Analyzing Perioperative Care and Safety in Laparoscopic Hemicolectomy

This case study delves into the perioperative care of a 69-year-old male undergoing laparoscopic left hemicolectomy due to a positive FOB test and a 4mm adenocarcinoma on the left descending colon. It emphasizes the critical role of patient safety during the pre-operative, intraoperative, and postoperative phases, highlighting how proper communication, teamwork, and adherence to safety protocols are essential for positive patient outcomes. The study explores the etiology and physiological processes of bowel diseases necessitating colectomy, the importance of preoperative assessments including CPET, and the use of risk scoring systems like POSSUM to predict complications. It also addresses the management of stress responses, fluid therapy, and pain, while examining potential legal and safety issues, such as incomplete patient consent and risks associated with anesthesia. Ultimately, the case underscores the need for a multidisciplinary approach to minimize complications and improve the quality of perioperative care in colorectal surgery. Desklib provides a platform to access this and similar solved assignments.

Introduction
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).
Laparoscopic left hemicolectomy:
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).
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)..
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.
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
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.

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