The Complication of Colorectal Surgery
The exact frequency and severity of complications are difficult to determine due to heterogeneous definitions, patient populations, procedures, comobidities, and intensity of follow-up. One perspective of the incidence of complications can be gleaned from four recent randomized controlled trials comparing laparoscopic to open colon resections for cancer.
Complication rates following laparoscopic and open colon resections
Wound Infection
Superficial wound infections are the most common complication of colorectal surgery. The previously held belief that preoperative cathartic and oral antibiotic bowel preparation was mandatory to prevent postoperative infections has recently been debunked by multiple randomized controlled trials. Superficial wound infections are recognized by any combination of erythema, induration, tenderness, or drainage at the wound site. Systemic signs of fever and tachycardia may also be present. The infection may manifest as an abscess, cellulitis, or a combination of the two. When suspected, the wound should be carefully inspected and when a collection is detected, it is drained by reopening the wound. Gram stain can assist in the management and antibiotic selection.
Anastomotic Leak
During laparoscopic colorectal surgery, an anastomotic leak is a common, potentially life-threatening complication associated with significant morbidity, increased risk of local recurrence of cancer, decreased functional outcomes, increased length of stay, high-risk of (permanent) ostomy, and death. Leaks are variably defined in the literature, but in general regarded as perianastomotic stool, gas, or abscess, peritonitis, or a fecal fistula. The incidence of an anastomotic leak following colectomy is generally reported between 2 and 6 percent. Anastomotic leaks present in one of three ways.
1. Asymptomatic leak
2. Subtle insidious leak
3. Dramatic early leak
After surgery, the asymptomatic leak is incidentally found during endoscopic or radiographic studies. The incidence of radiographically detected leaks is 4 to 6 times higher than clinically detected leaks. These leaks, which often present weeks or months later, are typically walled off sinuses, and are, as a general rule, harmless. Treatment is rarely necessary. The subtle insidious leak can present perioperatively with nonspecific signs and symptoms common in the postoperative period. Such signs include low-grade fevers, mild leukocytosis, protracted ileus, and failure to thrive and occur 5 to 14 days following surgery. Management of the stable patient without signs of peritonitis usually begins with imaging to identify and localize the process. Traditionally, water-soluble contrast enema has been the primary study to identify leaks.
Drawbacks include lower sensitivity for right-sided anastomosis as the contrast dilutes out before reaching the proximal bowel. It also provides little information on extracolonic conditions such as ileus and collections. Abdominopelvic CT scan with triple contrast (oral, intravenous, and rectal) has become the imaging modality of choice to evaluate suspected postoperative intra-abdominal infection. Specificity during the first five days postoperative, however, is reduced. During this period, infectious processes may be difficult to differentiate from acute postoperative inflammation and fluid collections. Sensitivity is much improved beyond 5 to 7 days. CT scan and contrast enema can also be used as complementary studies.
If there are large collections, it can often amenable to percutaneous, transgluteal, or transanal image-guided catheter drainage. The images should be reviewed with an interventional radiologist to identify a safe window of access that avoids vascular structures and other organs. Abscesses less than 3 to 4 cm are too small for most pigtail catheters and will often resolve with a course of antibiotics. In the era of modern CT scanning and interventional radiology, the routine practice of repeat laparotomy, abdominal washouts, large sump drains, and open abdominal wound management is rarely necessary and can be reserved for patients who fail to respond to, deteriorate following, or are not candidates for percutaneous drainage.
Sometimes the management of the patient with progressive generalized peritonitis with or without septic shock requires resuscitation in ICU with broad-spectrum antibiotics and urgent laparotomy. Laparoscopic management may be considered if the surgeon has sufficient laparoscopic skills and reoperative experience. At the time of surgery, the anastomosis should be scrutinized for signs which led to its failure. This can guide the appropriate method of repair. After laparoscopic colorectal surgery if the findings at operation show ischemia and necrosis of greater than one- third of the anastomosis, the anastomosis should be resected with the creation of a stoma. If the mucous fistula can be brought up to the skin, it should ideally be fashioned through the same site as the proximal ostomy. When performed in this fashion, subsequent ostomy reversal can be done via a circumstomal incision, obviating the need for formal laparotomy and its associated morbidity. If the findings at operation identify a smaller leak with healthy bowel, the anastomosis can usually be salvaged with suture repair, proximal diversion, and washout of the distal segment. Our preferred diversion is a loop ileostomy.
Early Postoperative Small Bowel Obstruction
After colorectal laparoscopic surgery, early postoperative bowel obstruction is rare, occurring in 1 percent of patients. This time period accounts for 5 to 29 percent of all small bowel obstructions. Most obstructions are caused by adhesions which form within 72 hours of surgery then become very dense and vascular after two to three weeks. Obstructions are more common following colorectal and gynecological procedures than following appendectomy or procedures located above the transverse colon. Signs and symptoms of early postoperative small bowel obstruction are similar to and hard to differentiate from the more common paralytic ileus. Patients typically develop abdominal distention, nausea, and vomiting, but cannot tolerate nasogastric tube clamping or removal. Most patients have a slow, smoldering course with emergencies being the exception.
The surgeon should try to manage obstruction conservatively initially. There is a fine balance between waiting for the obstruction to resolve and rushing a patient to the operating room. In the first week following surgery, obstruction is hard to differentiate from ileus. Between 2 weeks and 2 months, postoperative adhesions become thick, vascular, and obliterate natural planes making surgery much more difficult and prone to complications. The decision to operate should, therefore, occur between 7 and 14 days.
If a patient has symptoms of obstruction, plain films readily diagnose most small bowel obstructions. Oral administration of water-soluble contrast followed by an abdominal plain film or CT scan 4 hours later is a good predictor of resolution of a small bowel obstruction. The contrast in the colon indicates the obstruction is likely to resolve with non-operative means. CT scan may be useful in identifying signs of ischemia, other intraabdominal processes and in localizing the site of obstruction for operative planning. Initial management of the stable patient involves fluid and electrolyte replacement, bowel rest, nasogastric tube drainage, and nutritional evaluation.
Total parenteral nutrition should be started as soon as the detected leak. Operation is advised for high grade or complete bowel obstruction, concern for strangulated bowel, or unresolved small bowel obstruction despite prolonged NGT decompression. If proper care is insured most patients resolve with non- operative management. If surgery becomes necessary, it should occur prior to the two weeks mark after which the acute adhesions become dense, vascular, and problematic. Surgery involves careful re-exploration and lysis of adhesions. Operative findings usually reveal either a single adhesive band or multiple matted adhesions, each occurring with similar frequency.
After colorectal surgery, if obstruction develops, laparoscopic exploration and adhesiolysis are being increasingly utilized for small bowel obstructions. Advanced laparoscopic skills and experience are a prerequisite because access is difficult in these patients. Poor candidates for laparoscopic management include patients with signs of peritonitis, multiple previous operations for small bowel obstruction, small bowel diameter greater than 4 cm, or other medical contraindication to laparoscopy. Pneumoperitoneum should be established with an open technique at a site remote from the previous incision.
Atraumatic graspers are used to explore the bowel in a retrograde fashion beginning with decompressed bowel at the ileocecal valve. Distended bowel is fragile and should not be grasped: grasping the adjacent mesentery reduces the risk of inadvertent bowel perforation. Adhesiolysis is best performed with scissors or bipolar cautery devices to reduce the risk of adjacent bowel injury. Conversion rates range from 7 to 43 percent. Proactive reasons to convert include poor visualization, nonviable intestine, multiple dense adhesions, deep pelvic adhesions, and failure to progress in a reasonable time.
Tips and Tricks
To avoid intraoperative complications:
• Create adequate exposure
• Use proper traction and counter traction
• Develop the right planes
• Standardize the assistant's role
• Beware of the variations of vasculature and anatomy
• Should visualization be compromised during the procedure it is easy to switch to a 30° laparoscope for a more topographical view? Applying the angled 30° laparoscope can also be helpful to manage external arm collisions during tight set-up situations, as the camera arm angle changes depending on the endoscopy used. Additionally, with an angled 30° laparoscope the surgeon has the ability to rotate the viewing angle of the scope (out of the horizontal image plane) and minimize collisions as well.
• Leave 1 to 1.5 cm on either side of the transacted IMA and IMV so that if any bleeding occurs grasping of the vessel is still possible to allow the application of the hemostatic technique (clips, LigaSure™ or suture).
• Distance the ports as much as possible from each other during initial port placement (minimum of 7.5 cm). Placing the patient in a steeper Trendelenburg position can increase the vertical spacing between the arms and potentially eliminate or minimize arising collisions.
• Before dividing any tissues, identify the ureter and gonadal vessels one more time.
• During all procedure steps clear communication with the patient-side assistant is essential.
Conclusion
The laparoscopic technique reduces parietal aggression and achieves the same results as traditional surgery. Patients recover faster and experience less pain, with fewer wound infections, postoperative hernias, less time in the hospital, and reduced costs. But laparoscopic colonic surgery requires extensive and highly specialized training, with few surgeons qualified to perform these procedures. The recent conclusion of the oncologic debate together with the rapid development of technological means and the increase in public awareness will probably result in a substantial increase in the number of surgeons performing laparoscopic colorectal surgery.
The laparoscopic technique is an excellent approach though not yet the gold standard. Smooth performance of this technique depends on: the quality of the equipment; perfect knowledge of the operative steps; exposure of operative field; the experience of the surgical team. Operative times are somewhat longer than open procedures but become shorter along the learning curve. Right colectomies are shorter and easier to perform than left-sided and rectal resections and should be employed for teaching residents. The conversion rate would not necessarily drop after the first 50 cases and should reflect good surgical judgment rather than a surgical failure.
The exact frequency and severity of complications are difficult to determine due to heterogeneous definitions, patient populations, procedures, comobidities, and intensity of follow-up. One perspective of the incidence of complications can be gleaned from four recent randomized controlled trials comparing laparoscopic to open colon resections for cancer.
Complication rates following laparoscopic and open colon resections
Wound Infection
Superficial wound infections are the most common complication of colorectal surgery. The previously held belief that preoperative cathartic and oral antibiotic bowel preparation was mandatory to prevent postoperative infections has recently been debunked by multiple randomized controlled trials. Superficial wound infections are recognized by any combination of erythema, induration, tenderness, or drainage at the wound site. Systemic signs of fever and tachycardia may also be present. The infection may manifest as an abscess, cellulitis, or a combination of the two. When suspected, the wound should be carefully inspected and when a collection is detected, it is drained by reopening the wound. Gram stain can assist in the management and antibiotic selection.
Anastomotic Leak
During laparoscopic colorectal surgery, an anastomotic leak is a common, potentially life-threatening complication associated with significant morbidity, increased risk of local recurrence of cancer, decreased functional outcomes, increased length of stay, high-risk of (permanent) ostomy, and death. Leaks are variably defined in the literature, but in general regarded as perianastomotic stool, gas, or abscess, peritonitis, or a fecal fistula. The incidence of an anastomotic leak following colectomy is generally reported between 2 and 6 percent. Anastomotic leaks present in one of three ways.
1. Asymptomatic leak
2. Subtle insidious leak
3. Dramatic early leak
After surgery, the asymptomatic leak is incidentally found during endoscopic or radiographic studies. The incidence of radiographically detected leaks is 4 to 6 times higher than clinically detected leaks. These leaks, which often present weeks or months later, are typically walled off sinuses, and are, as a general rule, harmless. Treatment is rarely necessary. The subtle insidious leak can present perioperatively with nonspecific signs and symptoms common in the postoperative period. Such signs include low-grade fevers, mild leukocytosis, protracted ileus, and failure to thrive and occur 5 to 14 days following surgery. Management of the stable patient without signs of peritonitis usually begins with imaging to identify and localize the process. Traditionally, water-soluble contrast enema has been the primary study to identify leaks.
Drawbacks include lower sensitivity for right-sided anastomosis as the contrast dilutes out before reaching the proximal bowel. It also provides little information on extracolonic conditions such as ileus and collections. Abdominopelvic CT scan with triple contrast (oral, intravenous, and rectal) has become the imaging modality of choice to evaluate suspected postoperative intra-abdominal infection. Specificity during the first five days postoperative, however, is reduced. During this period, infectious processes may be difficult to differentiate from acute postoperative inflammation and fluid collections. Sensitivity is much improved beyond 5 to 7 days. CT scan and contrast enema can also be used as complementary studies.
If there are large collections, it can often amenable to percutaneous, transgluteal, or transanal image-guided catheter drainage. The images should be reviewed with an interventional radiologist to identify a safe window of access that avoids vascular structures and other organs. Abscesses less than 3 to 4 cm are too small for most pigtail catheters and will often resolve with a course of antibiotics. In the era of modern CT scanning and interventional radiology, the routine practice of repeat laparotomy, abdominal washouts, large sump drains, and open abdominal wound management is rarely necessary and can be reserved for patients who fail to respond to, deteriorate following, or are not candidates for percutaneous drainage.
Sometimes the management of the patient with progressive generalized peritonitis with or without septic shock requires resuscitation in ICU with broad-spectrum antibiotics and urgent laparotomy. Laparoscopic management may be considered if the surgeon has sufficient laparoscopic skills and reoperative experience. At the time of surgery, the anastomosis should be scrutinized for signs which led to its failure. This can guide the appropriate method of repair. After laparoscopic colorectal surgery if the findings at operation show ischemia and necrosis of greater than one- third of the anastomosis, the anastomosis should be resected with the creation of a stoma. If the mucous fistula can be brought up to the skin, it should ideally be fashioned through the same site as the proximal ostomy. When performed in this fashion, subsequent ostomy reversal can be done via a circumstomal incision, obviating the need for formal laparotomy and its associated morbidity. If the findings at operation identify a smaller leak with healthy bowel, the anastomosis can usually be salvaged with suture repair, proximal diversion, and washout of the distal segment. Our preferred diversion is a loop ileostomy.
Early Postoperative Small Bowel Obstruction
After colorectal laparoscopic surgery, early postoperative bowel obstruction is rare, occurring in 1 percent of patients. This time period accounts for 5 to 29 percent of all small bowel obstructions. Most obstructions are caused by adhesions which form within 72 hours of surgery then become very dense and vascular after two to three weeks. Obstructions are more common following colorectal and gynecological procedures than following appendectomy or procedures located above the transverse colon. Signs and symptoms of early postoperative small bowel obstruction are similar to and hard to differentiate from the more common paralytic ileus. Patients typically develop abdominal distention, nausea, and vomiting, but cannot tolerate nasogastric tube clamping or removal. Most patients have a slow, smoldering course with emergencies being the exception.
The surgeon should try to manage obstruction conservatively initially. There is a fine balance between waiting for the obstruction to resolve and rushing a patient to the operating room. In the first week following surgery, obstruction is hard to differentiate from ileus. Between 2 weeks and 2 months, postoperative adhesions become thick, vascular, and obliterate natural planes making surgery much more difficult and prone to complications. The decision to operate should, therefore, occur between 7 and 14 days.
If a patient has symptoms of obstruction, plain films readily diagnose most small bowel obstructions. Oral administration of water-soluble contrast followed by an abdominal plain film or CT scan 4 hours later is a good predictor of resolution of a small bowel obstruction. The contrast in the colon indicates the obstruction is likely to resolve with non-operative means. CT scan may be useful in identifying signs of ischemia, other intraabdominal processes and in localizing the site of obstruction for operative planning. Initial management of the stable patient involves fluid and electrolyte replacement, bowel rest, nasogastric tube drainage, and nutritional evaluation.
Total parenteral nutrition should be started as soon as the detected leak. Operation is advised for high grade or complete bowel obstruction, concern for strangulated bowel, or unresolved small bowel obstruction despite prolonged NGT decompression. If proper care is insured most patients resolve with non- operative management. If surgery becomes necessary, it should occur prior to the two weeks mark after which the acute adhesions become dense, vascular, and problematic. Surgery involves careful re-exploration and lysis of adhesions. Operative findings usually reveal either a single adhesive band or multiple matted adhesions, each occurring with similar frequency.
After colorectal surgery, if obstruction develops, laparoscopic exploration and adhesiolysis are being increasingly utilized for small bowel obstructions. Advanced laparoscopic skills and experience are a prerequisite because access is difficult in these patients. Poor candidates for laparoscopic management include patients with signs of peritonitis, multiple previous operations for small bowel obstruction, small bowel diameter greater than 4 cm, or other medical contraindication to laparoscopy. Pneumoperitoneum should be established with an open technique at a site remote from the previous incision.
Atraumatic graspers are used to explore the bowel in a retrograde fashion beginning with decompressed bowel at the ileocecal valve. Distended bowel is fragile and should not be grasped: grasping the adjacent mesentery reduces the risk of inadvertent bowel perforation. Adhesiolysis is best performed with scissors or bipolar cautery devices to reduce the risk of adjacent bowel injury. Conversion rates range from 7 to 43 percent. Proactive reasons to convert include poor visualization, nonviable intestine, multiple dense adhesions, deep pelvic adhesions, and failure to progress in a reasonable time.
Tips and Tricks
To avoid intraoperative complications:
• Create adequate exposure
• Use proper traction and counter traction
• Develop the right planes
• Standardize the assistant's role
• Beware of the variations of vasculature and anatomy
• Should visualization be compromised during the procedure it is easy to switch to a 30° laparoscope for a more topographical view? Applying the angled 30° laparoscope can also be helpful to manage external arm collisions during tight set-up situations, as the camera arm angle changes depending on the endoscopy used. Additionally, with an angled 30° laparoscope the surgeon has the ability to rotate the viewing angle of the scope (out of the horizontal image plane) and minimize collisions as well.
• Leave 1 to 1.5 cm on either side of the transacted IMA and IMV so that if any bleeding occurs grasping of the vessel is still possible to allow the application of the hemostatic technique (clips, LigaSure™ or suture).
• Distance the ports as much as possible from each other during initial port placement (minimum of 7.5 cm). Placing the patient in a steeper Trendelenburg position can increase the vertical spacing between the arms and potentially eliminate or minimize arising collisions.
• Before dividing any tissues, identify the ureter and gonadal vessels one more time.
• During all procedure steps clear communication with the patient-side assistant is essential.
Conclusion
The laparoscopic technique reduces parietal aggression and achieves the same results as traditional surgery. Patients recover faster and experience less pain, with fewer wound infections, postoperative hernias, less time in the hospital, and reduced costs. But laparoscopic colonic surgery requires extensive and highly specialized training, with few surgeons qualified to perform these procedures. The recent conclusion of the oncologic debate together with the rapid development of technological means and the increase in public awareness will probably result in a substantial increase in the number of surgeons performing laparoscopic colorectal surgery.
The laparoscopic technique is an excellent approach though not yet the gold standard. Smooth performance of this technique depends on: the quality of the equipment; perfect knowledge of the operative steps; exposure of operative field; the experience of the surgical team. Operative times are somewhat longer than open procedures but become shorter along the learning curve. Right colectomies are shorter and easier to perform than left-sided and rectal resections and should be employed for teaching residents. The conversion rate would not necessarily drop after the first 50 cases and should reflect good surgical judgment rather than a surgical failure.
