fecal stream (ie, after ileostomy or colostomy). It is thought to result from lack of exposure of colonocytes in the diverted segment to short-chain fatty acids. Most cases of diversion colitis are asymptomatic and do not require long-term monitoring. Diversion colitis is not associated with an increased risk for cancer. In symptomatic cases, the restoration of intestinal continuity is generally curative.

Colorectal cancer

If the cancer is a stage III, the authors refer the patient to a medical oncologist for adjuvant therapy. Patients with stage II cancers with specific features are also referred for postoperative chemotherapy.

The American Society of Colon and Rectal Surgeons (ASCRS) has issued practice guidelines for surveillance of patients who have undergone curative treatment of colon and rectal cancer.[36]

Long-term follow-up

Patients should be seen at 2 weeks and 6 weeks postoperatively and should receive instructions on what to look for and what to eat.

Colectomies can be performed either laparoscopically or via an open abdominal incision.

The advantages of laparoscopic surgery are as follows:

• Shorter hospital stay (which does not appear to be associated with an increased risk of readmission ^[37] ) 
• Faster return to activities of daily living
• Lower rate of perioperative complications
• Decreased formation of adhesions, and thus reduced occurrence of intestinal obstruction

In a retrospective cohort evaluation of 716 consecutive patients who underwent bowel resection at the Cleveland Clinic, laparoscopic access significantly reduced the incidence of small-bowel obstruction as compared with the open procedure.[38]

After patient positioning and rectal irrigation, a Foley catheter is placed with sterile technique.

After preparing and draping, the abdomen is entered with a 12-mm umbilical incision; once the peritoneum is opened, sutures are placed, and a 12-mm port is secured. This is known as the Hasson technique. After insufflation to 15 mm Hg with CO2, the authors place a right-upper-quadrant 5-mm port and a right-lower-quadrant 12-mm port. The patient is placed in Trendelenburg position and tilted to the right. The small bowel is placed in the right upper quadrant.

The authors use a medial-to-lateral approach. The inferior mesenteric vessels are identified at their takeoff from the aorta. The peritoneum is incised in this plane and the ureter identified. Once this is completed, the vessels are ligated. Whereas the authors commonly use an endoscopic stapler, other surgeons often use energy devices, clips, and Endoloops. Once the vessels are ligated, the plane under the mesocolon is developed laterally and superiorly. With the transected vascular pedicle retracted, dissection then proceeds down into the pelvis.

For cancer operations, the authors dissect at least 5 cm distal to a cancer. If the tumor is in the very distal rectum, a lower midline or Pfannenstiel incision is often required to facilitate exposure and transection of the rectum at the level of the anorectal ring. A total mesorectal excision (TME) is performed for all low rectal cancers, and sphincter preservation is possible if there is a 2-cm mucosal margin above the dentate line.

For diverticular operations, the authors dissect to the upper rectum where the taeniae coli coalesce. Once the distal margin is identified, the bowel is transected with an endoscopic stapler. The authors then divide the distal mesocolon or mesorectum with an energy device and proceed up the patient's left side, dividing the white line of Toldt. The authors routinely mobilize the splenic flexure to obtain adequate length for performing an anastomosis. Often, an additional port must be placed on the patient's left flank.

For left colon cancers, the authors divide the inferior mesenteric vein (IMV) at the level of the splenic flexure; these cases require extensive mobilization of the transverse colon and its mesentery. It is imperative to divide the mesocolon as close to its origin as possible, leaving extensive collateral blood supply to the proximal colon that will be anastomosed.

Once the colon is completely mobilized, the specimen is extracted. A wound protractor, GelPort, Dextrus, or other device may be used to facilitate extraction. The authors require a 4- to 5-cm incision for extraction. Graspers are placed on the distal end of the specimen. The CO2 is exsufflated through the ports, and the incision is made and the wound protector placed. Extraction may be done in the left flank or umbilical area or via a Pfannenstiel incision. For a coloanal anastomosis, the authors extract transanally.

After extraction, the specimen is transected on the proximal end. For diverticular cases, the authors transect where the bowel becomes soft and supple. For cancers, transection corresponds to the area of mesocolon and the segment of colon being removed.

Routinely, the authors perform colorectal anastomoses using a 29-mm circular stapler. The specimen is sharply transected, allowing visualization of the lumen and colonic-wall bleeding, confirming an adequate blood supply. A 2-0 polypropylene purse-string suture is then placed. The anvil is placed into the colon lumen, and the purse-string suture is tied. This area is inspected for any imperfections in the closure or in the distal edge of the colon wall.

The colon is then placed back into the abdomen, and the extraction site is closed. Subsequently, the authors reinsufflate and perform a stapled anastomosis, taking care to ensure that the colon is rotated appropriately. Air insufflation via the rectum with saline irrigation is performed to look for bubbles, indicating a defect in the anastomosis. The stapler donuts are also inspected to ensure that a complete circular rim of tissue has been obtained.

If bubbles emerge from the anastomosis, the authors laparoscopically oversew the anastomosis and perform the leak test again. If there is any concern with the anastomosis, proximal diversion with a loop ileostomy is performed.

Gloves, gowns, and instruments are then changed. Irrigation with 3 L of saline is performed. The small bowel is inspected to ensure that no internal hernias are present. Gas is exsufflated via the ports, and the incisions are closed.

For a coloanal anastomoses, the dentate line is mobilized at the anal verge. After the specimen is extracted, a handsewn transanal anastomosis is performed. Here, exposure is facilitated by the Lone-Star retractor.

For an abdominoperineal resection (APR), the authors perform the case as above, with the following exceptions.

The splenic flexure is not mobilized, and dissection is performed distal to the rectosacral fascia (Waldeyer fascia) circumferentially. Once dissection is complete, the authors transect proximally in the sigmoid colon and create the colostomy. The incisions are then closed, the colostomy is matured, and the patient is flipped into the prone jackknife position.

After preparation and draping, the authors mark an incision 1 cm from the coccyx and ischial tuberosities and then make the incision and dissect circumferentially to the level of the levators. The true pelvis is entered anterior to the coccyx in such a way as to “connect” with the previous posterior dissection. Once this plane is opened, the levators are pulled caudally with a finger and transected circumferentially.

The specimen is then exteriorized with only the anterior attachments still in place. Once this is done, careful dissection in this plane is performed under direct vision to avoid injury to the prostate or vagina. If the tumor is invading these structures, a posterior vaginectomy can be performed, or a portion of the prostate can be dissected with the specimen.

The specimen is extracted through the perineum, and the incision is closed in multiple layers.

For additional information, see Laparoscopic Left Colectomy (Left Hemicolectomy).

In open versions of these procedures, the same preoperative preparation and patient positioning is used, and the authors follow similar technique. A vertical midline incision is used routinely. For right and transverse colectomies, two thirds of the incision should be above the umbilicus and one third of the incision below. The reverse is true for left-side, sigmoid, and rectal surgery. For coloanal anastomosis or APR, the incision should be carried down to the symphysis pubis to facilitate pelvic exposure.

After patient positioning and rectal irrigation, a Foley catheter is placed with sterile technique. The patient is prepared and draped, and the midline incision is made. Once the incision is open, a wound drape is placed to protect the wound. The authors prefer a Balfour retractor with a bladder blade and C-arm attachment. The low profile permits a deeper reach into the pelvis without the need to struggle with the retractor. Others use the Buchwalter.

A wet lap sponge is placed over the small bowel, which is then placed in the right upper quadrant, exposing the takeoff of the inferior mesenteric artery (IMA) at its takeoff from the aorta. Once identified, the IMA is dissected free with long right-angle clamps and clamped. Prior to clamping and transection, the ureter must be identified, after which the mesocolon is divided laterally and up to the colon wall. The colon wall is divided with a stapler. This division is the proximal margin for sigmoid or rectal surgery.

The IMA is then retracted upward, and the plane under it is dissected until the lane between the mesorectum and the pelvic fascia is entered.

Dissection continues caudally until the distal margin of resection is encountered. Transection is performed with a stapler at the distal margin for a cancer or at the coalescing of the taeniae for diverticulitis. For a left colectomy, the initial division of the bowel is a distal transection. The white line is then mobilized proximally and the splenic flexure taken down, when indicated, as mentioned above. The distal transverse colon is transected and the remaining mesorectum divided. Omentum is mobilized off the transverse colon to facilitate obtaining sufficient length.

Both anastomosis and APR are performed exactly as described for the laparoscopic technique. Gowns, gloves, and instruments are changed, and the fascia is closed with running looped suture. The skin is closed with staples.

For additional information, see Open Left Colectomy (Left Hemicolectomy).

The abdomen is entered as above. Ports are placed in the left upper and lower quadrants. The patient is placed in the Trendelenburg position and tilted to the left.

The terminal ileum is identified and the mesocolon traced. By raising the terminal ileum, the mesentery is draped over the ileocolic artery. The takeoff of the ileocolic artery is identified at the level of the inferior margin of the duodenum. The vessels are skeletonized and transected. The plane under the mesentery is developed up to hepatic flexure and distal to the terminal ileum. The ureter should be seen in the retroperitoneum.

The mesocolon is then divided medial to the ileocolic vessel with an energy source. The ileum is transected 5 cm proximal to the cecum with an endoscopic stapler. The white line of Toldt is mobilized up to and including the hepatic flexure until the original plane of dissection at the inferior margin of the duodenum is encountered. The right branch of the middle colic artery is then taken with an energy source. A grasper is placed on the ileum and the appendix/cecum. The gas is exsufflated through the ports, and an extraction site is made at the umbilicus, as described above.

The colon is transected with a linear cutting stapler and the specimen sent to pathology. An anchor stitch is placed to orient the small intestine, and the proximal and distal crotch stitches are placed. A side-to-side functional end-to-end anastomosis is created with 75-mm cutting staplers. The end is closed with a noncutting linear stapler. The staple lines are oversewn, and the mesenteric defect is approximated, if feasible.

The bowel is then replaced into the abdominal cavity. Gowns, gloves, and instruments are changed, and irrigation is performed. The authors do not routinely reinsufflate unless there is very bloody irrigation. Fascial closure followed by skin closure is performed.

If a medial-to-lateral dissection cannot be performed, a lateral-to-medial approach can substituted. This approach is often used because of an inability to visualize the vessels owing to adhesions or redundant bowel. In addition, if the vital structures are difficult to identify, conversion to open surgery should take place. Prior to this, it is acceptable to use a hand-assist device.

In a review of the evolution of right colon resection, Gachabayov et al described techniques such as the medial-to-lateral mobilization used in minimal access surgery and the lateral-to-medial mobilization used in open surgery and D2 and D3 lymphadenectomy.[39] They also described various anastomotic configurations (eg, isoperistaltic and antiperistaltic anastomoses) and methods of anastomosis which are used in minimal access surgery (eg, intracorporeal, extracorporeal, totally stapled, and stapled-handsewn techniques). The review also covered laparoscopic and robotic suturing, mucosal eversion and inversion, and specimen extraction sites.

For additional information, see Laparoscopic Right Colectomy (Right Hemicolectomy).

Performing an open right colectomy requires a midline incision, after which the small bowel is retracted to the left side and covered with a wet sponge. The ileocolic vessel is dissected free at the inferior edge of the duodenum. The white line of Toldt is mobilized from the terminal ileum up to and including the hepatic flexure. The right branch of the middle colic artery is divided, and the ileum and transverse colon are brought out of the wound. The anastomosis is performed as described above.

For additional information, see Open Right Colectomy (Right Hemicolectomy).

Total/subtotal colectomy and total proctocolectomy

The authors approach these cases, whether laparoscopic or open, by ligating the vasculature and then mobilizing from the cecum to the distal transverse colon and down the left side. For an ileorectal anastomosis, the authors use a 29-mm stapler but always perform a side-to-end anastomosis. It is imperative to leave at least 4 cm of distal bowel to ensure collateral blood supply. The ileorectal anastomosis is anchored to avoid rotation and a "maypole effect."

End-to-end anastomosis vs side-to-end anastomosis (Baker)

Although the authors routinely perform an end-to-end anastomosis, a side-to-end anastomosis can also be performed. When using a stapler, it should be placed through the distal end and brought out 4 cm proximally at the antimesenteric border. The distal end is then stapled closed and oversewn. In low pelvic anastomoses, there may be a functional benefit for side-to-end anastomosis. In addition, a colonic pouch may be created to allow better function postoperatively.

Ostomy creation

Preoperative marking is imperative. An ostomy site should be placed through the rectus abdominis rather than through the external oblique muscles. In addition, the patient should be marked while lying flat and while sitting to permit identification of folds of skin that may interfere with ostomy pouching. Avoid beltlines when placing the ostomy, and ensure that an obese patient can see where the ostomy will be.

The authors’ technique is to excise a disk of skin and divide the subcutaneous tissues and anterior rectus sheath vertically. The muscle is bluntly split and the posterior sheath incised. The authors perform Brook ileostomies to facilitate pouching. Colostomies need not be raised above skin level.

The patient's home medications can be resumed during hospitalization post surgery. For pain control, patient-controlled analgesia (PCA) or intermittent morphine administration is appropriate. These can be transitioned to oral pain medications, such as oxycodone, acetaminophen, or ketorolac.

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort and promotes pulmonary toilet.

Morphine (MS Contin, Kadian, Duramorph)

Morphine is the drug of choice for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Morphine sulfate is easily titrated to the desired level of pain control. If administered IV, morphine may be dosed in a number of ways; it is commonly titrated until the desired effect is obtained.

Oxycodone (Oxaydo, OxyContin, Roxicodone)

Oxycodone is indicated for the relief of moderate to severe pain. Inhibits ascending pain pathways by binding to the opiate receptor.  Alters the response and perception of pain. Produces generalized CNS depression.

Acetaminophen (Acephen, Mapap, Cetafen, Ofirmev, Q-Pap, Tylenol, Valorin)

Acetaminophen is the DOC for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or who are taking oral anticoagulants.

Codeine/acetaminophen (Tylenol #3, Tylenol #4, Tylenol with Codeine)

This combination is indicated for the treatment of mild to moderate pain.

Hydrocodone/acetaminophen (Norco, Hycet, Vicodin, Zamicet)

Indicated for the relief of moderately severe to severe pain.

Ketorolac

Ketorolac inhibits prostaglandin synthesis by decreasing the activity of COX, which results in decreased formation of prostaglandin precursors.