Preoperative Planning Preoperative Work-Up

Many of the general principles that have been learned from open colon and rectal surgery can be applied to laparoscopic and robotic surgery. Patients undergoing minimally invasive colorectal surgery need a full history and physical exam, with particular attention paid to the number and types of previous abdominal surgeries, as well as any history of any signifi cant abdominal infection. This should be accompanied by appropriate blood work, electrocardiogram, chest x-ray, and other investigations as dictated by the patient’s age and comorbidities. For patients with colon and rectal cancer, routine preoperative evaluation includes preoperative staging and assessment of resectability, as well as a full colonoscopy to rule out synchronous lesions. In minimally invasive colon and rectal surgery, tumor localization is a key component of the preoperative work-up. Unlike in open or hand-assisted cases, the tumor cannot be palpated for localization during the case, and tumors may not be visible during laparoscopy. If accurate localization is not obtained prior to the operation, the wrong segment of the colon may be removed [ 1 ]. In fact, a survey of members of the American Society of Colon and Rectal Surgeons showed that 6.5 % of respondents had removed the wrong section of the colon [ 2 ]. Options available for preoperative localization include barium enema, computed tomographic (CT) colonography, colonoscopy with India ink injection or placement of metallic clips, and intraoperative endoscopy. Barium enema has been found to have a low sensitivity (0.35–0.41) and high specifi city (0.82–0.86) for detection of colon and rectal tumors with decreased reliability as the size of the lesion decreases [ 3 , 4 ]. CT colonography has been shown to be superior to barium enema with a higher sensitivity (0.49–0.73) and a higher specifi city (0.84–0.89). As with barium enema, the detection of lesions decreases with decreasing size [ 3 , 4 ]. Although preoperative imaging may adequately demonstrate the location of the tumor, translation to accurate intraoperative localization and resection may not be reliable. Colonoscopy has become the gold standard in detecting lesions as it has the highest sensitivity (0.97–0.987) and specifi city (0.996–0.999) [ 3 , 4 ]. Even though colonoscopy continues to be the best tool for detection, there are still errors in localization. The literature has shown an error rate in predicting the accurate location of a lesion within the colon ranging from 3 to 21 % [ 5 – 8 ]. Intraoperative colonoscopy can be used when lesions are not able to be located; however, this can insuffl ate the bowel and make the rest of the operation cumbersome [ 9 , 10 ]. The use of CO 2 insuffl ation may help to signifi cantly reduce this problem [ 11 ]. Serosal clips or sutures may be used with the help of intraoperative colonoscopy to mark the lesion; however, clips may fall off or be too small to see after placement [ 9 , 12 ]. Another option is preoperative marking of the lesion by endoscopically placing a metal clip. The clip is applied to the mucosa and then fl uoroscopy or ultrasound is used intraoperatively to locate the clip (Box 2.1 ). This technique can have disadvantages including migration or dislodgement of the clips, increased operative times, and radiation exposure to the patient [ 9 , 10 , 12 ]. Preoperative Planning and Postoperative Care in Minimal Invasive Colorectal Surgery