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Colorectal Channel
Colorectal Surgery: What does the anesthesia provider need to know?
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Many colorectal patients have associated malformations affecting the airway and cardiac system that are relevant to anesthesia choices.
When creating an anus, electrical stimulation is used to identify the ideal sphincteric ellipse for anus placement.
Neuromuscular blockade prevents the electrical stimulator from working, making it impossible to see muscle contractions needed to locate the sphincter.
Neuromuscular blockade should be avoided at the beginning of cases involving anal reconstruction until after the sphincter is marked.
Once the sphincter is marked, neuromuscular blockade can be administered.
Patients with Hirschsprung disease, fecal incontinence receiving Malone procedures, or those not undergoing anal reconstruction do not require neuromuscular blockade restrictions.
The prone position provides better access to the pelvis for colorectal surgery.
Alberto Pena's major advance in 1980 was approaching the rectum through a posterior sagittal approach, which was considered a radical idea at the time.
Prone positioning allows three surgeons to see the surgical field well, whereas supine perineal approaches only allow one surgeon good visualization.
Lower extremity IV access is acceptable and can be managed with sterile tubing across the drape.
Baseline hematocrit is important to know for long cases in case blood loss occurs, though transfusion is rare (occurring only once or twice per year).
Hyperviscosity should be avoided because some reconstructions (rectum, vagina, bladder augmentation) are based on a single blood vessel that could clot.
Some colorectal cases are analogous to free flap cases, where tissue is moved to another location based on a single vessel.
Patients often receive bowel preparation preoperatively, which causes dehydration requiring fluid catch-up.
When the bladder is open during surgery, urine output cannot be monitored for up to 6 hours, making fluid management more difficult.
Regional pain management has been so successful that ICU admission is almost never needed for these patients.
At the speaker's previous institution, rapid responses were common due to patients being in pain and not breathing well at night, which rarely happens at the current institution.
For patients with large operations where pain management will be challenging, there is value in leaving them intubated overnight to avoid pain crises at midnight on the floor.
Vasoconstrictive medications have been associated with loss of pedicled grafts in previous cases.
Dopamine is less vasoconstrictive than norepinephrine and is preferred when vasopressor support is needed.
Transverse incisions are more painful than vertical incisions and require adjusted pain management planning.
Oral narcotics should be delayed until patients are on a regular diet to avoid confounding nausea that could be mistaken for a surgical complication.
Epidurals should be left in place until patients are on a regular diet before advancing to oral narcotics.
NSAIDs like ketorolac are effective for pain management and avoid narcotics, and are generally safe even in patients with a single kidney if renal function is normal.
Norepinephrine and epinephrine have been associated with vasoconstriction of small vessels in pedicled graft situations.
At the speaker's previous institution, patients with cases longer than 6 hours routinely went to the ICU.
In the last 6 months at the current institution, only 1-2 patients needed ICU admission.
The reduction in ICU utilization is attributed to proactive planning and successful regional pain management.
A 16-hour case performed 6 weeks prior required ICU admission for both pain and fluid management.
Joint cases with urology and robotic cases can take 8-10 hours but typically do not require ICU admission.
Better regional pain management has reduced rapid responses for patients in pain and not breathing well at night.
It typically takes 3-4 months from initial contact to surgery due to paperwork, insurance, and medical record review.
Patients are safe during the waiting period because they have temporary diversion (colostomy or vesicostomy).
As long as patients have a colostomy and urine is draining successfully, the operation can take place anytime within the first year of life.
The ideal timeline is newborn colostomy, reconstruction between 2-6 months, colostomy closure thereafter, with all surgeries completed by 1 year of age.
Completing surgeries by 1 year allows 2 years for patients to learn their anatomy and attempt potty training before starting school.
If patients are not successfully potty trained by nursery school age, a bowel management program can achieve mechanical cleanliness.
Overhydration can cause dilated bowel that is difficult to close, but this has not been observed at the current institution due to accurate fluid management.