There are three main groups of patients presenting for colorectal surgery – those with intractable severe inflammatory bowel disease (IBD), those with malignancy, and those with benign anorectal problems. This chapter will concentrate on the first two patient groups.

Enhanced recovery has become synonymous with improved outcomes, shortened hospital stay, and improved patient satisfaction. The vast majority of research on enhanced recovery started in colorectal surgery. Many of the practices in care pathways, anaesthetic technique and post-operative care have subsequently been adopted by other surgical specialties.

Pre-operative assessment – general considerations

Pneumoperitoneum

The majority of major abdominal and pelvic colorectal surgery is now performed laparoscopically or with laparoscopic assistance. All patients must be assessed to see if they will tolerate:

i. Pressure effects of a pneumoperitoneum

ii. Physiological challenges of a pneumoperitoneum

iii. Physiological effects of steep Trendelenburg position

Nutrition and electrolytes

All patients are at risk of malnutrition and electrolyte imbalance. Specialised dietetics advice, and involvement of gastroenterologists will avoid complications and improve post-operative recovery. The malnutrition can be chronic and requires careful management of the ‘starved’ individual to prevent re-feeding syndrome or liver failure with nitrogen overload.

Items to consider specifically are:

i. Potassium (diarrhoea and vomiting), causes cardiac rhythm problems

ii. Magnesium (malabsorption), causes cardiac rhythm problems and muscle weakness

iii. Sodium (if on i.v. replacement fluids or sodium-depleting drugs)

iv. Albumin (indicator of liver function, healing problems, infection risk), important when considering whether to restore intestinal continuity with an anastomosis

v. Liver function (alters drug metabolism)