What are the latest developments and evidence-based practices in colorectal surgery, including minimally invasive techniques and management of complex conditions?

Latest Developments in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols combined with minimally invasive techniques represent the current standard of care in colorectal surgery, with laparoscopic approaches demonstrating superior outcomes to open surgery and emerging evidence supporting robotic-assisted surgery for faster recovery and reduced pain. 1, 2

Minimally Invasive Surgical Approaches

Laparoscopic Surgery - Established Standard

Laparoscopic colectomy should be the preferred approach for colon cancer over open surgery, as it provides:

• 2-day reduction in hospital stay 3
• Earlier return of bowel function 1
• Equivalent oncologic outcomes with similar pathology results and long-term survival 4
• Lower morbidity rates in multivariate analysis 3
• 30-day mortality of only 0.08% for large lesion resections versus 0.7% for surgical resection 1, 5

Critical requirement: Laparoscopic colectomy should only be performed by surgeons experienced in the technique, with thorough abdominal exploration as a required component 1. The limiting factor for laparoscopic adoption is surgeon skill rather than patient or tumor characteristics 6.

Important caveat for rectal cancer: While laparoscopic colon resection is well-established, two recent RCTs have questioned routine laparoscopic use for rectal cancer, as non-inferiority to open surgery has not been definitively demonstrated even in expert hands 4.

Robotic-Assisted Surgery - Emerging Evidence

Robotic-assisted surgery demonstrates clinically meaningful advantages over standard laparoscopy based on the most recent high-quality evidence:

• Significantly shorter hospital stays (6.5 vs 10.2 days for right colectomy, 5.5 vs 8.2 days for left colectomy) 2
• Lower postoperative pain scores (3.0 vs 4.1 for right colectomy, 2.9 vs 4.1 for left colectomy) 2
• Reduced ileus rates for left colectomy (6.2% vs 15.9%) 2
• Higher lymph node yields for right colectomy (31.4 vs 26.8 nodes) 2
• No increase in major complications 2

The robotic platform offers seven degrees of movement and 3D visualization, though whether these technical advantages translate to improved outcomes requires further evaluation within standardized ERAS protocols 3.

Enhanced Recovery After Surgery (ERAS) Protocols

Preoperative Optimization

Mechanical bowel preparation should NOT be routinely used, as it does not improve outcomes and may cause patient discomfort 1. However, mechanical bowel preparation combined with oral antibiotics should be re-evaluated as emerging evidence suggests potential benefits for reducing anastomotic leaks and surgical site infections 3.

Mandatory preoperative measures:

• Comprehensive patient counseling and education 1
• Nutritional screening with active support for malnourished patients 1
• Carbohydrate loading up to 2 hours before surgery to minimize fasting 1
• No routine nasogastric tube placement 1

Venous Thromboembolism Prophylaxis

All patients must receive multimodal VTE prophylaxis 1:

• Well-fitted compression stockings 1
• Intermittent pneumatic compression, particularly for malignancy or pelvic surgery 1
• Pharmacological prophylaxis with low-molecular-weight heparin (LMWH) 30-60 minutes before incision 1
• Extended prophylaxis for 28 days post-discharge specifically for colorectal cancer patients (reduces symptomatic DVT from 1.7% to 0.2%, NNT=66) 1

Intraoperative Management

Antimicrobial prophylaxis is imperative:

• Intravenous antibiotics covering aerobic and anaerobic bacteria given 30-60 minutes before incision 1
• Repeated doses during prolonged procedures based on drug half-life 1
• Chlorhexidine-alcohol skin preparation reduces surgical site infections by 40% compared to povidone-iodine 1

Fluid management: Doppler-guided fluid administration reduces morbidity 1. Goal-directed fluid therapy protocols with specified hemodynamic targets should be established 3.

Pain control strategy:

• For open surgery: Thoracic epidural analgesia (TEA) using low-dose local anesthetic and opioids is the gold standard 1
• For laparoscopic surgery: TEA is not mandatory; alternatives include carefully administered spinal analgesia with long-acting opioids or TAP blocks 1, 3

Postoperative Care

Early mobilization and feeding are mandatory 1:

• Patients should be mobilized on day of surgery 1
• Normal food intake should begin as soon as patient is lucid 1
• Early enteral feeding is safe and improves recovery 1

Multimodal ileus prevention 1:

• Chewing gum 1
• Prevention of postoperative nausea and vomiting 1
• Minimally invasive surgical approach 1
• Avoidance of fluid overload 1
• Early nasogastric tube removal 1

Endoscopic Management of Colorectal Lesions

Polypectomy Technique Selection

Cold snare polypectomy is the recommended technique for all polyps <10mm, with 98.2% complete resection rates and minimal complications 1, 5. Hot forceps polypectomy should never be used due to deep thermal injury risk 1, 5.

For diminutive (≤5mm) and small (6-9mm) lesions:

• Cold snare polypectomy is strongly recommended 1
• Cold forceps polypectomy is acceptable only for 1-3mm polyps where cold snare is technically difficult 5
• Cold forceps should NOT be used for 5mm lesions due to high incomplete resection rates 1

For pedunculated lesions >10mm: Hot snare polypectomy is recommended 5

Critical assessment: All polyps require structured visual assessment using high-definition white light and/or electronic chromoendoscopy with the NICE classification to identify submucosal invasive cancer 5. Non-pedunculated lesions with NICE type 3 or Kudo Vn patterns indicate deep invasion (>1000μm) and require cold biopsy, tattoo, and surgical referral rather than endoscopic resection 1.

Emergency Colorectal Surgery

Obstructive Left Colon Cancer

For facilities with stent placement capability, self-expanding metallic stents (SEMS) should be preferred over colostomy for palliation of obstructive left colon cancer, as SEMS provides similar mortality/morbidity with shorter hospital stay 1.

Important contraindication: Alternative treatments to SEMS must be considered in patients eligible for bevacizumab-based therapy, requiring oncologist involvement in decision-making 1.

Laparoscopy in emergency settings: Cannot be routinely recommended and should be reserved for selected favorable cases in specialized centers, though less than 10% of obstructive colon cancer cases are currently managed laparoscopically 1.

Iatrogenic Urinary Tract Injuries

Urologist involvement is paramount when iatrogenic urinary tract injury is suspected during colorectal surgery 1. The paradigm has shifted from primary surgeon management to mandatory urologist consultation due to technique complexity 1.

For bladder injuries (most common during pelvic surgery):

• Direct two-layer repair with absorbable suture 1
• Foley catheter placement for 5-14 days 1
• Cystography before catheter removal 1

For ureteral injuries (17.6% identified intraoperatively):

• Laparoscopic end-to-end ureteroureterostomy for intraoperatively detected injuries shows shorter operative time and less blood loss compared to ureteroneocystostomy 1
• Adequate drainage is essential to prevent urinoma and abscesses 1

Implementation Priorities

High-priority areas requiring standardization 3:

• Comparison of robotic-assisted surgery to conventional laparoscopy within ERAS protocols for definitive outcome data
• Optimal duration and components of prehabilitation programs to maximize complication reduction
• Effective implementation strategies to achieve high ERAS protocol adherence across diverse hospital settings

Common pitfall: Surgery for benign colon lesions has inappropriately increased from 6% in 2000 to 18% in 2014, despite endoscopic removal being more cost-effective with lower morbidity (14% major complications, 0.7% mortality) compared to endoscopic resection (0.08% mortality) 1.