Perioperative management - Colectomy with ileorectostomy, laparoscopic

• As prophylactic surgery for familial adenomatous polyposis coli with controllable involvement of the rectum; this situation is found particularly in the attenuated form.
• Multiple carcinomas in the right and left hemicolon; here with radical division of the vessels close to their origin and lymphadenectomy.

General Contraindications

• Familial adenomatous polyposis with rectal involvement (restorative proctocolectomy with ileoanal pouch anastomosis)
• Carcinomas arising on the basis of ulcerative colitis (restorative proctocolectomy with ileoanal pouch anastomosis)

• Limited operability due to severe comorbidity (e.g. severe pulmonary disease, heart failure, liver cirrhosis, uncontrollable coagulopathy, etc.). Whether such comorbidity constitutes a contraindication to surgery must be assessed on an individual basis.

Relative Contraindications for a Laparoscopic Approach

• pronounced intra-abdominal adhesions

• generalised peritonitis

• T4 tumor with infiltration of surrounding structures or large colon tumor (> 8 cm) of uncertain malignant potential, where resection is not technically feasible laparoscopically.

• Colonic ileus with massive distension

• Toxic megacolon

• Complete colonoscopy, possibly with ink marking for straightforward intraoperative localization of polyps or adenomas.
• Laboratory: CBC, CRP, coagulation, creatinine, electrolytes, blood group, antibody screening test, CEA
• Abdominal ultrasound, chest X-ray in two planes, possibly MRI of the liver, contrast-enhanced ultrasound of the liver, and/or CT of the chest/abdomen

• orthograde bowel lavage
• shaving of the abdominal wall
• marking of the optimal position for a potential stoma on the abdominal wall

in the OR:

• insertion of an indwelling catheter
• single-shot antibiotic prophylaxis (e.g. cefotaxime + metronidazole)
• trial positioning after application of the supports

General Risks

• Bleeding
• Rebleeding
• Need for transfusions with associated transfusion risks
• Thromboembolism
• Wound infection
• Abscess
• Injury to adjacent organs/structures (left ureter, iliac vessels, internal genitalia in women, bladder, spleen, kidney, pancreas)

Specific Risks

• Anastomotic insufficiency with local or generalised peritonitis and resulting sepsis, reoperation, discontinuity resection, or creation of a protective ileostomy
• Impotentia coeundi in men, incontinentia alvi, and bladder emptying disorders due to injury to the nervi hypogastrici inferiores
• Intra-abdominal abscess formation
• Primary creation of a protective ileostomy or primary discontinuity resection
• Conversion
• Change in bowel habits
• Trocar hernia
• Risk of injury to the sphincter apparatus by the stapler