brief anatomical relationships of rectum with different minimal invasive surgeries employed for management of CA Rectum

1. MINIMAL INVASIVE SURGERY IN CA RECTUM
DR. RAHUL JAIN
M.S. GENERAL SURGERY

9. Regional lymph nodes (N)
• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastases
• N1 Metastasis in 1–3 regional lymph nodes
N1a Metastasis in 1 regional lymph node
N1b Metastasis in 2–3 regional lymph nodes
N1c Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or
perirectal tissues without regional nodal metastasis
• N2 Metastasis in 4 or more regional lymph nodes
N2a Metastasis in 4–6 regional lymph nodes
N2b Metastasis in 7 or more regional lymph nodes

10. Distant metastasis (M)
• M0 No distant metastasis
• M1 Distant metastasis
• M1a Metastasis confined to one organ or site (for example, liver,
lung, ovary, nonregional node)
• M1b Metastases in more than one organ/site or the peritoneum

11. Surgical resection is the cornerstone of curative therapy. Following a
potentially curative resection, the 5-year survival rate varies according
to disease extent
• Stage 1 –upto t2-80 to 90%
• Stage 2-upto t4-n0-62 to 76%
• Stage 3-LAP-m0-30to40%
• Stage 4-mets-4to 7%

14. PREOPERATIVE PREPARATION
 Counselling and siting of stomas
 Correction of anaemia and electrolyte disturbance
 Cross-matching of blood
 Bowel preparation
 Deep vein thrombosis prophylaxis
 Prophylactic antibiotics
 Insertion of urinary catheter

15. • Studies have shown that mechanical bowel preparation provides
little, if any, additional benefit to reducing the perioperative infection
rate. However, we still recommend to our patients that a mechanical
bowel preparation be performed in large part because it allows for
easier manipulation of the colon and rectum with both open and
laparoscopic surgery

16. • Cancer removal should not be compromised in an attempt to avoid a
permanent colostomy.

17. RESECTION MARGINS
DISTAL MARGINS
• Distal intramural spread usually is limited to within 2.0 cm of the tumor
unless the lesion is poorly differentiated or widely metastatic
• A 2-cm distal margin is acceptable for resection of rectal carcinoma
,although a 5-cm proximal margin is still recommended.
RADIAL MARGINS
• the length of mesorectum beyond the primary tumor that needs to be
removed is thought to be between 3 and 5 cm because tumor implants
usually are seen no further than 4 cm from the distal edge of the tumor
within the mesorectum

18. LOCAL EXCISION
• Preoperative staging, primarily with ERUS or MRI, is most helpful in identifying
appropriate patients for a local excision.
CRITERIA FOR LOCAL EXCISION
• T1N0 or T2N0 lesion
<4 cm in diameter
<40% circumference of the lumen
<10 cm from dentate line
• Well- to moderately differentiated histology
• No evidence of lymphatic or vascular invasion on biopsy
• Patients with extensive metastatic disease and poor prognosis who require local control
• Adjuvant treatment for patients with lymphatic invasion, T1 with poor prognosis
features, T2 lesions

19. • In patients with a T2 lesion who undergo treatment with local
excision and adjuvant chemoradiation, those who have a recurrence
ultimately require a salvage APR for cure
Four approaches to local excision:
• Transsphincteric
• transanal
• transcoccygeal
• TEM

20. TRANSANAL EXCISION
• Tumors amenable to this approach usually range from 6–8 cm
above the anal verge which is the same as 3–4 cm above the
anorectal ring
• Prone jackknife position, and the buttocks are taped apart.
• A pudendal nerve block using 0.5% Marcaine (bupivacaine)
with 1:100,000 units of epinephrine is administered to relax
the sphincters and facilitate postoperative pain control.
• Bivalve retractor
• Once the tumor is viewed adequately, traction sutures using
2-0 Vicryl are placed 2 cm proximal to the tumor. The
circumferential dissection line is outlined on the mucosa using
the cautery with a pinpoint Bovie tip approximately 1 cm from
the border of the tumor

21. • Starting proximally and proceeding
circumferentially, a full-thickness incision
of bowel wall is made down to perirectal
fat using the cautery along the previously
marked mucosa
• Once the specimen is free, carefully
maintain and mark the orientation for the
pathologist (eg, proximal, anterior, left,
right).
• Irrigate and check for hemostasis.
• After excision, the defect in the bowel
wall is closed transversely with full-
thickness bites using interrupted 3-0
Vicryl suture.

22. TRANSCOCCYGEAL APPROACH
• Used for larger or more proximal lesions within
the middle or distal third of the rectum.
• Incision is made in the intergluteal fold over the
sacrum and coccyx down to the upper border of
the posterior aspect of the external sphincter.
• After division of the skin and subcutaneous
tissues, one encounters the coccyx and anal
coccygeal ligament.
• In order to obtain optimal exposure, the coccyx
is removed by cauterizing its attachments,
including the anal coccygeal ligament, from each
side and from its lower edge and then
proceeding with the dissection on its
undersurface.

23. • Levator ani muscles are separated in the
midline, exposing a membrane that is just
outside the mesorectal fat. Once this
membrane is divided, the rectum can be
completely mobilized within the
intraperitoneal pelvis
• For anterior lesions, a posterior proctotomy is
made; the anterior rectum is approached
under direct vision, with removal of the tumor
along with a 1-cm margin .
• For posterior-based lesions, after complete
mobilization of the mesorectum, the distal
margin of the tumor can be palpated via a
rectal examination; the mesorectum and
rectum are transected approximately 1 cm
distal to the tumor

24. • Incision is closed in a transverse manner using an absorbable suture
such as 3-0 Vicryl or 3-0 PDS .
• After closure of the rectum, an air test is performed by insufflating the
rectum with air and filling the operative field with sterile saline. After all
air leaks are controlled, the levator ani musculature is reapproximated
and the anal coccygeal ligament is reattached to the sacrum, followed by
closure of the subcutaneous tissues and skin.
• One of the most troubling complications of the transcoccygeal excision
is a fecal fistula extending from the rectum to the posterior incision. The
incidence of this complication ranges from 5 to 20%

25. TRANSANAL ENDOSCOPIC MICROSURGERY
• Useful for small benign and malignant lesions in the mid and
proximal rectum that are too high for a traditional transanal excision.
• specialized instrumentation includes a 4-cm Wolf operating
proctoscope
• The operating proctoscope is equipped with a binocular microscope
and videoscope attachment for viewing on a standard laparoscopy
tower. A CO2 insufflator and long operating surgical instruments are
needed as well.

26. • Preoperative localization in the office with a rigid sigmoidoscope is
essential so that the patient can be appropriately positioned. The
patient is positioned using a beanbag and fixation to the table with tape,
which allows the patient to be rotated laterally during the procedure.
• For an anterior lesion, the patient is placed in the prone jackknife
position.
• For a posterior lesion, the patient is placed in a modified lithotomy
position.
• For lateral lesions, the patient can be placed on the appropriate side so
that the lesion is at the inferior quadrant of the visual field

27. LAPAROSCOPIC RECTAL PROCEDURES
• Anterior resection or high anterior resection is for
tumors present proximal rectum or distal sigmoid ( >12
cm from anal verge)
• Low anterior resection used for pathology in mid- to
distal rectum.
• APR is required for tumors within 1 cm of the top of
anal canal.

28. LAPAROSCOPIC ANTERIOR RESECTION
• Four port technique is used.
• Estimation of the lower margins of rectum and
pathology is done.
• Descending colon and sigmoid are mobilized by
scoring on white line of toldt.
• Vascular ligation needs to be proximal incorporating
atleast superior haemorrhoidal and sigmoidal
vessels.

29. • Rectum is mobilized by entering presacral
space.
• The dissection continues laterally on either
side until it meets posteriorly developing a
presacral plane. The rectum is mobilized by
creating a plane anteriorly between the rectum
and seminal vesicles and prostate in men.
• Complete mesorectal excision along with distal
and circumferential clearance is the key factor
for achieving complete oncologic resection.
• specimen is extracted out through the
extended incision in the supraumbilical region.
• Anastamosis is performed either with circular
stapler or hand sewn single layer anatamosis
through extended incision.

30. LAPAROSCOPIC APR
• Five ports are used for more flexibility. One of the
port is introduced at the site of stoma site.
• Pathology is identified. The origin of the super
hemorrhoidal and sigmoidal vessels can be exposed
by scoring the right and perirectal peritoneum.
• vascular pedicle at the level of superior
hemorrhoidal and sigmoidal vessels can be divided
at the level of aortic bifurcation or just below takeoff
of the left colic vessels.
• Mobilization is done by retracting the rectum
anteriorly and to right and left lateral dissection of
sigmoid is continued along left lateral aspect of
rectum. Presacral space entered and developed with
sharp dissection to pelvic floor.

31. • The right presacral plane is opened to meet the left presacral plane.
• The rectum is then elevated anteriorly with sufficient traction that the
presacral plane can be developed as far distally as needed to achieve at
least 4 cm of distal mesorectal and 2 cm of distal bowel clearance below
the tumor.
• A purse-string suture is used to close the diamond-shaped perianal
incision created just outside sphincter complex to include the sphincters
in the specimens.
• the dissection of the ischial rectal fat is carried out anteriorly and
posteriorly all the way to level of levators.
• rectum can be brought out from the abdomen and pelvis through the
posterior perineal wound by creating a large defect in pelvic floor.

32. • The perineal wound is closed in sequential layers with absorbable
sutures leaving closed-suction drain through the perineum.
• The distal end of the colon is now brought to the colostomy orifice
using a grasper.

33. ROBOTIC SURGERY
• Approved in 2000 by FDA for da Vinci surgical
system
• Weber et al, in 2002 reported successful
telerobotic-assisted laparoscopic sigmoid and
right colectomies when actual dissection and
mobilization were performed with robotic
assistance.
• It has many advantages over the laparoscopic
surgery.

35. Robotic APR
• Robot is placed to left pf patient.
• Arm 1 positioned in right upper
quadrant for dissection and division of
superior rectal vessels.
• Arms 4 and 2 are the opening arms of
the perineal portion of procedure.
• Arm 1 is positioned in left lower
quadrant for retraction of prostrate or
vagina.
• Left lower quadrant trocar site is site for
stoma.

36. NOSE
• Natural orifice specimen extraction.
• performed in colon and rectal surgery specimen extraction through
transanal and transvaginal route.
• considered a prequel to NOTES.

37. NOTES
• Natural orifice transluminal endoscopic surgery.
• concept of approaching the internal viscera through natural openings
such as the mouth (stomach), the anus, and the vagina.
• first performed in India by Reddy and Rao in a burn patient where
abdominal incision was not feasible.
• potential advantages of NOTES include no scars, less pain, fewer
wound complications, earlier mobility, and potential to offer therapy
outside operating room (intensive care unit [ICU]).

38. NEOADJUVANT CHEMORADIATION
• Ability to deliver higher doses of chemotherapy with radiation.
• Not only to downstage the tumor, which has been noted in 60–80% of patients,
but also to achieve a pathologic complete response, which occurs in 15–30% of
patients.
• The ability to “shrink” the tumor facilitates surgical resection, thereby allowing
one to achieve negative margins and perform a sphincter preserving operation in
patients who otherwise would require an APR.
• Additional advantages include radiating tissues with a greater oxygen supply, not
radiating the anastomosis, and decreased likelihood of developing radiation
enteritis because small bowel is less likely to enter the pelvis.
• Patients are more likely to complete the course of radiation therapy because it
precedes their surgical resection.

39. CURRENT RECOMMENDATIONS FOR
CHEMORADIATION IN RECTAL CANCER PATIENTS
AFTER RADICAL RESECTION
Stage I No adjuvant therapy
Stage II or III Neoadjuvant chemoradiation
• Low/midlesion 5-FU–based chemotherapy or other investigational agents with XRT (180 cGy 5 d/wk ×
30 treatments)
• Rest for 4–8 wk
• Total mesorectal excision
• Rest for 4 wk
• Chemotherapy in appropriate patients for 4–6 mo
• High lesion Pre- or post-op chemoradiation therapy
• Total mesorectal excision
Stage IV LAR or APR for palliation/prevention of obstruction or bleeding
• Adjuvant chemotherapy 5-FU + leucovorin ± irinotecan or oxaliplatin with individualized XRT