Evidence synthesis sets 24-hour mobilization targets after laparoscopic colorectal cancer surgery

A systematic review has distilled 19 sources into 23 recommendations for early mobilization after laparoscopic radical resection for colorectal cancer, with in-bed activity beginning within 24 hours of surgery and patients being encouraged to stand or walk during that same period. The synthesis covers core principles, preoperative preparation, activity management, postoperative protocols and practical support, while emphasizing that clinical status and patient preference must determine how the pathway is implemented. It is not a meta-analysis of a single activity dose; rather, it integrates guidelines, consensus statements, systematic reviews, an evidence summary and randomized trials to produce a clinically usable framework for postoperative nursing and multidisciplinary care.

The researchers followed the “6S” evidence model, beginning with high-level systems and summaries and extending to individual studies. They searched international and Chinese-language websites and databases, including the National Institute for Health and Care Excellence, Joanna Briggs Institute resources, the Cochrane Library, PubMed, Embase, Web of Science, CNKI, Wanfang, VIP and SinoMed. Searches ran from the inception of each database through December 19, 2025, using terms for colorectal cancer, laparoscopic or minimally invasive surgery, enhanced recovery, ambulation, mobilization, physiotherapy and early exercise. The initial search retrieved 2,130 records; 1,885 remained after duplicates were removed, and 19 publications ultimately met the inclusion criteria.

Two researchers independently appraised the literature and extracted data, resolving disagreements by group discussion. AGREE II was used for guidelines, adapted Joanna Briggs Institute criteria for expert consensus statements and systematic reviews, the Critical Appraisal for Summaries of Evidence tool for the evidence summary, and corresponding critical-appraisal criteria for randomized controlled trials. The evidence was then converted into recommendations through the Joanna Briggs Institute grading system, with strength also informed by feasibility, appropriateness, meaningfulness, effectiveness, clinical applicability and safety. Secondary sources were treated as summaries of their underlying primary studies to avoid counting the same evidence more than once.

The resulting pathway treats early mobilization as a progressive, measurable part of enhanced recovery after surgery rather than a single intervention. Its recommended sequence runs from structured exercises in bed to sitting upright, standing at the bedside, assisted walking and independent walking, with activity duration and distance increasing according to recovery. In-bed exercises—including deep breathing, elbow flexion, ankle pumping, knee flexion, hip elevation and turning—should begin within 24 hours after regaining consciousness from anesthesia. Patients should be encouraged to attempt standing or walking within 24 hours of surgery, and from the first postoperative day the pathway calls for at least three hours of activity each day.

Before any activity begins, nurses should assess consciousness, vital signs, pain, muscle strength and the condition of the surgical incision. The synthesized criteria call for activity to be suspended when pain measured on the visual analogue scale exceeds 4, oxygen saturation falls below 90%, heart rate is above 100 or below 40 beats per minute, systolic blood pressure is below 90 mmHg or diastolic pressure below 50 mmHg, or dizziness, marked weakness or orthostatic intolerance develops. These thresholds are explicitly provisional rather than universal safety standards: they largely derive from one randomized trial, and the review assigned the stop criteria a weak recommendation pending validation in larger, multicenter studies.

Preoperative work is presented as a foundation for postoperative participation. Patients and families should receive education about the importance, components and goals of early mobilization, with additional strategies and success stories proposed for people who may have difficulty retaining verbal information. Exercise-based prehabilitation combining aerobic activity, cardiorespiratory exercise and resistance training may improve functional reserve and exercise endurance, although no standardized protocol is supported by the available evidence. Grip strength and the six-minute walk test can describe functional status before surgery, but the review cautions that they should not be presented as established predictors of surgical risk.

The postoperative plan also depends on removing barriers to movement. For patients without high-risk factors, urinary catheters should be removed within 24 hours; for those without risk of urinary retention, removal is recommended within 48 hours. Other drainage tubes should be reviewed promptly and removed when appropriate. Postoperative nausea and vomiting should be prevented, and excessive intravenous fluid should be limited because fluid overload can reduce a patient’s willingness and ability to get out of bed. Nutritional screening before surgery, daily monitoring afterward and early enteral nutrition within 24 hours, together with oral supplements, are recommended to support gastrointestinal recovery and shorten hospital stay.

Pain control is a central enabler of activity, and the review adjusts earlier evidence to reflect the laparoscopic population. Its recommended strategy is multimodal analgesia centered on acetaminophen combined with bilateral transversus abdominis plane blocks. For colon surgery, selective cyclooxygenase-2 inhibitors may be added, whereas nonsteroidal anti-inflammatory drugs should be avoided in rectal surgery; intrathecal morphine may be used as needed for visceral analgesia. The authors also recommend chewing gum three or four times daily for 10 to 15 minutes after surgery. Assessment should combine patient reports with objective measures such as time to first flatus, time to first bowel movement, time to mobilization, daily steps, walking distance, sleep duration, pain, fatigue, complications and quality of life.

The evidence supports a structured approach, but it does not establish that one mobilization dose independently improves every clinical outcome. The included trials were heterogeneous and generally small, and a colorectal trial in which staff facilitated mobilization found substantially greater in-hospital activity without better walking capacity at four weeks or other measured outcomes. The 2025 ERAS Society guidance likewise characterizes evidence for specific mobilization interventions as limited and finds no demonstrated improvement in functional capacity or complications from mobilization on the day of surgery. The review therefore distinguishes between encouraging movement to avoid prolonged immobility and claiming that a particular number of active hours independently produces better outcomes.

Implementation remains a substantial challenge. Age, beliefs about recovery, catheter use, duration of anesthesia, wound pain, preoperative hemoglobin and family support can affect adherence, while staffing shortages and heavy clinical workloads can prevent patients from getting out of bed. A colorectal cohort of 1,170 patients found that 58% did not meet a first-day target of at least six hours out of bed; emergency surgery, older age and intraoperative fluid overload were associated with delayed mobilization, which was in turn linked to more complications and longer hospitalization. Multidisciplinary quality-improvement work in other major abdominal surgery raised mobilization rates substantially and reduced length of stay, but that evidence is indirect. The review’s 23-item framework therefore calls for tailored goals, explicit safety criteria, adequate staffing, patient education and continued measurement rather than reliance on a uniform routine.

Subject of Research: Evidence-based early postoperative mobilization after laparoscopic radical colorectal cancer resection

Article Title: Summary of the best evidence for early mobilization following laparoscopic radical resection for colorectal cancer

Article References: She, R., Jin, X., Shi, Z., Wei, H., Wei, X., & Wu, Z. (2026). Summary of the best evidence for early mobilization following laparoscopic radical resection for colorectal cancer. Frontiers in Medicine, 13, Article 1967502. https://doi.org/10.3389/fmed.2026.1967502

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1967502

Keywords: colorectal cancer, laparoscopic surgery, early mobilization, enhanced recovery, postoperative care, evidence synthesis, nursing protocols, clinical safety, Summary, best, evidence, early