Awareness laparoscopic right colectomy in a heart transplant patient—a case report

Authors: Carmelo Magistro, Carlo Ferrari, Davide Vailati, Benedetta Basta, Michele Colasuonno, Matteo Tresoldi, Salvatore Barbaro, Jacopo Crippa

Abstract

Background

Despite recent advances, surgery remains burdened by a high-risk of complications. Awareness surgery (AS) is a novel operative approach in which the patient is in spontaneous breathing and can communicate throughout the procedure, whether open or minimal invasive. AS expands the concept of minimal invasiveness to anesthesia, making it feasible for all types of patients, including those considered unfit for general anesthesia. AS for major abdominal procedures is performed using neuraxial anesthesia, combining thoracic spinal and continuous epidural anesthesia. Given the well-established use of spinal or epidural anesthesia and the standardized surgical practice, AS may find its optimal application in colorectal procedures. We present a unique case of a heart transplant patient who underwent a laparoscopic right colectomy with complete mesocolic excision (CME) under AS. Our report explores the potential of AS as a safe alternative to standard of care, especially in frail and comorbid patients.

Case Description

In February 2024, a 72-year-old white male was diagnosed with hepatic flexure adenocarcinoma. Diagnosis and staging were conducted via colonoscopy and computerized tomography (CT) scan after testing positive for anemia. His medical history included Marfan syndrome, aortic valve and ascending aorta replacement in 1987, and a heart transplant in 2020, as well as chronic kidney disease (CKD) stage III. Medications at the time of diagnosis included cyclosporine, mycophenolate mofetil, acetylsalicylic acid (ASA), proton pump inhibitor (PPI), furosemide, bisoprolol, allopurinol, magnesium, calcium carbonate, and cholecalciferol. Surgical risk assessment identified a high-risk case, with indication to right colectomy with CME under AS. Following a prehabilitation period, the operation took place in April 2024. Spinal anesthesia was performed at the T9–T10 level with 0.5% levobupivacaine (10 mg) and 5 mcg dexmedetomidine as an adjuvant. The epidural catheter was placed at T7–T8 and used for intraoperative boluses of 1% lidocaine and postoperative analgesia. A laparoscopic right colectomy with CME was completed in approximately 130 minutes. Intraoperative hemodynamic fluctuations were treated with noradrenaline boluses. The postoperative course was uneventful, and the patient was discharged on the third postoperative day. Pathology revealed a T2N0 adenocarcinoma.

Conclusions

AS may represent a significant alternative to standard care, with the potential for routine application in colorectal procedures.

Introduction

The constant increase in pathologies requiring surgical care poses new challenges in surgical practice (1). Surgical patients face a high risk of perioperative complications and prolonged hospital stay (2). There is a constant need for consolidated practices to make surgery safer and more reproducible.

Awareness surgery (AS) is a new concept of operative approach in which surgeon, anesthesiologist, and patient are capable of interaction during surgery. The patient is in spontaneous breathing and can communicate throughout the procedure, either open or minimally invasive, including cases where general anesthesia (GA) is typically deemed necessary. AS expands the concept of minimal invasiveness to anesthesia, feasible for all type of patients, including those considered unfit for GA.

AS for major abdominal procedures is performed using neuraxial anesthesia (NA), administered as combined thoracic spinal and continuous epidural anesthesia without orotracheal intubation and neuromuscular blockade, and is suitable for both young and elderly patients. Spinal anesthesia is commonly used in lower abdominal surgeries (3). Epidural anesthesia provides effective pain control and reduces the need for systemic opioids (4), minimizing respiratory depression (3,5). Moreover, epidural reduces the odds of delirium, affecting up to 50% of elderly patients after major surgery (4). Additionally, AS can be offered to patients classified ineligible for GA due to high risk of morbidity and mortality.

AS is an appealing evolution of the multimodal analgesia advocated by enhanced recovery protocols (ERPs), which are strongly recommended for colorectal patients. Given the well-established improvements in patient outcomes associated with ERPs (6), the high prevalence of colorectal diseases, the duration of surgery, the wide age span, and the high prevalence of frail patients, AS may find its finest application in colorectal procedures.

From the surgeon’s perspective, spontaneous breathing without neuromuscular blockade might be seen as a limitation during laparoscopic surgery due to the need for a wide and stable operative field. However, during AS, the pneumoperitoneum is achievable without contraindication. Slow insufflation and gentle movements of the operative table minimize the patient’s discomfort.

AS has the potential to reduce patients’ anxiety associated with the need for GA, which limits self-consciousness and causes a loss of control. On the other hand, a highly coordinated team is required during AS, which may burden the initial phases of application.

Several experiences have been reported, mostly as case reports limited to minor procedures (7). A solid report on AS in major abdominal surgery is needed to provide better evidence and enhance AS in surgical practice.

To demonstrate the procedure’s feasibility and safety, here we present a case report of a 72-year-old heart transplant patient who underwent laparoscopic right colectomy with complete mesocolic excision (CME) under AS. We present this article in accordance with the SCARE reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-28/rc) (8).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and the video. A copy of the written consent is available for review by the editorial office of this journal.

A 72-year-old male patient tested positive for fecal occult blood, with blood tests revealing anemia (hemoglobin 7.8 g/dL; normal values 13–16 g/dL) in February 2024. He subsequently underwent a colonoscopy at our institution, which identified a 3-cm long, circumferential neoplasm in the hepatic flexure, transitable, confirmed by biopsy as adenocarcinoma with microsatellite stability. Staging with a contrast-enhanced CT scan showed a T3N+ neoplasm of the hepatic flexure. Figure 1 shows the timeline of the current case report.

The patient’s medical history included Marfan syndrome, diagnosed approximately 40 years ago. He underwent an aortic valve and ascending aorta replacement in 1987. Progressively, he developed a cardiomyopathy, with the necessity of an ICD implantation and finally received a heart transplant in 2020. He underwent an appendectomy when he was a teenager. He also had stage III chronic kidney disease, followed-up at the nephrology clinic at our institution. Medications at time of diagnosis included cyclosporine, mycophenolate mofetil, acetylsalicylic acid (ASA), proton pump inhibitor (PPI), furosemide, bisoprolol, allopurinol, magnesium, calcium carbonate, cholecalciferol.

The case was reviewed by the institutional tumor board, which recommended surgery. At our institution, the standard approach for node-positive right colon adenocarcinoma is minimally invasive right colectomy with CME.

Given his medical history, the patient was considered high-risk in the preoperative assessment. Our institution offers patients the option to participate in an “AS pathway”. Patients undergoing AS receive the same oncologic treatment as those receiving standard care but have the option of remaining awake during the operation, supported by NA and conscious sedation. This approach allows direct communication with the anesthesiologist and surgeon during surgery. The patient can talk, ask questions, and provide feedback on his condition, as there is no intubation or neuromuscular blockade. This method is particularly suitable for patients with cardiopulmonary comorbidities, as it helps preserve cardiac and pulmonary function.

After comprehensive counseling, the patient opted for the “AS pathway”. At our institution, AS is offered as an extension of a well-established ERP, which all patients undergoing major abdominal surgery are encouraged to follow. The patient underwent routine preoperative tests, including bloodwork, electrocardiogram (ECG), and a cardiologic evaluation with an echocardiogram and coronary angiogram, given his history of heart transplantation. A nephrology consultation revealed no contraindications to surgery.

Following surgical evaluation, the patient attended an ERP counseling session where he received detailed information about his perioperative course. He was also provided with a prehabilitation program, including guidance on physical activity (e.g., at least 30 minutes of moderate-intensity walking daily), a breathing exercise incentive spirometer, and immunonutrition. Typically, cancer surgery is scheduled two or three weeks after ERP counseling. The operation took place on April 9^th^ 2024.

Anesthesia was achieved by means of combined thoracic spinal-epidural anesthesia. Spinal anesthesia was performed at T9–T10 level with 0.5% levobupivacaine (10 mg) and 5 µg dexmedetomidine as adjuvant, diluted in 1 mL of saline solution. The epidural catheter was placed at T7–T8 and exploited for both intraoperative boluses (5 mL each) of 1% lidocaine during critical surgical steps, as well as to provide post-operative analgesia. A skin prick test confirmed a level of anesthesia corresponding to the T2 dermatome. Conscious sedation was achieved through continuous intravenous dexmedetomidine infusion at a rate between 0.1 to 1 µg/kg/h and ketamine boluses (10 mg each). Postoperative analgesia was obtained by means of continuous epidural perfusion of 0.2% ropivacaine a 5–7 mL/h for maximum 48 hours postoperatively, with rescue boluses maximum every 2 hours.

The surgical procedure begins with the establishment of pneumoperitoneum using a Veress needle in the left hypochondrium. This is a crucial step during AS, as the pneumoperitoneum must be induced gradually to avoid rapid changes in intra-abdominal pressure. Each time inflation is needed, the CO2 flow should not exceed 3 L/min. During AS, an intra-abdominal pressure of 10–12 mmHg is attainable without contraindications.

A four-trocar technique is routinely used to perform a laparoscopic right colectomy with CME. Two 12 mm trocars are placed lateral to the left rectus abdominis muscle, slightly above the umbilical line (camera site), and 4 cm suprapubic along the midline, which will be the site of the suprapubic incision for specimen extraction. Two additional 5 mm trocars are positioned in the left hypochondrium and the right flank. In this case, the tumor location was confirmed at the hepatic flexure.

The patient is positioned in a slight Trendelenburg position with minimal rotation toward the left side. During AS, there are no specific contraindications to even extreme table positions, but movements should be gentle to avoid creating a feeling of instability that could alarm the patient. Some paradoxical diaphragm movements are expected during AS, and the anesthesiologist may need to adjust the sedation depth to minimize respiratory contractions and maintain a stable operative field.

The ileocolic vessels are identified and ligated separately. The duodenum is carefully detached from the mesocolon to expose the pancreatic head. Continuing from above, the transverse mesocolon is detached from the infrapyloric region. Dissection proceeds by locating the duodenum and connecting with the plane previously created below. The right colon is fully mobilized from the hepatic flexure to the cecum. The right branch of the middle colic vessels is identified, and the vein and artery are ligated separately.

The colon and terminal ileum are prepared, ensuring a margin of at least 10 cm from the tumor and the ileocecal valve. Real-time angiography is then performed to confirm adequate vascularization before transecting the colon and ileum. The specimen is extracted through a suprapubic incision created at the site of the suprapubic 10 mm trocar, using a wound protector. Finally, a side-to-side mechanical ileocolic anastomosis is created, and the anastomosis breach is closed with a two-layer barbed suture

The operation lasted approximately 130 minutes, after which the patient was transferred to the surgical ward. Intraoperative hemodynamic fluctuations were controlled with bolus of noradrenalin during surgery. Post-operative pain was effectively managed with epidural analgesia. A blood sample including blood count, C-reactive protein and renal function parameters, was retrieved, as routinely performed in our unit, every morning until the third post-operative day. The remaining post-operative course was uneventful, and the patient was discharged on the third post-operative day without any complications.

The pathology report indicated a T2N0 adenocarcinoma, grade 2, with 68 lymph nodes tested negative for tumor presence.

Video 1 provides a summary of the present case report.

Discussion

Our report shows a successful use of awake surgery in a high-risk patient undergoing major abdominal surgery, effectively highlighting the potential of AS as an alternative to general anesthesia in frail patients.

In frail patients, GA can increase the risk of persistent postoperative cognitive decline (POCD) (9). POCD affects more than one-third of patients undergoing cardiac surgery and up to 26% of those undergoing non-cardiac surgeries, leading to increased mortality, longer hospital stays, diminished quality of life, and higher healthcare costs. In this case, the patient did not develop any signs of POCD and was able to talk freely even during surgery. His optimal condition was further evidenced by his discharge on the third postoperative day.

An important aspect of this case was the achievement of optimal surgical conditions during the surgery, as reflected by high scores on the Leiden Surgical Rating Scale (10) and the Surgeon’s Surgical Conditions Assessment Scale (11). These scores are completed by the operating surgeon at the end of the procedure and evaluate various aspects of surgical comfort during the operation. This process is particularly helpful for both the anesthesiologist and the surgeon in assessing the patient’s condition during surgery to maintain an optimal operative chamber and a stable field.

As the population ages, the number of patients undergoing surgery is expected to rise (12). Due to the natural decline in physiological function and reduced functional reserve, older patients face a higher risk of perioperative complications (13). However, a shift in paradigm now suggests that age alone is no longer a reliable indicator of perioperative risk. Instead, frailty—a state of diminished physiological reserve beyond normal aging—has emerged as a key predictor of poor surgical outcomes (14). Frailty rates in surgical populations range from 10.4% to 37% among general surgery patients (15) and reach up to 62% in those undergoing vascular, cardiac, thoracic, and orthopedic surgeries (14). Our case report suggests that AS could be a valuable approach for frail and vulnerable patients, prioritizing long-term well-being and successful surgical outcomes while reducing the physiological stress associated with anesthesia and surgery.

Although rare, a common fear among patients facing GA is the potential of being awake and paralyzed during surgery, unable to communicate, a rare condition referred to as ‘intraoperative awareness’. Through the standardized application of AS, our team aims to shift this perception, transforming awareness during anesthesia from a source of fear to a positive, intentional concept. In this approach, awareness signifies that all key participants—surgeons, anesthesiologists, the patient, and the care team—are fully engaged in applying minimally invasive techniques to their fullest extent. This collective awareness reflects our commitment to preserving cognitive function by minimizing the physiological stress of anesthesia and surgery, particularly for frail and vulnerable patients. By embracing this new definition of awareness, we prioritize the patient’s long-term well-being alongside successful surgical outcomes.

A potential advantage of AS for frail patients is its minimal sedation requirement, which may reduce the risk of POCD (16). Despite mixed findings in the literature, regional anesthesia is often recommended for frail patients, as it has been linked to reduced risks of thrombolytic events, blood loss, and deep vein thrombosis, especially in hip surgeries (17). Regional anesthesia also provides superior postoperative pain control, enhancing patient comfort and reducing the risk of adverse cardiac events. Additional benefits include faster bowel function recovery and better preservation of immune function postoperatively—both particularly important for frail patients.

Numerous studies have examined the effects of anesthesia techniques across various surgical specialties, such as urology (18,19), vascular surgery (20-23), and gynecology (24-27). Regional anesthesia in laparoscopy offers several benefits, including faster recovery, less postoperative nausea and vomiting, reduced pain, shorter hospital stays, cost savings, higher patient satisfaction, and enhanced overall safety (28). AS avoids common issues associated with GA, such as sore throat, muscle pain, and airway trauma (28). Contrary to common beliefs, our case demonstrates that achieving comparable working pressures, table tilt, and oxygen saturation to those in laparoscopic surgeries under GA is feasible. Surgical comfort during the procedure was assessed using validated scores commonly applied in laparoscopic surgery, with positive results.

Recent evidence highlights the protective role of regional anesthesia, particularly NA, in reducing the perioperative stress response. Epidural anesthesia has been shown to attenuate the endocrine and metabolic response to surgery, reducing stress markers like catecholamines and cortisol, which typically rise under GA (29). This reduction positively impacts postoperative recovery, including faster gastrointestinal function recovery, improved glucose tolerance, and shorter hospital stays (30). Notably, epidural anesthesia has been found to decrease postoperative ileus and enhance pain management, contributing to better surgical outcomes (31). In cardiac surgery, thoracic epidural anesthesia has demonstrated benefits by reducing stress hormone levels and improving cardiac recovery, especially after coronary artery bypass grafting (32). By mitigating the surgical stress response, regional anesthesia supports faster recovery and reduces postoperative complications, underscoring its growing importance in modern surgical care.

Our report has some limitations. Being one of the initial applications of AS, this single experience is not supported by evidence in the literature and represents our team’s unique experience with a comorbid patient who was treated successfully with AS at our center. For this reason, the case report does not imply successful reproducibility, and its conclusion must be interpreted with caution.

Conclusions

This case report provides valuable insights into AS in laparoscopic colorectal procedures. Further evidence is needed to explore the impact of AS and its role as an alternative to standard of care.

Supplementary