Preoperative Assessment and Optimization Evaluation of medication compliance and control of risk factors: hypertension, diabetes, COPD, smoking, alcohol, asthma, CAD, malnutrition, anemia Psychologic preparation for surgery and postoperative recovery: provide written information and e-module link including daily milestones in perioperative pathway (diet, ambulation, presence of drains, pain management, and expected hospital stay [3-4 days]) Physical preparation with exercises at home: aerobic 30 minutes/ day at moderate intensity (4-6 on Borg Scale) 3 days/week; resistance exercises; breathing exercises Surgical considerations: operative approach (laparoscopic vs open) Oral bowel preparation with antibiotics for rectal resections with planned ileostomy; fleet enemas for left sided resections Stoma teaching as needed Nutritional supplements if diminished oral intake, weight loss, low BMI Day of surgery Drink clear fluids with carbohydrates up to 2 hours before operation unless risk factors are present (e.g., gastroparesis, obstruction, dysphagia, previous difficult intubation, achalasia, pregnancy) Preinduction Short-acting sedative medication if needed for anxiety Intraoperative Management Anesthetic Management Anesthesia protocol: Total intravenous anesthesia (TIVA)/desflurane/sevoflurane Epidural catheter at appropriate level for postoperative analgesia for open surgery and infuse local anesthetics during surgery. Bilateral transversus abdominis plane block for laparoscopic surgery Intravenous lidocaine infusion 1.5 mg/kg bolus then 2 mg/kg/hr for duration of case if no epidural Prevent PONV with dexamethasone and ondansetron plus others on the basis of baseline risk score Avoid overhydration. IV Ringer’s lactate 1.5-2 mL/kg/ hr for laparoscopic surgery, 3-5 mL/kg/hr open surgery. Additional 1 L of Ringer’s lactate if bowel preparation used. Colloid 1:1 to replace blood loss Maintain normothermia (>36° C) Maintain glucose <10 mmol/L Antibiotic and DVT prophylaxis Neuromuscular blockade to allow lower pressure pneumoperitoneum (12 mm Hg) Titrate depth of anesthesia with bispectral index Surgical Care Minimize incision size. Laparoscopic surgery if feasible. Maximize use of small trocars. Infiltrate incisions with long acting local anesthetic at beginning and end of procedure. Anastomotic leak test and endoscopy Remove NG tube before extubation Remove urinary catheter after right hemicolectomy Postoperative Care Postoperative Day 0 Discontinue IV fluid infusion (heparin-locking catheter) after discharge from recovery room Gum chewing for 30 minutes TID (continue daily) Full fluids with 1 can of nutritional supplement beverage if no PONV and no abdominal distension Out of bed (sitting in chair) encouraged Oral acetaminophen 650 mg every 4 hours and Celecoxib 200 mg BID for 72 hours routine Glucose monitor and treatment if >10 mmol/L Postoperative Day 1 Discontinue urinary drainage catheter Gum chewing for 30 minutes TID Full oral diet as tolerated including nutritional supplementation beverage with each meal Mobilize out of bed for 4 to 6 hours. Walk length of hallway with assistance TID Glucose monitor and treatment if >10 mmol/L Postoperative Day 2 Gum chewing for 30 minutes TID Mobilize out of bed for 8 hours Transition from epidural to oral medication (oxycodone + acetaminophen + NSAIDs) if stop test successful Discharge criteria assessed: passing gas or stool, no fever, pain <4/10 with oral analgesia, walking unattended, eating Postoperative Day 3 Discharge before lunch if discharge criteria met Instructions for home including eating normal diet with supplements as needed, daily exercise, avoid opioids, accessing psychologic support Schedule follow-up appointment in clinic 2 weeks after surgery | 
