Updates in Colorectal Surgery

1. Updates in Coloproctology
Grandround presentation
West Suffolk Hospital
Department of General Surgery

2. Coloproctology
• The field of Medicine/Surgery
that deals with disorders of the
colon, rectum and anus
• Includes benign and malignant
pathology

3. Functions of the Colon
• Absorption of water &
electrolytes ( Na , Cl )
• Formation & temporary storage
of faeces
• Bacterial fermentation of
undigested materials

4. Diseases of the colon
Mechanical
• Polyps & cancer
• Diverticular disease
• Inflammatory bowel disease
(Crohn’s, Ulcerative colitis)
• Rectal prolapse
• Haemorrhoids
• Anal fistulas & fissures
Functional
• Obstructive defecation
• Constipation
• Pseudo-obstruction
• Irritable bowel syndrome (IBS)
• Hirschsprung’s disease
• Pelvic floor dysfunction

5. Haemorrhoids
• Conservative: laxatives, topical ointments “Anusol”
• Rubber band ligation
• Phenol injection
• Open Milligan Morgan Haemorrhoidectomy
• Stapled haemorrhoidectomy
• Haemorrhoidal artery ligation operation “HALO”

6. Milligan-Morgan Open Excisional Haemorrhoidectomy
• Developed in the UK in 1937
• Can only be done under GA
• Associated with postop pain
• Suitable for G3&4 haemorrhoids
• Lowest rates of recurrence

7. Rubber Band Ligation for Haemorrhoids
• Cheap
• Can be done in OPD or endoscopy
• Does not require LA or GA
• Can be repeated
• Higher rate of recurrence

8. Haemorrhoidal Artery Ligation Op “HALO”

9. Transanal Haemorrhoidal Dearterialisation “THD”
• Expensive
• Can only be done under GA
• Can be repeated
• Lower rates of recurrence

10. Stapled Haemorrhoidectomy

11. Stapled Haemorrhoidectomy
• Rectal bleeding
• Pain & swelling
• Faecal incontinence
• Rectal perforation
• Rectovaginal fistula
• Anastomotic/anal stenosis

14. Anal Fistulas
• Fistula is a tract between 2 epithelised surfaces
• Anal fistula is a tract/tunnel between anal canal & external skin
• Cryptoglandular theory by Park’s in 1972
• Anal glands, that secrete mucous, get blocked  infected  abscess
• About 50% of these abscesses may develop into a fistula

15. Anal Fistulas
Aetiology
• Cryptoglandular theory
• Crohn’s disease
• Radiation
• Trauma
• STDs
• TB
• Diverticulitis
• Cancer
Symptoms
• Recurrent anal sepsis
• Pain & swelling around the anus
• Bloody/purulent discharge
• Irritation in the perianal skin
• Painful bowel movements
• Fever, chills, fatigue

16. Park’s classification
• Intersphincteric ~ 60-70%
• Transsphincteric ~ 15%

17. Goodsall’s Rule

18. Treatment modalities
• Conservative with antibiotics
• Incision & drainage of an abscess
• EUA +/- full or partial lay open of a fistula
• Staged procedure: EUA + seton insertion (encourage fistula tract to
migrate more distally/superficially)
• Fibrin glue / Fistula plug
• Mucosal advancement flap
• LIFT procedure (Ligation of the Intersphincteric Fistula Tract)
• VAAFT (Video Assisted Anal Fistula Treatment)

19. Draining Seton

20. Fistula Plug(synthetic porous bio-absorbable polymer)

21. Fibrin Glue
• The fibrin clots to seal the tract
• Sphincter-sparing treatment
• Stimulates the migration,
proliferation & activation of
fibroblasts

22. LIFT procedure
• Novel modality
• 50-95% success rates
• Involves dissection , ligation &
excision of the fistula tract
• Sphincter-sparing treatment

23. LIFT procedure

24. VAAFT procedure
• Identifies the fistula opening
• Flushing of the fistula tract
• Can be combined with other
modalities e.g. glue
• Cautery/laser can be applied with
precision to fibrose & obliterate
the fistula tract

25. Parastomal hernias
• Very common in clinical practice
• Associated with significant comorbidity
• Very challenging to manage/repair
• S&S
• Swelling
• Abdominal pain
• Reduce stoma output
• Obstruction
• Ischaemia & perforation

26. Sugarbaker repair technique

27. Crohn’s disease

28. Biological & Anti-TNF treatment

29. Kono-S anastomosis for SB resection

30. Ulcerative Colitis

31. Robotic Colorectal Surgery

32. Robotic Surgery