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Background on Colorectal Surgery

Question:

Discuss about the Preoperative Preparation for Elective Laparoscopic.

In this essay, there will be a study of the perioperative care of the patient with laparoscopic left hemicolectomy surgery. The key patient safety during the pre-operative, intraoperative and postoperative phase supports the positive outcomes. Improper measures of the safety, communication and the team issues are the causative factors for the higher morbidity and high mortality within the operated patients (Han and Min, 2016). Thus, there is the huge importance of the proper management of the perioperative journey by the providing proper safety, communication and the management of the team issues. In this report, there is a case study on the laparoscopic left hemicolectomy. The patient perioperative journey will be detailed from the admission to the hospital till the discharge of the patient from the post-operative department (Han and Min, 2016).. The essay will properly explore the aetiology and physiological process of the disease and patient predication for the justification treatment's surgical course, the negative impact of the surgery and the related care, safety, issues during the perioperative journey of the patient. The essay will explore the actual or the potential safety, team issues and communication that arise during the care of the perioperative condition and explore the impact of the above on the patient health outcomes.

The colectomy is the surgical removal of a section of the bowel or the large intestine. These types of surgeries are done for the treatment of the bowel diseases such as ulcerative colitis, crohn’s disease or colon cancer. The symptoms of the bowel diseases include constipation, diarrhea, nausea, abdominal cramps, weakness, fever, chills, weight loss, and loss of the appetite or bleeding or there may be no symptoms that are why screening is essential. Colorectal surgery is generally performed for cancer and other pathological condition of the colon (Voron, Douard and Berger, 2016). In spite of the noteworthy advancement in surgical technique such as laparoscopic and evaluation of the multidisciplinary recovery plans, the morbidity rate, and the mortality rate is much higher and vary amongst the various surgical centers. The scoring system that is used and assessment of the capacity of the functionality may support the identification of the patients with high risk and with the predication of the complications. There is a necessity to have the understanding of the factors affecting stress response suppression, optimum fluid therapy, and the pain management. Anesthesiologists are the people that significantly contribute the enhanced recovery and improvement of the perioperative care quality (Voron, Douard and Berger, 2016).

Preoperative Considerations

In the case, 69 years man is scheduled for the laparoscopic left hemicolectomy with positive FOB test. Colorectal surgery (CR) for the diverticular, inflammatory diseases or cancer is the surgery that is associated with the high risk. For colorectal surgery, other indications include iatrogenic injury or perforation, ischemic colitis or volvulus (Voron, Douard and Berger, 2016). For the positive perioperative outcomes and management of successful anesthetic, a knowledge of the basic science that is specific for the CR surgery such as colonic blood flow, stress response, preoperative assessment, and pain and fluid management is essential. In addition to above enhanced recovery, evidence-based principles and multidisciplinary team works can potentially support in minimizing the complications incidences (Voron, Douard and Berger, 2016).

There are significant numbers of the patient over 75 years suffered from rectal cancer. The patient’s general fitness is a good predicator of after surgery outcomes for the CR cancer than the age of chronology. Electrolyte imbalance, anemia, nutritional deficiency and weight loss should be recognized and corrected in the preoperative care. In the elective cases that underwent non cancer surgery, the detailed medical problem evaluation and treatment are necessary. However, in the case of the patient that require urgent or cancer surgery, time is very limited (Voron, Douard and Berger, 2016). During the emergency surgery, the main objectives are the identification of deterioration function of the vital physiological organ and their main cause such as hypovolemia and sepsis. Clinical examination, history, monitored parameters review, and the laboratory investigations are necessary to judge the problem severity.

Respiratory and cardiac diseases are common among the patients those are undergoing the major colorectal surgery during the preoperative periods. CPET-cardiopulmonary exercise testing suggests as the integrated objective of functional reserve measurement and helpful in the determination of complications and resulted in outcomes (Mekhail et.al, 2011). The CPET results have high prediction value for the patients those are at the risk of development of cardiopulmonary complications during the postoperative period. The CPET also found to be useful for the prediction of the death risk with no ischemic heart disease history or the risk factors for the same (Poylin et. al, 2014).


Various types of risk indicators and scoring systems are being used for stratification of risks for the patients those are going on the gastrointestinal surgery. The indicators for the clinical risks are consequents of history, physical examination, functional capacity, serum makers and specific variables to surgery for example; surgery emergency (Mekhail et.al, 2011). In 1991 & 1996, there was the development of the POSSUM-The physiological and operation severity score for the morbidity and mortality Enumeration and Portsmouth (Mekhail et.al, 2011). The scoring system based on POSSUM predicts the outcomes and the complications. The CR POSSUM that is specific special uses the ten measures of which six are physiological and four are operative is easy to use, accurate and validated (Mekhail et.al, 2011). On comparison, a scoring system based on POSSUM with ACPGSI that is Association of Coloproctology of Great Britain and Ireland, it was found that ACPGSI and CR-POSSUM are best predicators of mortality than POSSUM and the P-POSSUM (Mekhail et.al, 2011). In the US, there is the application of NSQIP-National Surgical Quality Improvement Programme for the provision of risk adjustment in the 30 days outcome data, but it is less accepted by the other health providers. In the case study, the patient is undergoing the surgery due to 4mm adenocarcinoma on the left descending colon and the patient was diagnosed by the General Surgeon with adenocarcinoma and booked for the surgery (Mekhail et.al, 2011).

Risk Indicators and Scoring Systems

For the preoperative preparation, the review of more than 3000 patients concluded that aerobic and anaerobic antimicrobial prophylaxis reduces the infection at the surgical site by 75%. The patient with Crohn’s disease may intolerant to enteral diet (Daniels et. al, 2013).  Status of poor nutrition especially with hypoalbuminemia is being associated with postoperative complications enhancement such as increased hospital stay and infections. Preoperative loading of carbohydrates orally supports the reduction of preoperative discomfort, insulin resistance postoperative, postoperative vomiting and nausea, loss of the muscle mass and improvement of the muscle strength (Daniels et. al, 2013).

Chewing of gums mimics feeding, promotion of the peristalsis through hormonal and neural mechanisms that increase the gastrointestinal juices secretion and colon motility and reduction of paralytic ileus postoperative (Poylin et. al, 2014).

Modification of the stress responses can be easily achieved through absence or presence of peritonitis, nutritional support preoperative, anesthetic agents’ intraoperative use and employment of anesthetic techniques, adjuvants preoperative use such as the use of alpha agonists and beta-blockers, postoperative analgesic and patient pathway may cause (Daniels et. al, 2013).  During CR surgery, the surgical issues that affect the stress response are open surgery duration, surgery urgency, laparoscopic techniques and blood loss and transfusion amount. Associated stress responses are fatigue, bowel dysfunction postoperative, delay in wound healing, a complication associated with infection such as anastomotic leak, wound infection and the cardiopulmonary complications. In cancer patients, there will be delayed recovery and metastasis increased susceptibility and some long term side effects (Mufty et.al, 2012)

Suppressed immune function recovery is faster in the laparoscopic surgery and influences the cancer surgical patient’s recurrence.

There are several strategies that counteract the stress response such as shortening of the fasting periods, nutritional support use and glycemic control, epidural analgesia and laparoscopic surgery (Mufty et.al, 2012)

Researchers had found that there are no differences in the inflammatory responses in the patient undergoing CR cancer surgery, they receive either intravenous anaesthesia; remifentanil and propofol or the inhalational anesthesia; fentanyl and sevoflurane. Researchers revealed that plasma concentration of the cortisol and epinephrine were tremendously lower and T-cells and lymphocyte numbers were expressively higher during the epidural anesthesia. During the surgery, systemic lidocaine has anti-inflammatory activity and also supports the suppression of the stress response in the patients those are intolarent to epidural anaesthetia (Mufty et.al, 2012)


Methyl Prednisolone also helps in the modification of the stress response and improvement of the postoperative pain and pulmonary function and reduction in length of hospital stay. During the Laparoscopic surgery, dexamethasone administration in dose 8 mg supports lower interleukin-6 and interleukin-13 concentration peritoneal on the first day and significant reduction of postoperative fatigue. Flubiprofen, Parecoxib, and pentoxiphylline (NSAID) are also very useful as the multimodal approach markedly enhances recovery and reduce stress after CR surgery(Chow, 2011)..

Strategies to Counteract Stress Response

For the preoperative management of the patient, the team should take the proper measures and treatment that can reduce the later problems(Chow, 2011). These preoperative treatments should be properly communicated with the intraoperative and postoperative team as the preoperative care favors the patient health improvement rapidly after surgery. In the case, the preoperative care team did not properly handover the patient history, preoperative treatment, and consent to the intraoperative team (Chow, 2011).

The first legal potential issue regarding the case is that the preoperative care team has handover the consent that is without the signature of the patient and also the patient has little knowledge about the preoperative assessment. If during surgery, any type of miss happening may occur that can create legal issue without patient consent. It is a key responsibility of the preoperative team to properly clear the preoperative assessment procedure and also the anesthetic procedure to the patients before surgery (Shin, 2012).

According to the polices, there should be active involvement of the patient during identification of validation of procedure and consent(Parker, 2016). There is a vital role of patient involvement, if there is miscommunication between health care professional and patient then it will lead to increase in risk potential adverse outcomes of the patients that will be associated with the errors in the procedure (Parker, 2016). There should be confirmation of the patient’s consent through signature and also the patient’s dual identity should be confirmed by the band. Here the associated risk is the improper documentation of the patient.

After the patient identification, then there is conductance of the anesthetic assessment. At this stage, there is potential safety risk related to the anesthesia management, airway management, and intraoperative management were observed (Schwartzberg, 2017). The perioperative anesthetic management goals are the minimization of immune responses and stress maintenance, multimodal analgesia, electrolyte and meticulous fluid therapy, and postoperative gut dysfunction prevention. As in the preoperative care treatment and care support the positive outcomes in the management of above factors (Schwartzberg, 2017). Hypothermia is the condition that causes unwanted systemic changes that includes stress response exaggeration and immune function suppression in the patients that underwent the CR surgery. Active thermoregulation should be carried out during laparoscopic surgery as it cannot be maintained after surgery by bowel exposure reduction (Schwartzberg, 2017). During Laparoscopic surgery, physiological changes lead to cardiorespiratory problems. Patient’s position should be maintained carefully during surgery for the prevention of complication that is position-related.

Postoperative Care

In the laparoscopic surgery case, epidural analgesia may be valuable if the patient substantial respiratory disease during preoperative condition. It is significant to insert the epidural catheter if there are chances of conversion to open surgery(Kim and Ogawa, 2012).. The regional anesthesia such as a combined technique that is spinal-epidural is possible for the resection of low anterior of the rectum. The intraoperative thoracic epidural analgesia and anesthesia is associated with an increase in CBF and good gastrointestinal recovery (Kim and Ogawa, 2012).. Epidural analgesia and pain control does not affect the recurrence of the CR cancer. After the establishment of spinal anesthesia by heavy 0.5% fentanyl and bupivacaine, 0.5% isobaric bupivacaine is recommended for the extension of spinal anesthesia. Though, the microcatheter was detached at the surgery ended(Kim and Ogawa, 2012)..

Several types of research have shown that the management of hemodynamics reduces the gastrointestinal complications that are postoperative (Sumi, 2013). For the achievement of the end points fluids & inotropes of fluid alone are recommended. Oxygen saturation changes in the CNS, during the intraoperative and postoperative period, leads to complications(Sumi, 2013). Oxygen saturation >73%, during the intraoperative period, is able to prevent the complications. Dopexamine preoperative use improves the circulation is a controversial statement.

In the case, there is lack of the intraoperative team communication as most of them are unfamiliar and less experienced (Sumi, 2013).  The team consists of the anaesthetic nurse, the scrub and circulating nurse, the anaesthetist and the surgeon. The surgeon has experience of 25 years with the surgical procedure and the anaesthetist is trainer registrar that was supervised by the consultant that is from a different hospital and visited from last 7 years. The anaesthetist and the surgeon have not worked together previously (Sumi, 2013). The scrub nurse is also less experienced and the circulating nurse who has experience is supervising the RN that is a beginner. As the whole team has less experience so they have less knowledge of the policies and safety risks and the experienced team members lacks communication as they are less familiar. Thus, the key safety potential that the team should communicate properly before surgery for their management, are not communicated properly due to time shortage and communication gap (Wang et al., 2016).

Due to the communication gap, the scrub nurse left the light source on the patient's drapes that have a risk of fire. After the surgery, the anaesthetic registrar is worried about the aspiration as the patient has the problem of coughing and slight regurgitates

Conclusion

After the whole surgery, the last procedure is time out. This procedure requires the active involvement of all team members, communication, and participation that is essential for safe surgery.

After the intraoperative management, the surgical team should properly handover the patient to the PACU team. But in the case, the intraoperative team did not properly handover the patient to the nurse and nurse complained about it to the head nurse.

According to the pain protocol, medication chart is followed and the patient’s vital signs were within the limit but he is complaining of pain and vomiting episodes. Because of the patient discomfort, the registrar was called upon to see the patient and he recommended the medication and overnight stay in HDU but the patient discharge time was after 2 hours and he is just sedated. The nurse was relieved by the other in the afternoon (Wang et al., 2016).


The key potential issue in the postoperative care is the communication gap between the intraoperative and postoperative care team because of which the patient faced the discomfort, nausea, and pain and the longer stay in the hospital. Thus, during the postoperative care, the nurse should be properly handover by the anaesthetic registrar (Wang et al., 2016).

By adoption of the evidence based practices in perioperative period can enhance the recovery after laparoscopic surgery. This practice is designated as fast track or enhanced or accelerated recovery after surgery (Hu, Zheng and Li, 2017). The pathway for recovery, enhanced or conventional can be managed by the multidisciplinary teams that include surgeons, anesthesiologists, nursing staff, acute pain team, nutritional experts, physiotherapists, and pharmacists. ERP is related to postoperative morbidity reduction (Hu, Zheng and Li, 2017). Despite, it does not lead to mortality reduction. It is recommended to decrease the hospital stay length. The ERP aim is the reduction of perioperative organ dysfunction and stress associated bowel by the incorporation of the multimodal approach (Hu, Zheng and Li, 2017).

The postoperative therapy for the fluid maintenance considers the requirements, pathological changes and losses associated with CR surgery.  During the postoperative segment, restrictive therapy for fluid management has shown beneficial results (Kalady and Church, 2014). There are several advantages of early enteral diet such as improvement in intestinal anastomoses healing, improvement in colon intake, positive nitrogen balance, and preservation of functionality of gut barrier, improvement in calorie intake, infection complications reduction, reduction in insulin resistance and hyperglycemia, reduction in septic complication and reduction in hospital stay length. It is safer and effective than TPN that requires the central line (Kalady and Church, 2014).

After the surgery, thoracic epidural analgesia is advised. For the postoperative pain, intrathecal analgesia, pain-controlled analgesia, wound infiltration; wound infusion, systemic lidocaine infusion, and transverses abdominis plane are used (Kalady and Church, 2014). Opioids are less recommended as they have side effects such as vomiting, nausea, bowel motility inhibition and constipation and their use lead to delayed bowel function return and intake orally aylimopan; a peripheral antagonist showed the reduction paralytic ileus duration after CR surgery (Kalady and Church, 2014). There is a risk of anastomotic leak after the use of inhibitors of cyclooxygenase 2 (Han and Min, 2016). However, NSAID is the part of the multimodal approach. Other analgesics such as gabapentin, tramadol, and ketamine are not recommended as they are used in the routine recommendation. For the laparoscopic surgery, there is no evident analgesic method (Daniels et. al, 2013).  Same benefits may not be obtained from the epidural analgesia as in the open surgery. Epidural analgesia is benefitted, if the patient has pulmonary morbidities in the preoperative conditions and also if the surgery is converted to open surgery. One of the recent studies has shown that there is the earlier return of the bowel function through IT analgesia as compared to the epidural analgesia. Some reported also shown faster recovery with the epidurals after the laparoscopic surgery (Han and Min, 2016).

Conclusion

In the last, it is concluded that the perioperative care includes preoperative, intraoperative and postoperative care. If the key issues and problems associated with the perioperative care should be properly maintained during the perioperative care then this will lead to lower morbidity and mortality after surgery. In  preoperative care if the antibiotic prophylaxis, immune and stress management has been done, in the intraoperative management, if position, hyperthermia, proper anesthetic therapy and in the postoperative management, diet and fluid management, pain management can be done properly then this help in the faster recovery and reduce the hospital stay of the patient. In the case, there is a number of the key safety potential that was by not fulfilled by the perioperative team due to lack of communication, experience and less practice of the policies regarding the perioperative care. If all of them communicate properly for the patient care and multimodal approach for the patient care then recovery of the patient can be assured to the maximum extent. CR surgery has significant mortality and morbidity. As in above case, there is communication gap and less concentration on the potential and principles, there is increased morbidity and long stay of the patient in hospital after surgery.

References

Chow, A. (2011). Single-Incision Laparoscopic Surgery for Right Hemicolectomy. Archives Of Surgery, 146(2), 183.

Daniels, S., Saha, A., Proctor, V., & Habib, K. (2013). Is laparoscopic surgery for right hemicolectomy cost-effective?. International Journal Of Surgery, 11(8), 621.

Han, J., & Min, B. (2016). Laparoscopic-assisted radical left hemicolectomy for colon cancer. Journal Of Visualized Surgery, 2, 148-148.

Hu, W., Zheng, J., & Li, Y. (2017). Laparoscopic extended right hemicolectomy with D3 lymphadenectomy. Annals Of Laparoscopic And Endoscopic Surgery, 2, 120-120.

Kalady, M., & Church, J. (2014). Prophylactic colectomy: Rationale, indications, and approach. Journal Of Surgical Oncology, 111(1), 112-117.

Kim, S., & Ogawa, S. (2012). Biophysical and Physiological Origins of Blood Oxygenation Level-Dependent fMRI Signals. Journal Of Cerebral Blood Flow & Metabolism, 32(7), 1188-1206.

Mekhail, P., Saklani, A., Naguib, N., & Masoud, A. (2011). Internal herniation after laparoscopic left hemicolectomy: An under-reported event. International Journal Of Surgery, 9(7), 530.

Mufty, H., Hillewaere, S., Appeltans, B., & Houben, B. (2012). Single-incision right hemicolectomy for malignancy: a feasible technique with standard laparoscopic instrumentation. Colorectal Disease, 14(11), e764-e770.

Parker, B. (2016). Preoperative Preparation for Elective Laparoscopic Cholecystectomy Using Spinal Anesthesia: A Case Report. MOJ Surgery, 3(1).

Poylin, V., Curran, T., Lee, E., & Nagle, D. (2014). Laparoscopic Colectomy Decreases the Time to Administration of Chemotherapy Compared with Open Colectomy. Annals Of Surgical Oncology, 21(11), 3587-3591.

Schwartzberg, D. (2017). Laparoscopic Right Hemicolectomy with Isoperistaltic Intracorporeal Anastomosis. Csurgeries. https://dx.doi.org/10.17797/fdschc17au

Shin, J. (2012). Comparison of Short-term Surgical Outcomes between a Robotic Colectomy and a Laparoscopic Colectomy during Early Experience. Journal Of The Korean Society Of Coloproctology, 28(1), 19. https://dx.doi.org/10.3393/jksc.2012.28.1.19

Sumi, Y. (2013). Laparoscopic hemicolectomy in a patient with situs inversus totalis after open distal gastrectomy. World Journal Of Gastrointestinal Surgery, 5(2), 22.

Voron, T., Douard, R., & Berger, A. (2016). Conservation of the left colic artery during laparoscopic left-hemicolectomy for cancer. Journal Of Visceral Surgery, 153(1), 39-43.

Wang, G., Hu, H., Zhang, Q., Liu, Z., Chen, Y., & Wang, X. (2016). Laparoscopic right hemicolectomy with transvaginal specimen extraction. Annals Of Laparoscopic And Endoscopic Surgery, 1, 28-28.

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