Colectomy / Bowel Resection
Patient phenotype
Wide range: colorectal cancer (60s–70s, often anemic, sometimes obstructed), inflammatory bowel disease (younger, on biologics + steroids), diverticular disease. May be open, laparoscopic, or robotic. Mostly elective but can be emergent for perforation/obstruction.
Procedure
Resection of segment of colon (right hemi, left hemi, sigmoid, total/subtotal) with primary anastomosis or end colostomy. 2–5 hours. Lithotomy + supine combination common. Bowel prep (or no prep — increasingly debated) preop.
Anesthetic plan
GETA. ERAS protocol now standard: multimodal analgesia (acetaminophen, ketorolac if no contraindication, gabapentin, lidocaine infusion 1–2 mg/kg/h), TAP block or rectus sheath catheters, restrictive fluid strategy (goal-directed), early extubation + early ambulation/feeding.
Setup
- ·1-2 PIVs (16-18g)
- ·A-line if comorbidities or expected long case
- ·Forced air warmer + fluid warmer
- ·OG tube
- ·Foley
- ·Bilateral TAP blocks or rectus sheath catheters preinduction (or surgeon-placed under direct vision)
Biggest concerns by phase
Volume status after bowel prep
Mechanical bowel prep + NPO = often 2-3 L volume deficit. Recheck electrolytes (K, Mg) — diarrheal losses. Hypovolemia + induction = significant hypotension. Consider 500-1000 mL crystalloid before induction in dehydrated patient.
ERAS fluid balance — restrictive but not dry
Goal: euvolemia, not 'dry.' Use SVV/PPV with continuous BP monitor. Crystalloid 1-3 mL/kg/h maintenance, bolus only for true hypovolemia. Excess fluid → bowel edema → anastomotic leak risk doubles.
Avoid N₂O + minimize neuromuscular blockade reversal issues
N₂O distends bowel — surgical view + anastomosis quality compromised. Use rocuronium with sugammadex reversal (or cisatracurium if sugammadex unavailable) to enable adequate relaxation without hangover.
Hypothermia in long open case
Open abdomen + 3-4 hours = rapid heat loss. Maintain core ≥ 36 °C — hypothermia increases SSI 3x, blood loss, cardiac events. Forced air upper body + warm IV fluids + room ≥ 21 °C.
Multimodal analgesia + early extubation
Lidocaine infusion stopped 30 min before end; reduces opioid need by 30%. TAP block lasts 12-18h. Reverse NMB carefully (TOF > 0.9). Extubate in OR — early ambulation is ERAS cornerstone. PONV prophylaxis (Apfel-guided).
Anastomotic leak surveillance
POD 3-7 typical presentation: tachycardia, low-grade fever, abdominal pain, ileus persisting. Lactate trending up. CRNA's role: don't overlook these signs in PACU — appropriate handoff to floor team about baseline vitals.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
65-year-old M for sigmoid colectomy after diverticular abscess. He has CAD, EF 45%, on aspirin + atorvastatin. He's on ERAS pathway. How do you tailor your anesthetic?
What an examiner probes for
- ▹ERAS principles: multimodal analgesia, opioid-sparing, restrictive fluids, early extubation
- ▹Cardiac risk stratification + perioperative beta-blocker continuation
- ▹Holds aspirin or not (low risk for bleeding, continues for cardiac protection)
- ▹TAP block vs epidural decision
- ▹Goal-directed fluid management
Sources
- ERAS Society Colorectal Guidelines 2018
- Miller's Ch 71
- Apfelbaum perioperative pain
Anatomy reference
Sourced reference images. 4 matches for "colon bowel intestine abdomen".
Browse the full image library →
