Difference between revisions of "Colectomy"
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| anesthesia_type = General +/- Epidural | | anesthesia_type = General +/- Epidural | ||
| airway = ETT | | airway = ETT | ||
| lines_access = | | lines_access = 1-2 PIV <br/> | ||
| monitors = Standard ASA | | monitors = Standard ASA | ||
5-Lead EKG | 5-Lead EKG | ||
Urine output | Urine output | ||
+/- | +/- Arterial line | ||
| considerations_preoperative = Full stomach precautions if acute abdomen | | considerations_preoperative = Full stomach precautions if acute abdomen | ||
| considerations_intraoperative = | | considerations_intraoperative = Goal directed fluid therapy | ||
| considerations_postoperative = | | considerations_postoperative = Pain control <br/> | ||
PONV | |||
}} | }} | ||
A '''colectomy''' is a surgical procedure to remove all or part of the colon. A partial colectomy (also known a segmental or hemi-colectomy) involves removing a portion of the colon, followed by the creation of an anastomosis or stoma. With more advanced disease, the entire large intestine is removed (total colectomy). Colectomies are often done laparoscopically. Common indications for the procedure include cancer, bowel obstruction, colitis, or diverticulitis. | A '''colectomy''' is a surgical procedure to remove all or part of the colon. A partial colectomy (also known a segmental or hemi-colectomy) involves removing a portion of the colon, followed by the creation of an anastomosis or stoma. With more advanced disease, the entire large intestine is removed (total colectomy). Colectomies are often done laparoscopically or robotically. Common indications for the procedure include cancer, bowel obstruction, colitis, or diverticulitis. | ||
== Preoperative management == | == Preoperative management == | ||
| Line 28: | Line 29: | ||
|Bowel rupture can cause sepsis or septic shock and hemodynamic instability. | |Bowel rupture can cause sepsis or septic shock and hemodynamic instability. | ||
|- | |- | ||
| | |Pulmonary | ||
|If bowel obstruction and abdominal dissension, there may be impaired diaphragmatic excursion, which could negatively impact FRC and result in more rapid desaturations. Ensure adequate preoxygenation | |If bowel obstruction and abdominal dissension, there may be impaired diaphragmatic excursion, which could negatively impact FRC and result in more rapid desaturations. Ensure adequate preoxygenation | ||
|- | |- | ||
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* BMP / Electrolytes | * BMP / Electrolytes | ||
* Coags | * Coags | ||
* Consider T&S or T&C | * Consider T&S or T&C | ||
* | * | ||
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* Patients often have bowel prep | * Patients often have bowel prep | ||
* Presurgical ERAS protocol | ** Patients typically dehydrated and may have electrolyte abnormalities | ||
* Consider preop acetaminophen / gabapentin / | * Consider pre-loading patients that are hypovolemic | ||
* | * Presurgical ERAS protocol | ||
* Consider preop acetaminophen / gabapentin / celecoxib | |||
* Evaluate for anemia and consider corrective options, if needed | |||
* Verify desired pre-incision antibiotics | * Verify desired pre-incision antibiotics | ||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
* Consider truncal block | |||
* Consider thoracic epidural (for open procedures)<ref>{{Cite journal|last=Nimmo|first=Susan M|last2=Harrington|first2=Lorraine S|date=2014-10-01|title=What is the role of epidural analgesia in abdominal surgery?|url=https://doi.org/10.1093/bjaceaccp/mkt062|journal=Continuing Education in Anaesthesia Critical Care & Pain|volume=14|issue=5|pages=224–229|doi=10.1093/bjaceaccp/mkt062|issn=1743-1816}}</ref> | * Consider thoracic epidural (for open procedures)<ref>{{Cite journal|last=Nimmo|first=Susan M|last2=Harrington|first2=Lorraine S|date=2014-10-01|title=What is the role of epidural analgesia in abdominal surgery?|url=https://doi.org/10.1093/bjaceaccp/mkt062|journal=Continuing Education in Anaesthesia Critical Care & Pain|volume=14|issue=5|pages=224–229|doi=10.1093/bjaceaccp/mkt062|issn=1743-1816}}</ref> | ||
** Improved post-op pain, earlier return of bowel function, faster ambulation | ** Improved post-op pain, earlier return of bowel function, faster ambulation, improved dietary tolerance | ||
== Intraoperative management == | == Intraoperative management == | ||
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* Typically only 1 PIV for laparoscopic and 2 for open cases | * Typically only 1 PIV for laparoscopic and 2 for open cases | ||
** Upgrade access if anticipate more significant blood loss or fluid shifts | ** Upgrade IV access if anticipate more significant blood loss or fluid shifts | ||
** Confirm IVs still good after tucking arms | |||
* | * | ||
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* Potential for hypotension if patient hypovolemic or septic | * Potential for hypotension if patient hypovolemic or septic | ||
** Consider co-loading fluids | ** Consider co-loading fluids | ||
** Consider pre-emptive vasopressor administrator with induction | ** Consider pre-emptive vasopressor administrator with induction (or phenylephrine drip on standby) | ||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine | * Supine | ||
* May need steep Trendelenburg | * May need steep Trendelenburg or Reverse Trendelenburg | ||
* Possible lithotomy | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* General endotracheal anesthesia +/- epidural (for open cases) | * General endotracheal anesthesia +/- epidural (for open cases) | ||
* Standard maintenance (avoid N<small>2</small> | * Standard maintenance (avoid N<small>2</small>O) | ||
** Run epidural if present | ** Run epidural if present | ||
* Maintain euvolemia | |||
** Avoid excessive hypovolemia or hypervolemia | |||
** Individualized, stroke-volume-guided fluid administration<ref>{{Cite journal|last=Yates|first=David R. A.|last2=Davies|first2=Simon J.|last3=Warnakulasuriya|first3=Samantha R.|last4=Wilson|first4=R. Jonathan T.|date=2014-12-01|title=Volume Management and Resuscitation in Colorectal Surgery|url=https://doi.org/10.1007/s40140-014-0078-1|journal=Current Anesthesiology Reports|language=en|volume=4|issue=4|pages=376–385|doi=10.1007/s40140-014-0078-1|issn=2167-6275}}</ref> | |||
** Administer fluids towards a specified goal | |||
** Fluid losses can be significant (particularly for open cases) | |||
*** Blood loss, third-spacing, insensible losses | |||
* Maintain normothermia | * Maintain normothermia | ||
** Be particularly vigilant in open cases, where heat losses are greater | ** Be particularly vigilant in open cases, where heat losses are greater | ||
* Place OG tube (or NG if going to be left in post-operatively) | * Place OG tube (or NG if going to be left in post-operatively) | ||
* Consider opiate-sparing analgesia | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* | * Typically extubate, depending on patient's hemodynamics, fluid status, respiratory status, neurologic status, etc. | ||
* PONV prophylaxis | * PONV prophylaxis | ||
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* Typically go to PACU | |||
* May require ICU, depending on magnitude of surgery and/or patient condition | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Multi-modal pain management | |||
* Epidural / PCA | |||
* Consider non-opiate adjuncts | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Hemorrhage | |||
* Visceral injuries | |||
* Anastomotic leak | |||
* Sepsis / Septic shock | |||
** Potential for hemodynamic instability due to evolving sepsis | |||
* Aspiration | |||
* VTE | |||
* PONV | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
| Line 122: | Line 151: | ||
|+ | |+ | ||
! | ! | ||
! | !Open colectomy | ||
! | !Laparoscopic colectomy | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | |More fluid shifts, more insensible fluid loss, higher bleeding risk, more pain | ||
| | | | ||
|- | |- | ||
|Position | |Position | ||
| | |Supine | ||
| | |Supine | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
| | |1-3 hours | ||
| | |1-3 hours | ||
|- | |- | ||
|EBL | |EBL | ||
| | |100-200 mL (although can be much higher, depending on degree of pathology, technical complexity, and patient factors) | ||
| | |<100 | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
| | |PACU | ||
| | |PACU | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |Pain typically high. Consider multi-modal pain regimen, epidural anesthesia, PCA | ||
| | |Pain typically moderate | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
Latest revision as of 11:40, 5 April 2022
Colectomy
| Anesthesia type |
General +/- Epidural |
|---|---|
| Airway |
ETT |
| Lines and access |
1-2 PIV |
| Monitors |
Standard ASA 5-Lead EKG Urine output +/- Arterial line |
| Primary anesthetic considerations | |
| Preoperative |
Full stomach precautions if acute abdomen |
| Intraoperative |
Goal directed fluid therapy |
| Postoperative |
Pain control |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A colectomy is a surgical procedure to remove all or part of the colon. A partial colectomy (also known a segmental or hemi-colectomy) involves removing a portion of the colon, followed by the creation of an anastomosis or stoma. With more advanced disease, the entire large intestine is removed (total colectomy). Colectomies are often done laparoscopically or robotically. Common indications for the procedure include cancer, bowel obstruction, colitis, or diverticulitis.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Bowel rupture can cause sepsis or septic shock and hemodynamic instability. |
| Pulmonary | If bowel obstruction and abdominal dissension, there may be impaired diaphragmatic excursion, which could negatively impact FRC and result in more rapid desaturations. Ensure adequate preoxygenation |
| Gastrointestinal | Bowel obstruction increases risk for aspiration. Consider NG tube to decompress stomach. |
| Hematologic | Anemia can result from cancer, chronic inflammation and GI blood loss. Dehydration can cause hemoconcentration and mask anemia. GI malabsorption can impair coagulation system. |
| Renal | If oral intake reduced or there's been vomiting, there may be electrolyte abnormalities. Potential for metabolic acidosis in patients with diarrhea or having a bowel prep. |
| Endocrine | |
| Other |
Labs and studies
- CBC
- BMP / Electrolytes
- Coags
- Consider T&S or T&C
Operating room setup
- NGT/OGT
- Warming blanket
Patient preparation and premedication
- Patients often have bowel prep
- Patients typically dehydrated and may have electrolyte abnormalities
- Consider pre-loading patients that are hypovolemic
- Presurgical ERAS protocol
- Consider preop acetaminophen / gabapentin / celecoxib
- Evaluate for anemia and consider corrective options, if needed
- Verify desired pre-incision antibiotics
Regional and neuraxial techniques
- Consider truncal block
- Consider thoracic epidural (for open procedures)[1]
- Improved post-op pain, earlier return of bowel function, faster ambulation, improved dietary tolerance
Intraoperative management
Monitoring and access
- Typically only 1 PIV for laparoscopic and 2 for open cases
- Upgrade IV access if anticipate more significant blood loss or fluid shifts
- Confirm IVs still good after tucking arms
Induction and airway management
- RSI if bowel obstruction, distended abdomen, urgent/emergent, or non-NPO cases
- +/- cricoid pressure
- +/- removal of a pre-existing NG tube prior to induction
- Potential for hypotension if patient hypovolemic or septic
- Consider co-loading fluids
- Consider pre-emptive vasopressor administrator with induction (or phenylephrine drip on standby)
Positioning
- Supine
- May need steep Trendelenburg or Reverse Trendelenburg
- Possible lithotomy
Maintenance and surgical considerations
- General endotracheal anesthesia +/- epidural (for open cases)
- Standard maintenance (avoid N2O)
- Run epidural if present
- Maintain euvolemia
- Avoid excessive hypovolemia or hypervolemia
- Individualized, stroke-volume-guided fluid administration[2]
- Administer fluids towards a specified goal
- Fluid losses can be significant (particularly for open cases)
- Blood loss, third-spacing, insensible losses
- Maintain normothermia
- Be particularly vigilant in open cases, where heat losses are greater
- Place OG tube (or NG if going to be left in post-operatively)
- Consider opiate-sparing analgesia
Emergence
- Typically extubate, depending on patient's hemodynamics, fluid status, respiratory status, neurologic status, etc.
- PONV prophylaxis
Postoperative management
Disposition
- Typically go to PACU
- May require ICU, depending on magnitude of surgery and/or patient condition
Pain management
- Multi-modal pain management
- Epidural / PCA
- Consider non-opiate adjuncts
Potential complications
- Hemorrhage
- Visceral injuries
- Anastomotic leak
- Sepsis / Septic shock
- Potential for hemodynamic instability due to evolving sepsis
- Aspiration
- VTE
- PONV
Procedure variants
| Open colectomy | Laparoscopic colectomy | |
|---|---|---|
| Unique considerations | More fluid shifts, more insensible fluid loss, higher bleeding risk, more pain | |
| Position | Supine | Supine |
| Surgical time | 1-3 hours | 1-3 hours |
| EBL | 100-200 mL (although can be much higher, depending on degree of pathology, technical complexity, and patient factors) | <100 |
| Postoperative disposition | PACU | PACU |
| Pain management | Pain typically high. Consider multi-modal pain regimen, epidural anesthesia, PCA | Pain typically moderate |
| Potential complications |
References
- ↑ Nimmo, Susan M; Harrington, Lorraine S (2014-10-01). "What is the role of epidural analgesia in abdominal surgery?". Continuing Education in Anaesthesia Critical Care & Pain. 14 (5): 224–229. doi:10.1093/bjaceaccp/mkt062. ISSN 1743-1816.
- ↑ Yates, David R. A.; Davies, Simon J.; Warnakulasuriya, Samantha R.; Wilson, R. Jonathan T. (2014-12-01). "Volume Management and Resuscitation in Colorectal Surgery". Current Anesthesiology Reports. 4 (4): 376–385. doi:10.1007/s40140-014-0078-1. ISSN 2167-6275.
Top contributors: Barrett Larson, Tony Wang and Chris Rishel