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Management of the Unhealed Perineal Wound 465
too low. The obliteration of the pelvic dead space
may be useful in preventing later infection. For this
reason, an intersphincteric dissection should be con-
sidered whenever possible, and the pelvic peri-
toneum should not be sutured in order to allow the
descent of the bowel loops into the pelvis. A suction
drainage is useful for preventing the collection of
blood and the formation of an haematoma, thus
reducing the risk of infection. The drainage is best
delivered through the abdominal wall [16]. Primary
closure is certainly a choice, provided that pelvic
contamination has not occurred and suction
drainage has been put in place. Packing should be
reserved for those patients in whom contamination
has occurred or when intraoperative haemostasis has
not been satisfactorily accomplished. According to
Jalen et al. [17], an unhealed perineal wound was
present at 6 months after operation in 40% of
patients with primary closure and in 60% of patients
with perineal packing.
Treatment Options
Conservative Treatment
Spontaneous healing can occur in about half of all
patients who still have an unhealed wound 12 months
after rectal excision, if the diagnosis is ulcerative coli-
tis; almost all persistently discharging wounds will
have healed in 18–24 months. Even in Crohn’s dis-
ease some perineal sinuses can heal spontaneously
up to 12 months after proctocolectomy [16]. The
patient should be advised and instructed to take an
active part in the daily care of the wound. Simple sitz
baths are rarely sufficient, and a regular use of a
small shower-like “Water Pik” (Water Pik Technolo-
gies Inc., CA, USA) will favour a correct wound
cleansing. The dressing should not be too tight to
deter mechanical delay of the healing process. Topi-
cal antibiotic agents are sometimes useful to alleviate
symptoms such as pain, pruritus and local inflamma-
tion while systemic antibiotics cannot usually reach
therapeutic tissue concentrations [18] and are gener-
ally less helpful.
Adequate debridement of the perineal wound with
surgical removal of all devitalised and infected tissue
is of great importance. Unfortunately, the presence
of multiple tracks or abscess on the buttocks or sur-
rounding perineal skin often interferes with the
above-mentioned local procedures. It is usually
advisable to examine all fistulae under anaesthesia in
order to define its exact position, dilate any strictures
present and collect some samples for histology and
cultures [16]. A daily irrigation of the cavity with
antiseptic solution is effective in reducing purulent
discharge [20]. In selected cases, oral metronidazole
and low doses of steroids may be confidently used to
reduce inflammation.
Special and complex dressings have been empiri-
cally used over the years to help closure. Among the
many different types of advanced dressings, subat-
mospheric pressure dressings (SPD) are safe and
easy to manage. The wound is filled with a sterile
sponge, a silastic drain tube is placed on top and the
system is sealed with airtight plastic drape. The tube
is connected to a vacuum device or a vacuum bottle
to maintain the wound bed at subatmospheric pres-
sure. A vacuum allows higher blood flow in the
wound bed favouring granulation tissue formation
and absorbs exudates thus reducing bacterial con-
tamination. This method has been adopted in many
cases with good results [8, 21, 22].
Curettage
According to Keighley [16], curettage alone brings
poor results and often requires many repeated treat-
ments. Corman et al. [23] achieved closure in all the
patients with ulcerative colitis and in 10 of 11
patients with Crohn’s disease after repeated sessions
of curettage of the wound (mean 3 treatments/patient).
Excision and Primary Closure
Wide excision and primary closure with removal of
all fibrous tracks can be a very difficult procedure to
carry out, especially in high presacral tracks. Quite
often the wound cannot be sutured directly, and
resulting the dead space is likely to become infected.
As a matter of fact, Scammel and Keighley [24], in a
group of 17 patients with Crohn’s disease, obtained
primary closure in three cases only. Neoadjuvant RT
increases the risk of perineal wound complications
after APR [25]. Bullard et al. [26] have recently
reported the results of primary perineal closure after
APR in a series of 117 patients who received neoad-
juvant radiotherapy to downstage rectal cancer and
decrease the risk of local recurrence. Major perineal
wound complications were reported in 35%. Delayed
healing was the most common complication with a
mean healing time of 3.8±2.7 months (range 1–12).
Five patients developed a PPS: four in the RT group,
one in the control group. The authors concluded that
in patients undergoing neoadjuvant radiotherapy,
primary closure of the perineum should not be con-
sidered the option of choice.
466 D. Segre, H.M. Dal Corso, M. Londra, M.C. Giuffrida
Skin Grafting
This rather easy approach may be indicated in
patients with very superficial tracks or with small
cavities. Unfortunately, the majority of perineal
sinuses are quite long and tortuous and after the
complete excision of the cavity a complex recon-
struction is often required [16].
Cutaneous and Myocutaneous Flaps
Many techniques of muscle transposition have been
described for the treatment of PPS. The procedure
can be carried out soon after the excision of the sinus,
usually involving parts of the coccyx and lower
sacrum, or a few days later, when the walls of the cav-
ity are covered with granulation tissue [16]. Marti et
al. [27] used a wide V-Y full-thickness flap to cover
large perineal defects in six cases (Fig. 1). The
authors used this technique in two cases of giant
condyloma of the perineum without the involvement
of the anal canal, two cases of hidradenitis suppura-
tiva and two cases of salvage total rectal excision after
failed radiotherapy for anal carcinoma. All wounds
healed primarily without infection even in the last
two patients who, as reported, had signs of perineal
radiodermitis. In persistent perineal sinus after proc-
tectomy for Crohn’s disease, Bascom et al. [28] sug-
gest an easy technique, using a skin flap 1 cm thick,
whose healing is favoured when an asymmetric
suture line is placed to one side of the repair.
Gracilis Muscle Flap
Bartholdson and Hulten described the gracilis mus-
cle flap for perineal reconstruction in 1975 [29]. This
fusiform muscle lies along the medial side of the
thigh and knee and serves to adduct the thigh, and to
flex and medially rotate the leg. It attaches proximal-
ly at the body and inferior ramus of the pubic bone
and distally to the superior part of the medial surface
of the tibia. The dominant vascular pedicle of this
flap is the medial femoral circumflex artery and vein
that branches off the profunda femoris artery and
vein [18]. The muscle is exposed through a longitudi-
nal thigh incision and the distal end is divided near
the knee (Fig. 2). It may be rotated as a muscle or as
a myocutaneous unit. Usually the muscle alone is
used for rotation as the overlying skin has a rather
uncertain blood supply. Moreover, the inclusion of
the skin tends to limit the degree of muscle transpo-
sition into the perineal wound. Furthermore, the
donor site may be difficult to close [16].
This flap can be used as a pedicle graft for filling
the cavity created after excision of a long perineal
sinus. Some authors consider the gracilis muscle flap
the technique of choice for many perineal wounds.
Ryan [30] reported a successful healing in 12 of 15
patients [80%), including 9 with ulcerative colitis and
6 with Crohn’s disease. The same good results have
Fig. 1. V-Y fasciocutaneous flap. Two large triangular flaps
extending to the inner aspects of the thighs are marked
(top). The skin, subcutaneous fat and deep fascia are
incised (middle). The flaps are mobilised 4–6 cm medially
on each side and sutured (bottom)
Management of the Unhealed Perineal Wound 467
recently been reported by Rius et al. [31].
According to Keighley [16], the gracilis muscle
flap is a useful option in postirradiation perineal
sinuses, and he warns about the risk of sensory loss
related to the long and potentially painful thigh inci-
sion. The principle drawback to this flap is that it fre-
quently may not provide sufficient bulk to fill the
dead space in large, complex perineal wounds. In
addition, the proximal two thirds of the gracilis mus-
cle, which represents the main bulk of the flap, may
not reach the deepest point of the perineal wound
due to its low axis of rotation [18]. Finally the vascu-
larity of the distal third of the flap may be unreliable.
For these reasons many reconstructive surgeons are
actually cautious in utilising this flap.
Gluteal Thigh Flap
This fasciocutaneous flap, based on the descending
branch of the inferior gluteal artery, includes the
skin and subcutaneous tissue of the proximal poste-
rior thigh. The posterior cutaneous nerve of the
thigh is intimately associated with the vascular pedi-
cle and provides the opportunity of transferring a
flap that maintains a certain skin sensitivity. The
point of rotation of the flap is 5 cm above the ischial
tuberosity which overlies the emergence of the infe-
rior gluteal artery from underneath the piriformis
muscle. The central axis of the flap is midway
between the greater trochanter and the ischial
tuberosity, running perpendicularly to the gluteal
crease.
The donor site can be usually sutured straightfor-
wardly. To facilitate donor site closure, the flap
should be designed to be less than 12 cm in width. It
may be extended to within 8 cm from the popliteal
fossa. In a series of 19 patients with 21 buttock and
perineal wounds closed in a single stage, Hurtwitz et
al. demonstrated the reliability, versatility and low
morbidity of the gluteal thigh flap [18, 32]. It pro-
vides excellent soft tissue bulk and usually little to no
functional deficit is noted postoperatively [19]. Many
authors consider it to be the gold standard for the
chronic, deep midline perineal defect, while others
feel that de-epithelialised fasciocutaneous flaps have
a limited capability in filling completely dead spaces,
especially in complex sinuses [18].
Gluteus Maximus Muscle and Musculocutaneous
Flap
The gluteus maximus muscle is one of the largest
muscles in the body. Its principle actions are to
extend the thigh and assist in its lateral rotation,
steady the thigh and assist in raising the trunk from
the flexed position. It has a dual blood supply from
the superior and inferior gluteal vessels. The inferior
gluteal artery and posterior cutaneous nerve of the
thigh supply the inferior portion of gluteus maximus
and the skin of the posterior thigh. Excision of the
lower aspect of the gluteus maximus results in no
functional deficit; the donor site can be closed pri-
marily and the muscle is sufficiently bulky to fill the
cavity [16]. Baird et al. reported a series of 16 patients
in which the inferior gluteal myocutaneous flap was
employed to close large perineal wounds [33], all but
one patient achieved complete healing of the perineal
wound. In addition, Gottlieb and Jejurikar [18] prefer
the inferior gluteus maximus muscle. To facilitate
exposure, dissection and elevation of the lateral dis-
tal aspect of the inferior gluteus maximus muscle
from the ileotibial tract, a counter-incision is made in
the upper lateral posterior thigh. By detaching the
origin and insertion of the inferior portion of the glu-
teus maximus muscle, leaving it attached only by its
vascular pedicle, the flap will be able to fill the dead
space of very large and deep perineal and pelvic
Fig. 2. Gracilis muscle flap reconstruction for PPS
468 D. Segre, H.M. Dal Corso, M. Londra, M.C. Giuffrida
wounds (Fig. 3). Bell et al. [34] think that this flap
cannot fill the pelvis deeply and reserve this tech-
nique for patients in whom a chronic sinus occurs
after primary simple closure of the perineal wound.
This has the important advantage of avoiding re-
entering the pelvic cavity from the abdomen.
Gluteus Maximus V-Y Advancement Flaps
Shallow perineal defects may be closed utilising sin-
gle or bilateral gluteus maximus V-Y flaps. The ori-
gins of the gluteal muscles are detached from their
attachment to the sacrum, advanced medially and
secured to each other in the midline. A V-shaped
incision is made in the posterior/lateral buttock skin
down to the gluteal muscle. The musculocutaneous
unit is advanced medially and a midline closure is
performed without tension. The donor site is closed
as a V-Y plasty [18]. Hurst et al. [19] utilised this flap
in 4 of 12 patients (12.4% of 97 patients submitted to
proctectomy for Crohn’s disease) achieving primary
closure.
Gluteal Posterior Thigh Chimera Flap
If additional skin is required to accomplish perineal
wound closure without tension, the gluteal thigh flap
may be elevated in combination with a gluteal mus-
cle flap based on the same pedicle. The pedicle of the
gluteal thigh flap, the descending branch of the infe-
rior gluteal artery can be separated from beneath the
gluteal muscle and dissected to its take-off from the
inferior gluteal artery as it emerges from underneath
the piriformis muscle, allowing independent place-
ment of the muscle in the cavity and the skin paddle
on the surface [18]. This technique allows two sepa-
rate tissue transfers in a single flap procedure and is
well suited for patients that require a wider pelvic
dissection in addition to an extensive resection of the
perineal skin [19].
Rectus Abdominis Myocutaneous Flap
This technique was described by Taylor et al. in 1983
[35]. It is an excellent method for closing a large per-
ineal defect. Based on the inferior epigastric artery and
vein, it may be passed into the pelvis to close the pelvic
floor and fill the dead space. It is best employed pro-
phylactically in high risk patients at the time of proc-
tectomy when potential perineal wound problems are
anticipated [17], or at the time of abdominoperineal
excision for a large neoplasm [34] when extensive per-
ineal excision is needed in Crohn’s disease [36], or,
finally, when the combined approach is used to excise
a large perineal sinus in Crohn’s disease or after radio-
therapy [16]. As a delayed or secondary procedure, the
advantages of this flap must be weighed against the
potential difficulties and morbidity of having to re-
enter the lower abdomen and mobilise the bowel to
provide space to pass this flap into the pelvis, which is
often severely fibrotic. Moreover, in very large pelvic
wounds, the bulk of a single rectus abdominis muscle
is inadequate to entirely obliterate the dead space [17].
In cases in which a completion proctectomy is per-
formed solely by a perineal approach or for closure of
a chronic perineal sinus gluteus maximus, posterior
thigh or even gracilis, flaps are often adequate and do
not require laparotomy [19].
A rectus abdominis myocutaneous flap has to be
designed opposite to the site of the stoma provided
that the muscle on that side has not been damaged by
repeated laparotomies or by a previous stoma. It is
important to assess the vascular supply of the flap
preoperatively and, if necessary, an angiogram can
be performed, particularly if the patient has received
groin irradiation [34]. The abdomen is opened and a
synchronous combined excision of the rectum and
the perineal sinus is completed. A disc of skin slight-
ly larger than the perineal defect is cut over one rec-
tus muscle, 3–4 cm below the costal margin, to recon-
struct the perineum and occasionally the posterior
aspect of the vagina.
Fig. 3. The gluteus maximus musculocutaneous flap
Management of the Unhealed Perineal Wound 469
Traditionally, the two main types of flap are
described by the orientation of the skin paddle, i.e. the
vertical rectus abdominis flap (VRAM] or the trans-
verse rectus abdominis flap (TRAM) [37]. The subcu-
taneous tissue is divided with the skin to the rectus.
The segment of rectus above the flap is divided, ligat-
ing the superior epigastric vessels. The inferior epigas-
tric vessels are then dissected free, dividing branches
or tributaries which do not supply the inferior aspect
of the rectus muscle. An adequate length of vascular
pedicle is needed to rotate the skin disc and underly-
ing muscle through the pelvis and on to the perineum.
The defect in the rectus sheath is closed over suction
drainage and the skin flap is sutured to the perineal
skin over suction drainage with the muscle filling the
dead space above (Fig. 4) [16]. Undoubtedly this tech-
nique may compromise the strength of the abdominal
incision and may compromise management of stoma
complications or recurrent ileal disease, particularly if
the stoma needs to be resited [12].
Smith et al. [38] published the results of 22
patients undergoing the Taylor flap, 21 at the time of
primary operation, but these were predominantly for
vaginal reconstruction alone. Bell et al. [34] reported
a series of 31 consecutive patients undergoing one-
stage rectus abdominis myocutaneous flap recon-
struction of extensive perineal wounds expected to
generate substantial morbidity: 26 had surgery for
recurrent or persistent epidermoid anal cancer or
low rectal cancer and 21 had high-dose preoperative
radiotherapy.
The authors modified the original Taylor’s tech-
nique using an oblique skin paddle over the longitu-
dinal rectus muscle, mainly because the oblique flap
showed many advantages compared to the vertical
one. In fact, the laxity of the abdominal skin is more
significant in the oblique direction than in the verti-
cal direction, allowing a larger paddle and minimis-
ing tension at the donor site [34]. Three weeks after
operation, complete healing of the perineal wound
was seen in 27 of the 31 patients and none developed
a chronic sinus. At the completion of follow-up
(median 9 months) there were no unhealed wounds.
Collie et al. [36] reviewed a series of 15 patients
who received proctectomy for Crohn’s disease, five of
which had a gracilis interposition and 11 a rectus
abdominis flap (one that had failed after gracilis
interposition). All 11 patients with a rectus abdomin-
is flap had a healed perineum at 3 months after sur-
gery and no donor-site complications. The perineum
healed in only one of those who had gracilis interpo-
sition.
Loessin et al. [39] employed an inferiorly based
transpelvic rectus abdominis muscle or musculocu-
taneous flap to treat persistent sacral and perineal
defects secondary to radiation and abdominoper-
ineal resection with or without sacrectomy-14 of the
15 patients achieved healing and 7 had no complica-
tions. The remaining eight patients required one or
more operative debridement or prolonged wound
care to accomplish healing of the wound. Many
authors think that reconstruction with a VRAM flap
represents the best chance for facilitating healing in
irradiated pelvises and they recommend its use for
locally advanced rectal cancers requiring intense pre-
operative and intraoperative chemoradiation [40,
41]. In Table 1, the results of VRAM flap repair used
for primary perineal repair soon after APR and for
repair after PPS wide excision are reported.
Omentoplasty
In patients who have undergone proctectomy for
inflammatory bowel disease, the main problem may
be a deep presacral cavity with only a small skin
Fig. 4. Vertically oriented rectus abdominis myocutaneous
(VRAM) flap. The skin paddle is designed to match the size
of the defect (top left). The myocutaneous flap is raised and
includes the anterior fascia of the rectus sheath (top right).
Marking the line of perineal resection including posterior
vaginal wall (bottom left). The skin paddle is secured with
interrupted sutures (bottom right)
470 D. Segre, H.M. Dal Corso, M. Londra, M.C. Giuffrida
defect. Use of a pedicled omental graft to fill this cav-
ity is a simple solution which does not compromise
skeletal muscle bulk or function and can be more
readily applied by general and colorectal surgeons
than the more specialised myocutaneous flap [42,
43]. It is particularly appropriate in Crohn’s disease
where the rectus muscle may already have been dam-
aged because of multiple stoma sites. The omentum
may be based on the right gastroepiploic artery, in
which case the left gastroepiploic close to the short
gastric vessels is divided and the left side of the
omentum is mobilised in order to bring the apex
down to the perineum (Fig. 5).
In some cases, to allow a longer pedicle, the omen-
tal flap can be obtained on the left gastroepiploic
artery, dividing the right gastroepiploic at the level of
the second portion of the duodenum [16]. For Bell et
al. [34], primary closure over a pedicled omentoplas-
ty is the standard practice for perineal wound repair
following APR. Radice et al. [41] employed primary
perineal wound closure with or without an omental
pedicle graft for pelvic space obliteration, followed
by delayed myocutaneous flap advancement as
required for wound complications, after resection of
locally advanced pelvic malignancies. Pujol [44], in a
multicentre study, reported 100% success utilising
epiploonplasty in 28 abdominoperineal resections
and 32 pelvectomies. Brough et al. [45], in a series of
ten cases with a persistent sinus after previous proc-
tectomy, used a plug of greater omentum (two cases),
a muscle plug using the rectus abdominis muscle
(two cases) and a full myocutaneous flap based on
the rectus abdominis muscle where there was consid-
erable loss of perineal skin (six cases). Complications
of omentoplasty include haemorrhage, infarction,
causing peritonism, intestinal obstruction and per-
ineal hernia. Reoperation for omentoplasty-related
complications is required in 0–7% of patients [42, 43,
46].
Conclusion
The unhealed perineal wound is a complication that
is disabling for the patient, causing a significant
amount of morbidity and anxiety, and is difficult and
Table 1. Comparison of VRAM flap use for perineal primary closure and for PPS repair
Author Primary perineal PPS repair Major flap- Healed at
repair with with related
3
months
VRAM VRAM complications
Brough [45] 0707
Loessin [39] 0743
Smith [38] 21 1 2 – [*]
Radice [41] 13 0 1 12
Hurst [19] 5015
D’Souza [40] 12 0 2 12
Bell [34] 31 0 9 27
Collie [36] 10 1 0 11
[*], unreported date
Fig. 5. Omentoplasty. The
right portion of the great
omentum is transposed in
the sacral cavity after APR
(left). View of the per-
ineum after omentoplasty
is completed and before
skin suturing (right)
Management of the Unhealed Perineal Wound 471
challenging for the colorectal surgeon. Fortunately,
in the last few decades treatment options have pro-
gressed from repeated unreliable procedures to suc-
cessful one-stage closure, considering modern prin-
ciples of wound management.
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Introduction
Rehabilitation medicine can be defined as the multi-
disciplinary and interdisciplinary science that aims
at attaining the complete functionality and health of
a person by reducing the disability and its correlated
symptoms. Rehabilitation is a both a process that
involves finding solutions to given problems and also
a process of education whereby a person is helped to
achieve the best possible level of life in its physical,
functional, social and emotional dimensions with the
least possible limitation to their operative choices.
The process also requires the involvement of the
patients’ family and those around them. Consequent-
ly, “the rehabilitation process concerns not only
strictly clinical aspects” but also “encompasses psy-
chological and social dimensions. To achieve a good
level of efficacy, each patient’s rehabilitation project
must have rationally planned, multiple objectives so
that the autonomy to be attained in various areas can
be translated into the personal independence of the
patient as a whole being, with enhanced quality of life
for the patient” [1].
In patients affected by inflammatory bowel dis-
ease (IBD) and familial adenomatous polyposis
(FAP), the rehabilitation process aims at attaining,
recovering and maintaining an increased level of
autonomy by relying on: (1) surgical intervention,
and (2) study of the disability problems associated
with these pathologies.
Surgery for IBD and FAP
The rehabilitation process takes into account surgi-
cal intervention and its technical aspects, as well as
the probable quality of life of the patient after thera-
peutic treatment. Whenever possible, the rehabilita-
tion process will begin before surgery by informing
and educating the patient about the therapeutic strat-
egy to be adopted. After surgery, all efforts will con-
centrate on maintaining and/or recovering the
patient’s autonomy and functionality.
On this subject, attention will be paid to both the
recovery of basic functions, that is to say, those
linked to vegetative life (such as correct breathing,
blood circulation and the tegumentary function) and
to functions related to social life. The main objectives
are to:
– improve overall functionality.
– Reduce or to keep in check all postoperative
symptoms and/or complications.
– Reduce the level of disability.
– Promote rehabilitation to social and working life.
– Help the patient become aware of the disability
and actual functionality and to support that new
awareness.
Diagnostic evaluation and planning an appropri-
ate therapeutic intervention are needed in order to
realise these objectives.
Among the existing colic surgery protocols, one
that certainly deserves to be mentioned is the proto-
col developed by Kehlet and his Danish team [2]:
with their concept of “accelerated rehabilitation”,
they developed a series of perioperative treatments
that allow speedy recovery and an early dismissal.
This treatment concept preserves bodily organ func-
tions and avoids the usual postoperative deteriora-
tion in pulmonary function, body composition and
cardiovascular response to exercise [3]. (See Table 1
for a comparison of this protocol with the Conven-
tional Care and Multimodal Rehabilitation pro-
grammes.) The multimodal rehabilitation pro-
gramme, with epidural analgesia, early oral nutrition
and mobilisation, besides application after open
colonic surgery for noninflammatory bowel disease,
is also used after ileocolic resections for Crohn’s dis-
ease [4]. Andersen and Kehlet, at the end of this
prospective, nonrandomized study, observed that
open ileocolic resections for Crohn’s disease com-
bined with fast-track multimodal rehabilitation with
continuos epidural analgesia and enforced early oral
feeding and mobilisation enhanced recovery and
decreased median hospital stay to 3 days with a low
morbidity and readmission rate. Moreover, they sug-
gested that “prospective studies using multimodal
Rehabilitation in Patients with Inflammatory Bowel
Disease and Familial Adenomatous Polyposis
Federica Lipanje, Gianluca Colucci, Gian Gaetano Delaini
474 F. Lipanje, G. Colucci, G.G. Delaini
rehabilitation are indicated to evaluate the role of
laparoscopic assisted vs open resection for ileo-colic
Crohn’s disease”.
Fundamentals of Rehabilitation
The definition of a rehabilitation program is based
upon four areas of intervention:
– physical training and the development of a physi-
cal training programme.
– A programme of health education in order to
eliminate or reduce all risk factors that may affect
clinical condition.
– Evaluation of the patient’s psychological condi-
tion and social and working environment and the
development of a program of topical intervention.
– Evaluation and treatment of possible surgical or
internal complications.
Physical Training and the Development of Physical
Training Programs
A physical training programme is developed in three
phases: preoperative, acute postoperative and long term.
Pre-operative Phase
During this phase, patients learn all the exercises
they will have to practise also in the postoperative
Table 1. Protocol for anaesthesia, surgery and rehabilitation programme after colonic resection with conventional care
(group 1) and multimodal rehabilitation (group 2) [3]
Group
1
Group
2
Anaesthesia Premedication: oral diazepam 10 mg Premedication: none
Epidural catheter: T8-T10 Epidural catheter
Carbocaine 2% (4+4) ml with epinephrine Right hemicolectomy: T6-T7
Sigmoid resection: T9-T10
Carbocaine 2% 4 ml with epinephrine hourly Test: lidocaine 2% 3 ml with epinephrine
General anesthesia: Bupivacaine 0.5% (6+6)ml
Fentanyl 0.1 mg Bupivacaine 0.25% 5 ml 2 h intraoperatively
Thiomebumal 3-5 mg/kg Morphine 2 mg if <70 years
Rocuronium Morphine 1 mg ⭓70 years
O
2
-N
2
O-sevoflurane General anaesthesia:
Dextran 70 (Macrodex) 500 ml Remifentanil 1 mg/kg/min
Saline 3,000 ml (max) Propofol 2-4 mg/kg/h
Cicatriceum 0.15 mg/kg
Hydroxyethyl starch (HAES) 500 ml
Saline 1500 ml (max)
Ondansetron 4 mg
Ketorolac 30 mg
Bupivacaine 0.25% 20 ml (incision)
Surgery Median laparotomy Transverse or curved incision
Postoperatively Continuous epidural analgesia (3 days): Continuous epidural analgesia (2 days):
Bupivacaine 0.25% 4 ml Bupivacaine 0.25% 4 ml and morphine 0.2 mg/h
and morphine 0.2 mg/h Breakthrough pain: ibuprofen 600 mg orally
Breakthrough pain: morphine IM or IV Bupivacaine 0.125% 6 ml epidurally
After removal of epidural catheter: Morphine 10 mg orally (last choice)
morphine 10 mg orally Food, protein drink 60–80 g protein per day and
No standard care program: fluid, food, mobilization from the day of surgery following a
mobilization and discharge depending well-defined nursing care programme
on the attending surgeon Day of surgery start: acetaminophen (slow release)
Postoperative nasogastric tube depending 2 g/12 hourly
on surgeon who performed the operation Cisapride 20 mg/12 hourly
Physiotherapy: breathing exercise 10
min
per day during the first 2 postoperative days 1
st
postoperative day: remove bladder catheter in
and only on working days the morning
2
nd
postoperative day: remove epidural catheter in
the morning; discharge after lunch
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