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Similar to operations of Carcinoma rectum
operations of Carcinoma rectum
- 1. Operations of CaRectum and video club on TME Moderator Dr. M Talukdar Asso. Prof Deptt of surgery , SMCH Presenter Dr. Biswajit Deka 3rd yr PGT
- 2. Weeks of Development •3rd : gut tube- foregut, midgut , hindgut • 6th : cloaca- anterior urogenital and post. anal & sphincter elements • 10th : external anal sphincter- from posterior cloaca • 12th : internal anal sphincter from enlarged circular muscles of rectum
- 4. Rectum – grossly •12 – 15 cm in length • Lacks taenia coli & epiploic appendices • Posterior surface – extraperitoneal
- 5. Extent of rectum: controversial Proximal Extent 1. Recto-sigmoid junction at sacral promontory 2. Point where taenia converge Distal extent 1. Dentate line ( anatomist ) 2. Proximal border of anal sphincter ( surgeons )
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- 12. Lymph nodes position Epicolic Along bowelwall and epoploic appendices Para colic Adjacent to marginal artery Internediate Along main br of large blood vessels Primary On SMA / IMA
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- 20. APR : History •Jean Amusat : introduced colostomy ( early 19th century) • Early surgeons : 1st mini laparotomy to creat colostomy several days later Distal proctectomy through perineum Limilations : 1. inability to remove mesorectum recurrence 2. high rate of perineal fistula
- 21. • W ErnestMiles : modern APR ( 1908 ) • One stage – abdominal colostomy Removal of : • Entire pelvic colon + rectum • Pelvic mesocolon below common iliac artery • LN at bifurcation of common iliac artery • Anus • Ischiorectal fat • Levator muscles
- 22. Symptoms of caRectum • Hematochezia • Mucus discharge • Tenesmus • Change in bowel habits
- 23. D/D • Ulcerative colitis •Crohn’s proctocolitis • Radiation proctitis • Procidentia • Colitis cystica profunda
- 24. Operations of CaRectum • Local excision – T1 / palliative • Transanal Endoscopic Microsurgery • Fulguration • Abdomino Perineal Resection • Anterior resection (ant. Proctosigmoidectomy with colorectal anasto.) • Sphincter sparing APR with Coloanal anastomosis • Hartman’s operation
- 25. Margins • optimal distalresection margin : controversial • Although the 1st line of spread is upward along the lymphatics, tumors below the peritoneal refection can spread distally via intra- or extramural lymphatic and vascular routes. • APR : for low rectal cancers traditionally -- 5-cm distal margin
- 26. • Distal intramuralspread limited to within 2cm unless poorly differentiated or widely metastatic • So, 2-cm distal margin is acceptable , although a 5-cm proximal margin is still recommended. • The circumferential radial margin (CRM) is more critical than the proximal or distal margin for local control.
- 28. Patient Selection andchoice of Operation • Tumors < 3 cm from the dentate line , not invading the sphincters : transanal procedure. • 5 cm from the dentate line : transcoccygeal approach or transanal endoscopic microsurgery (TEM). • 7–10 cm from the dentate line : TEM or LAR. • Tumors tethered to the mesorectum or pelvic floor , S/O transmural involvement, are not amenable to local excision. Patients with such lesions should undergo preoperative radiation followed by a radical resection.
- 30. ? ? Bowelpreparation: • Standard: Clear-liquid diet 1–3 days prior to surgery, Laxatives and/or enemas, and GIT irrigation with polyethylene glycol electrolyte lavage or saline • Advantage : Easier manipulation of the colon and rectum Reduce peri- operative infection • Elevated s/Cr or CCF - avoid the magnesium citrate preparation, • Gastroparesis- avoid polyethylene glycol
- 31. • Oral antibiotics: decrease post-operative infectious • MC regimen : Nichols/Condon preparation: neomycin 1 g + erythromycin 1 g, both non-absorbable antibiotics, by mouth at 1 , 2 & 10:00 pm on the day prior to surgery ( Many substitute metronidazole 500 mg for the erythromycin )
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- 40. J Pouch Descending colon LowAR syndrome or Clustering
- 41. Coloplasty 8 – 10cm 4 – 6 cm
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- 54. Complications • Urinary complication •Sexual dysfunction • Infection • Colostomy related complications • Changes in lifestyle
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