Many of the general principles that have been learned from open colon and rectal surgery can be applied to laparoscopic and robotic surgery. Patients undergoing minimally invasive colorectal surgery need a full history and physical exam, with particular attention paid to the number and types of previous abdominal surgeries, as well as any history of any significant abdominal infection. This should be accompanied by appropriate blood work, electrocardiogram, chest x-ray, and other investigations as dictated by the patient’s age and comorbidities. For patients with colon and rectal cancer, routine preoperative evaluation includes preoperative staging and assessment of resectability, as well as a full colonoscopy to rule out synchronous lesions.

In minimally invasive colon and rectal surgery, tumor localization is a key component of the preoperative work-up. Unlike in open or hand-assisted cases, the tumor cannot be palpated for localization during the case, and tumors may not be visible during laparoscopy. If accurate localization is not obtained prior to the operation, the wrong segment of the colon may be removed [1]. In fact, a survey of members of the American Society of Colon and Rectal Surgeons showed that 6.5 % of respondents had removed the wrong section of the colon [2].

Options available for preoperative localization include barium enema, computed tomographic (CT) colonography, colonoscopy with India ink injection or placement of metallic clips, and intraoperative endoscopy. Barium enema has been found to have a low sensitivity (0.35–0.41) and high specificity (0.82–0.86) for detection of colon and rectal tumors with decreased reliability as the size of the lesion decreases [3, 4]. CT colonography has been shown to be superior to barium enema with a higher sensitivity (0.49–0.73) and a higher specificity (0.84–0.89). As with barium enema, the detection of lesions decreases with decreasing size [3, 4]. Although preoperative imaging may adequately demonstrate the location of the tumor, translation to accurate intraoperative localization and resection may not be reliable.

Colonoscopy has become the gold standard in detecting lesions as it has the highest sensitivity (0.97–0.987) and specificity (0.996–0.999) [3, 4]. Even though colonoscopy continues to be the best tool for detection, there are still errors in localization. The literature has shown an error rate in predicting the accurate location of a lesion within the colon ranging from 3 to 21 % [5–8]. Intraoperative colonoscopy can be used when lesions are not able to be located; however, this can insufflate the bowel and make the rest of the operation cumbersome [9, 10]. The use of CO₂ insufflation may help to significantly reduce this problem [11]. Serosal clips or sutures may be used with the help of intraoperative colonoscopy to mark the lesion; however, clips may fall off or be too small to see after placement [9, 12].

Another option is preoperative marking of the lesion by endoscopically placing a metal clip. The clip is applied to the mucosa and then fluoroscopy or ultrasound is used intraoperatively to locate the clip (Box 2.1). This technique can have disadvantages including migration or dislodgement of the clips, increased operative times, and radiation exposure to the patient [9, 10, 12].

Submucosal injection of India ink to tattoo the area distal to the lesion is increasingly being used and is the most reliable method for endoscopic localization of colon lesions (Box 2.2) [13]. The injection is performed in three to four areas circumferentially to improve localization of the tattoo, as injecting only one area may lead to inadequate identification if the tattoo is on the side of the colon attached to the retroperitoneum or the greater omentum [9, 10]. Overall, tattooing with India ink allows for accurate localization (97.9 %) with a low complication rate (0.22 %) [14, 15].

Controversy exists regarding the use of a preoperative bowel preparation for colon and rectal surgery (Box 2.3). Although several randomized trials and meta-analyses have demonstrated that there is no clear evidence of benefit from a mechanical bowel prep, the practice is still widely used [16–21]. These findings, however, cannot be generalized to minimally invasive surgery. Evidence-based guidelines concerning this specific issue are lacking. Some authors support the use of a bowel preparation for laparoscopic surgery, as an empty colon can ease handling of the bowel and allow for better exposure [22, 23]. Others have argued that no bowel preparation allows for better visualization secondary to no increase in diameter of the small bowel due to large volume preparations and solid matter in the bowel may allow for gravity to increase exposure [17, 22, 24]. To alleviate the increased diameter of the small bowel, some surgeons are using a 2–3-day preparation or a smaller volume of preparation [25].

One of the main concerns with minimally invasive surgery is the associated learning curve [26–28]. Studies have shown that the required case numbers range from 11 to 152 [26, 28, 29] and there is an increased incidence of adverse events early in training [27, 28]. This is significant as several studies show that patients who undergo conversion from a minimally invasive approach have been shown to have a higher rate of complications [29–32]. If conversion is done early in the case, these patients have similar outcomes to patients undergoing conventional surgery [33]. Factors influencing conversion have been shown to include increased age, body mass index, body surface area, American Society of Anesthesiologists Classification, presence of abscess at time of operation, pelvic dissection, previous abdominal surgeries, and diagnosis of inflammatory bowel disease and cancer [27, 34–36]. Even though there is no consensus that careful patient selection decreases complications during the early portions of the learning curve, some evidence exists to support this concept [26, 28].

During the early institution of minimally invasive surgery for cancer, port site implants were a significant concern [37]. The results of multiple trials have demonstrated that similar oncologic resections can be obtained with laparoscopic colon resections when compared to the standard open operations [38–41]. Laparoscopic resection of rectal cancer has been proven by multiple single-institution studies to be safe and results in similar recurrence and disease-free survival [42–45]. Robotic colorectal surgery has shown similar recurrence and disease-free survival in short-term follow-up, but long-term studies are needed [46–48].

Very few absolute contraindications to minimally invasive surgery still remain [49, 50]. It was previously believed that advanced age, obesity, cancer, fistulas, previous abdominal surgeries, severe pulmonary disease, or congestive heart failure were contraindications to laparoscopic colon and rectal surgery. [49]. Recently, studies have called into question whether these remain as contraindications.[49–55]. Invasive monitoring is recommended in patients who have an American Society of Anesthesiologists Grade of III–IV [55]. Authors have reported using laparoscopic techniques even in emergency cases such as sigmoid volvulus and bowel obstruction [56, 57]. Most still perform standard open operations for fecal peritonitis, toxic megacolon, and in unstable patients [49].

Traditionally after colorectal surgery patients were kept nothing by mouth (NPO) until they demonstrated return of bowel function [58, 59]. Decompression with nasogastric tubes was often used along with this protocol [58, 60]. Research supports the elimination of nasogastric tubes after colorectal surgery in favor of selective use [58, 60–62], and no obvious benefit has been found for keeping patients NPO [59]. Fast-track or enhanced recovery after surgery (ERAS) often includes the institution of oral fluids on postoperative day zero [63]. No universal protocol exists, but the main points include preoperative patient education, avoidance of preoperative bowel preparation, early institution of nutrition and advancement as tolerated, omitting the use of nasogastric tubes, early ambulation, and multimodal analgesia. ERAS has been shown to accelerate return of bowel function and reduce postoperative morbidity, mortality, and average length of hospitalization [63–66].

Scatizzi et al. showed that ERAS can be safely instituted for laparoscopic colorectal surgery and was found to reduce length of hospital stay [67]. Implementation of ERAS specifically for laparoscopic rectal surgery only showed a success rate of 52.5 % [68]. Patients with low rectal lesions are at a greater risk of ERAS failure secondary to surgery-related complications [68].

Postoperative nausea and vomiting (PONV) are common complications after surgery. Approximately 20–30 % of patients will suffer from PONV after surgery [69–71], and in high-risk patients PONV can be as high as 70–80 % [69]. Risk factors include type of surgery, female gender, nonsmokers, history of PONV or motion sickness, and younger age. Laparoscopic surgery was found to be the second most common type of surgery causing PONV [70]. Research demonstrates that prolonged duration of anesthesia, postoperative opioid use, and the use of volatile anesthetics and nitrous oxide are also risk factors for PONV [69, 70]. Use of propofol for induction, perioperative oxygen supplementation, increased hydration, avoidance of volatile anesthetics and nitrous oxide, and decreasing the intra- and postoperative use of opioids decreases the incidence of PONV [72]. Consensus guidelines regarding the administration of prophylactic antiemetic medications based on risk score stratification recommend that only patients who are moderate to high risk for PONV should receive prophylaxis [72]. After instituting these guidelines, one study showed a significant decrease from 8.36 to 3.01 % of PONV [69].

Many pharmacologic options are available for prophylaxis against postoperative nausea and vomiting. 5-HT₃ receptor antagonists have been found to be most effective when given at the end of surgery [72]. Dexamethasone effectively prevents PONV when given prior to induction of anesthesia. Droperidol is as effective as 5-HT₃ in the prevention of PONV when given at the end of surgery; however, its use has been limited by the FDA due to safety concerns. Other medications that can be used include dimenhydrinate, scopolamine, promethazine, prochlorperazine, and ephedrine [72]. Less conventional options for treatment of PONV include acupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, acupressure, and hypnosis [72–75].

Postoperative ileus (POI) is defined as the temporary decrease in motility of the gastrointestinal tract after surgery. It can present with nausea, vomiting, abdominal pain, abdominal distention, and absence of flatus and bowel movements [76]. The frequency of POI ranges from 3 to 32 % of patients and can cause considerable distress to those affected. It can also increase length of stay, which may increase hospital-acquired infections and healthcare costs [77].

The cause of POI is multifactorial [76]. Use of opioids significantly correlates with POI, whereas epidural analgesia has not been shown to have this negative effect [76, 78]. Since opioids are known to decrease gastrointestinal motility, recent research has focused on pharmacologic agents such as alvimopan, a peripherally acting μ-opioid receptor antagonist [78, 79]. The use of alvimopan may decrease time to return of bowel function [79], but the use of this medication has not been studied following laparoscopic colorectal surgery. Currently there is no standard pharmacologic treatment or consensus of management of POI [80].

Gum chewing, a form of sham feeding, promotes the cephalic phase of digestion. This may be the reason that gum chewing was reported to reduce the time to first flatus and bowel movement [81]. Zaghiyan et al. though, showed no benefit to chewing gum when compared to no gum chewing in colorectal surgery patients [82]. Other factors shown to decrease POI include early feeding, elimination of nasogastric tubes, and early ambulation [78, 81].

Minimally invasive techniques have been shown to be associated with earlier recovery of gastrointestinal function and decreased POI [83, 84]. Laparoscopy has been reported to have a POI of 10 % [77]. van Bree et al. reported laparoscopic surgery was a significant independent predictive factor of improved colonic transit [85]. Delaney et al. also showed mean bowel recovery and length of stay after laparoscopic colectomy was accelerated when compared with open colectomy [86].

Adequate control of postoperative pain is of great importance in colorectal surgery, as it allows for early ambulation and can increase patient satisfaction [87]. Following minimally invasive colorectal surgery, there is no evidence that any specific postoperative analgesic option is optimal [88]. The use of narcotics results in adequate pain control; however, their use is known to decrease gastrointestinal activity via stimulation of μ-opioid receptors [80] thereby potentially prolonging postoperative ileus. When compared to intravenous narcotics, epidural analgesia has reduced pain scores without a significant change in return of bowel function or length of stay [89, 90]. Epidurals containing only local anesthetic (bupivacaine) have been shown to reduce the duration of ileus when compared with epidurals containing only opioids or a combination of opioids and bupivacaine [91, 92].

Other alternatives to narcotics are available for postoperative pain management. Nonsteroidal antiinflammatory drugs and acetaminophen are widely used to augment pain management postoperatively [88]. Nonsteroidal antiinflammatory drugs, however, may be associated with an increased risk of anastomotic leakage [93]. Studies have demonstrated that the addition of ketorolac can decrease postoperative pain, use of narcotics, and time to return of bowel function, but has no effect on length of stay [94, 95]. The use of tramadol and gabapentin has not been thoroughly studied in colorectal surgery patients [88]. Intravenous acetaminophen has been found to be safe and well tolerated in adult inpatients with statistically significant analgesic efficacy when compared with placebo after abdominal laparoscopic surgery [96, 97]. Liposomal bupivacaine injected into the surgical site prior to wound closure has been shown to decrease postoperative opioid use by half and shorten length of stay [98].

Pulmonary complications are a well-known problem after colorectal surgery [87]. All patients have some form of pulmonary impairment after abdominal surgery [99]. When compared to open surgery, studies have shown an earlier return of forced expiratory volumes and decreased incidence of postoperative pulmonary complications in laparoscopic cases [100–103]. Incentive spirometry is designed to compel patients to take long, slow, deep breaths resulting in decreased pleural pressure, increased lung expansion, and better gas exchange [104]. Incentive spirometry has been widely adopted in most hospitals, but studies show inconclusive results for its support [99, 104–106]. Delayed ambulation and uncontrolled pain have been found to correlate with worsened pulmonary function [107, 108].

The concept of early ambulation following surgery was proposed as early as 1817 [109]. Leithauser published several articles, which popularized early ambulation as a means to decrease pulmonary, circulatory, and gastrointestinal complications [110, 111]. Early ambulation has been shown to correlate with reduced morbidity, recovery time, and length of stay after colorectal surgery without an increase in complications [63, 112]. Benefits from early ambulation on gastrointestinal function remain inconclusive at this time, as studies have shown a reduced length in stay, but no change in time to flatus or bowel movement [113, 114].

Hospitalization confers a high risk of venous thromboembolism (VTE) in the form of deep vein thrombosis (DVT) and pulmonary embolism (PE). Without thrombophylaxis, the incidence of hospital-acquired DVT ranges from 10 to 40 % [115]. Risk factors include type of surgery, inflammatory bowel disease, malignancy, immobilization, increasing age, and venous compression [115–119]. Laparoscopic surgery was shown to reduce the risk of VTE when compared to open techniques [120].

VTE prophylaxis should be a standard component of the postoperative care of colorectal patients. The American Society of Colon and Rectal Surgeons published their practice guidelines for the prevention of VTE. Patients are stratified preoperatively into low, moderate, high, and highest risk, and postoperative prophylaxis is based on this stratification. Low-risk patients do not require any specific measures other than early ambulation. Either mechanical sequential compression devices or low-dose unfractionated heparin (LDUH) every 8–12 h may be used for moderate-risk patients. High-risk and highest-risk patients should be given either LDUH or low-molecular-weight heparin (LMWH) [121]. Some controversy exists, though, regarding the use of LMWH. One study showed that prophylactic therapy with LMWH was not completely effective in the prevention of postoperative VTE in patients with inflammatory bowel disease [122].

Wound infections are one of the most common postoperative complications in surgical patients. Surgical site infections (SSIs) are the second leading cause of all nosocomial infections [123]. Up to 13.5 % of patients undergoing bowel surgery will develop an SSI [124]. The Surgical Care Improvement Project (SCIP) uses evidence-based medicine to establish surgical practice guidelines. SCIP measures to reduce SSIs include prophylactic antibiotics received within 60 min prior to incision, appropriate antibiotic selection, discontinuation of antibiotics postoperatively within 24 h, maintaining normothermia perioperatively, and the use of clippers for hair removal [125]. There is some evidence that compliance with SCIP guidelines has decreased SSIs, but this has not been substantiated by large-scale national studies [126]. Laparoscopy has been shown to significantly decrease SSI when compared to open operations [127]. When wound complications occur following laparoscopic surgery, they are often much less severe than open laparotomy SSIs [127].

An anastomotic leak is one of the most dreaded complications following colorectal surgery. The prevalence has been reported to range from 0.5 to 21 % [128–131], and both morbidity and mortality significantly increase after an anastomotic leak. Mortality following anastomotic leak has been reported to range from 12 to 27 % [132–136]. Anastomotic leaks are also associated with longer hospital stays and increased hospital costs [137]. Anastomotic complications can be secondary to technical factors including ischemia, tension, stapler malfunction, malnutrition, immunosuppression, morbid obesity, radiation exposure, and an anastomosis less than 10 cm from the anal verge [138, 139]. Although most studies show equivalent leak rates when compared with open surgery, laparoscopy was shown to decrease anastomotic leaks in a recent study [137]. Ricciardi et al. demonstrated that if an anastomosis was found to have an air leak at the time of surgery, suture repair alone was associated with the highest rate of postoperative clinical leak (12.2 %) compared with diversion (0 %) or reconstruction of the anastomosis (0 %) [140].

Anastomotic bleeding has been reported to occur in 5.4 % of stapled and 3.1 % of hand-sewn colorectal anastomoses [141]. Most cases resolve with conservative management. One study reported an intervention rate requiring therapy in addition to a blood transfusion of 0.8 % [142]. For those who require intervention, options include endoscopic control with injection or clip application and reoperation with refashioning of the anastomosis. Angiographic embolization or injection of vasopressin should be avoided as this may result in ischemia of the anastomotic segment with subsequent leak or stricture formation [142, 143].

Intra-abdominal abscesses can form from an anastomotic leak, spillage of stool at the time of surgery, missed enterotomies, or postoperative hematomas. Patients that demonstrate signs of infection such as localized peritonitis, fever, or increased white blood cell count should be evaluated with a CT scan of the abdomen and pelvis with oral and intravenous contrast [139, 144]. The extravasation of rectal contrast, when used, is the most reliable marker of an anastomotic leak. Some authors therefore believe that it should be used in all cases to evaluate left-sided anastomoses [145]. CT-guided abscess drainage is an effective intervention with a 65 % rate of resolution after the first and 85 % resolution after the second drainage [146]. CT-guided drainage may be appropriate for patients with abscesses over 3 cm, but operative intervention should be undertaken for patients with generalized peritonitis, if drainage is not feasible or if the patient shows no improvement or continues to deteriorate. For abscesses smaller than 3 cm in diameter, CT-guided aspiration may also be an option [144]. Broad-spectrum intravenous antibiotics should also be started, as small abscesses may respond to antibiotics alone [147].

Adhesive small bowel obstructions (SBO) are common after abdominal surgeries and remain a leading cause of hospital admissions [148]. The rate of SBO has been reported to be as high as 10 % after colectomies [149]. Some authors have shown that there is a significant reduction in the readmission rate after laparoscopic colorectal surgery when compared with open surgery [150], while others have found no difference in the rates of SBO [151].