This document discusses the surgical management of colon and rectal cancers. It covers the surgical anatomy, principles of surgical resection, and pre-operative and intra-operative techniques. The key goals of surgery are cure, local tumor control, and palliation of symptoms. Surgical strategy depends on tumor location, stage, patient factors, and extent of resection. Standard resections include right and left hemicolectomies, sigmoid colectomy, and total proctocolectomy. Pre-operative preparation involves bowel cleansing, antibiotics, and thromboembolism prophylaxis. Intra-operative steps include inspection, mobilization, vascular division, exteriorization of the bowel, anastomosis, and closure.

1. SURGICAL MANAGEMENT OF
CARCINOMA COLON & ANORECTUM
ANKITA SINGH
PG III
UNIT I, general surgery
MAMC , Delhi

2. SURGICAL ANATOMY OF COLON & ANORECTUM

3. SURGICAL ANATOMY OF COLON & ANORECTUM
BLOOD SUPPLY
Ileocolic
Right colic
Middle colic
Artery rectae
Superior rectal
Marginal artery
Abdominal aorta
Superior mesentric
Inferior mesentric
Left colic
Sigmoid ateries
Jejunal and ileal arteries
Artery of drummond

4. SURGICAL ANATOMY OF COLON & ANORECTUM
Portal vein
IMV
IVC
Common iliac
External iliac
Internal iliac
Superior rectal v
Internal hemorrhoidal
plexus
External hemorrhoidal
plexus Middle rectal v
Inferior rectal v
IMA & IMV
IIA & IIV
Superior rectal a &
v
Middle rectal a & v
Internal
pudedal a & vInferior rectal a & v

5. SURGICAL ANATOMY OF COLON & ANORECTUM
LYMPHATIC DRAINAGE paracolic
epicolic
principle
intermediate
Internal iliac glands
Inguinal glands
Upper zone
Middle zone
Lower zone
• Lymphatic follicles
(submucosa)
• Drain through muscle
wall into
• Epicolic nodes
• Paracolic nodes (along
blood vessels)
• Principlal LN (arterial run
off at aorta)
1. Celiec
2. Superior mesentric
3. Inferior mesentric
groups

6. SURGICAL ANATOMY OF COLON & ANORECTUM
RELATIONS
• PERITONIAL RELATION
• RIGHT HEMICOLECTOMY
Right ureter, duodenum, gonadal
vessels
• TRANSVERSE COLON RESECTION
SMA,SMV, Gastroepiploic vessels
• SPLENIC FLEXURE takedown
Spleen, pancreas, left kidney
• LEFT HEMICOLECTOMY
Left ureter, gonadal vessels,
hypogastric nerves

7. “SURGERY IS THE CORNERSTONE OF CURATIVE
THERAPY FOR COLORECTAL or ANORECTAL
CANCERS”
• Any colorectal cancer is indicated for surgery except
1. Widespread tumour dissemination
2. General contraindication due to patient factor

8. OTHER INDICATIONS
• Precursor pathology not managable non operatively
• Distant mets in liver or lung (solitary or limited no.)-
cure or palliation/ prevention of complications

9. GOAL OF SURGERY
• To achieve cure
• Extension of survival or at least disease free survival
(local tumour control)
• In precursor pathology, prevention of cancer
• In palliative setting, for symptom free survival

10. PRINCIPLES OF SURGICAL MANAGEMENT OF
COLORECTAL CANCERS
• Curative resection - the cancerous segment of colon,
the mesentery with the primary feeding vessel and
the lymphatics, and any organ with direct tumor
involvement.
• Primary artery supplying the segment of the colon to
be resected is divided at its origin because the
lymphatics run with the arterial supply.
• 5cm clearance at both proximal and distal margin

11. • Tumor adherent to or invading an adjacent organ an
en bloc resection if technically feasible.
• Synchronous cancers in colon- extended resection or
even total colectomy, with ideally only one
anastomosis preffered.
• pancolonic disease (eg, UC or FAP) requires a total
proctocolectomy with either an ileoanal pull-through
procedure or an ileostomy
• Young patients (<50 years, with/without proven
HNPCC gene constellation) with tumors proximal to
sigmoid colon should be offered a total abdominal
colectomy to reduce the risk of metachronous
cancers and to facilitate surveillance.

12. • Limited wedge resection may be considered for an
unfit patient or for palliative resection in those with
widespread tumor.
• In contrast to rectal cancer, neoadjuvant treatment is
not indicated in overwhelming majority of colonic
cases.

13. SURGICAL & ONCOLOGIC STRATEGY
DEPENDS ON:
1. Location of tumour
2. Stage
3. Synchronous or metachronous lesions
4. Underlying colonic disease
5. Patient factors
6. Extent of local procedure and timing

14. PREOPERATIVE PREPARATION
1. Transfusion
2. Bowel cleansing
3. Antibiotic prophylaxis
4. Thromboembolic prophylaxis
5. Urinary catheter & stents
6. NG tube
7. Marking of ostomy site
8. Preemptive pain management

15. TRANSFUSION:
• Indications
• Blood group typing and screening, crossmatching
recommended
• Controversy regarding transfusion related increase in
recurrence
• Allogenic vs autologous transfusion
BOWEL CLEANSING:
• Surgeon’s personal preference

16. • Mechanical preparation vs no preparation for
elective colorectal surgeries
• Rationale based on colon being large reservoir of
microbes
• Advantage:
1. If need be intraoperative colonoscopy feasible
2. Ease of anastamosis, inabsence of preanastamotic
fecal load
• Mechanical cleansing- oral cathartics/
enema/washouts

17. • Generally used are based on PEG or sodium
phosphate (later C/I in renal failure)
ANTIBIOTIC PROPHYLAXIS
• Aim- reduce colonic and dermal bacterial
concentration
• Action should start within 1 hour of skin incision and
limited to within 24 hours
• Coverage- both anaerobic & aerobic

18. • Intravenous broad-spectrum antibiotics most
commonly used:
(1) single antibiotics (ertapenem, piperacillin-
tazobactam);
(2) Combination of two (second- or third-generation
cephalosporin + metronidazole, uoroquinolone +
metronidazole, clindamycin + aminoglycoside,
clindamycin + quinolone, clindamycin + aztreonam);
(3) triple combinations such as amoxicillin-clavulanic
acid + metronidazole + aminoglycoside.

19. • Oral antibiotics (eg, metronidazole combined with
nonabsorbable neomycin) in conjunction mechanical
bowel preparation may yield similar results but may
increase risk of nosocomial superinfections,
particularly with Clostridium diffcile.
THROMBOEMBOLIC PROPHYLAXIS:
• Reduce incidence of postoperative DVT & pulmonary
embolism.
• Both pharmacologic and physical prophylaxis(eg,
pneumatic calf compression) proven to be effective

20. • Both low-dose unfractionated heparin and LMWH
shown to be equally effective
• However LMWHs have shown to have slightly higher
rate of minor bleeding events
• use of subcutaneous heparin as being more cost-
effective than LMWHs
• Recommendation- drugs be commenced at least 2
hours before surgery and continued postoperatively
until full ambulation.
• Intermittent pneumatic calf-compression boots are
equally successful ,advantage of no risk of increased
bleeding.

21. • Patients on warfarin ,switched perioperatively to iv
heparin to allow for stopping warfarin medication
and antagonizing its effect with vitamin K.
• Four hours before incision, the heparin may be
discontinued & resumed within 24 hours
postoperatively with a stepwise increase in the dose.
URINARY CATHETERS/STENTS:
• Monitoring
• For ease of identification & preservation

22. INTRAOPERATIVE SURGICAL
TECHNIQUE
COLON

23. STANDARD RESECTIONS OF COLON

24. PATIENT POSITION
1. Open surgery-
• Supine
• Modified lithotomy- access to anus
2. Laparoscopic surgery-
• table tilted and moved to steep
Trendelenburg’s position

25. SKIN INCISION
• Midline laparotomy incision
• Infraumbilical - for pelvic dissection for
proctocolectomy
• Higher midline- for proximal resection
• transverse incision/subcostal incision may give
excellent exposure for a right hemicolectomy.

26. • Laparoscopic surgery-
Right hemicolectomy Left hemicolectomy Sigmoid colectomy with
anterior resection
APR
Total proctocolectomy

27. STEPS
1. Inspection
2. Mobilization
3. Vascular
division
4. Exteriorization
5. Anastamosis
6. Closure

28. STEPS STOMA FORMATION

29. STEPS FOR END COLOSTOMY

30. STEPS FOR END LOOP COLOSTOMY

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