Preoperative instructions and postoperative care in the 21st century
The preoperative and postoperative management of patients undergoing right hemicolectomy for colon cancer has undergone significant change in the 20th century. From a time where a postoperative stay of 10 days was not uncommon, patients are now routinely discharged on postoperative day 2–3, and same day colectomy is also practiced in some centers. Enhanced recovery programs are standard practice and their guidelines are developed from a strong evidence base around perioperative management and recovery. The preoperative visit is increasingly important and is used to identify modifiable risk factors such as malnutrition, anemia, smoking, and alcohol abuse. Detailed counselling and preoperative education should also be undertaken so patients are psychologically prepared for their cancer surgery and have clear expectations and goals for their recovery. Nausea and vomiting postoperatively is a common cause of delayed discharge. Patients at risk should be identified preoperatively and treated prophylactically. Prehabilitation is an exciting field in colorectal surgery but its role in right hemicolectomy for colon cancer is limited due the necessary short interval between diagnosis and surgery. Patients should be fasting for the minimal amount of time preoperatively and should be allowed clear carbohydrate containing fluids up until 2 hours before surgery. The intraoperative use of opioids should be minimized and high risk patients should have goal-directed fluid therapy (GDFT). As the majority of right colectomies are performed laparoscopically, TAP blocks should be used instead of epidural analgesia for postoperative pain relief. The routine use of nasogastric tubes or abdominal drains should be avoided. Patients should be mobilized the evening after surgery and diet advanced early to prevent postoperative ileus. In modern colorectal practice, regular audits should be undertaken in the unit to ensure adherence to enhanced recovery programs and to identify areas for improvement.