Colectomy

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 PONV
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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)
  • 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
  • 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