Awareness surgery: laparoscopic right colectomy in a heart transplant patient-a case report

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.

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.

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