The following guidelines apply for open colonic resection. However, if conditions allow, the laparoscopic approach is preferable rather than open surgery, due less postoperative pain and faster recovery. PROSPECT/colonic resection/SUMMARY recommendations/Intra-operative/ see Operative techniques

Evidence-based recommendations specific to the condition

For overall recommendations see: PROSPECT/colonic resection/OVERALL Prospect recommendations

For overview of treatments NOT recommended see: PROSPECT/ colonic resection/OVERALL Prospect recommendations

Preoperative

See: PROSPECT/Colonic Resection/SUMMARY recommendations/ preoperative

For patients not receiving epidural analgesia:

• COX-2-selective inhibitors however, they may contribute to an early anastomotic leakage.
• Continuous IV lidocaine infusion, continued in the early postoperative period.

Local, regional and neuraxial-analgesia-based techniques

• Thoracic epidural analgesia with LA and opioid (e.g. sufentanil), at the appropriate level (site of incision) as it offers better analgesia compared to systemic analgesia, earlier extubation and reduced duration of postoperative ilius French 10.4, p 408.

  • Use of opiods in the epidural may delay first bowel movement due to systemic absorption.
  • The greatest benefit is with a LA only solution
• Epidural is not recommended for laparoscopic surgery. The exception being in HIGH RISK pulmonary patients

Intraoperative

See PROSPECT /Colonic Resection/SUMMARY recommendations/intra-operative

Systemic-based options

• COX-2-selective inhibitors - only for patients not receiving epidural anaesthesia.
• IV strong opioids - only for patients who do not receive epidural anaesthesia
• If administered already, continue with continuous administration of IV lidocaine.

Local, regional and neuraxial analgesia-based techniques

• Continue with thoracic epidural

Pre-peritoneal infusion

• Continuous pre-peritoneal infusion of LA, as an alternative when epidural analgesia is not feasible or contraindicated.

Operative techniques

• In the event of open surgery, a transverse incision will produce less pain and better cosmetic outcome compared to a vertical incision.
• The use of diathermy is recommended over scalpel due to better analgesia and less blood loss.

Postoperative

See PROSPECT /Colonic Resection/SUMMARY recommendations/postoperative

Systemic-based options

• Whenever possible, patients should be given multimodal pain management therapy.
  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel %u03B1-2-%u03B4 antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or paracetamol. ASA section V Multimodal techniques for Pain Management, p 253-254.
• Continue with pre-operative IV lidocaine infusion in patients not receiving epidural infusion.
• After cessation of epidural analgesia OR in patients without an epidural:
  • Strong opioids for severe pain or weak opioids for moderate to mild pain and COX-2-selective inhibitors or conventional NSAIDs.
  • Opioids can be administered by IV-PCA.
• Paracetamol is only recommended for moderate or low pain (VAS < 50 mm) in combination with COX-2-Inhibitors or conventional NSAIDs

Local, regional and neuraxial analgesia-based techniques

• Continue with continuous epidural LA and strong opioid.
  • Epidural opiods may delay first bowel movement due to systemic absorption.

Pre-peritoneal infusion

Continue with continuous pre-peritoneal infusion of LA, as an alternative when epidural analgesia is not feasible or contraindicated.

Summary

Patients undergoing open colonic surgery should be treated with a pre-operatively inserted thoracic epidural catheter. If epidural treatment is not feasible or contraindicated, patients should be treated with opioids via an IV-PCA and COX-2-selective inhibitors. Alternatively, IV lidocaine can be initiated before surgery and continued into the postoperative period. Pre-peritoneal infusion is another alternative. In the event of laparoscopic surgery, epidural analgesia is not indicated, except for high risk pulmonary patients.

Supplementary reading

1. Beaussier M, El'Ayoubi H, Schiffer E, et al Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: a randomized, double-blind, placebo-controlled study. Anesthesiology. 2007 Sep;107(3):461-8.
2. Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012 May;37(3):310-7.