BYDr. G .MADHU KUMAR

UNDER THE GUIDANCE OF DR. P. NANCHARAIAH

The large intestine is formed by the following anatomic entities:

Ileocecal valve Appendix Cecum Ascending colon Hepatic flexure Transverse colon Splenic flexure Descending colon Sigmoid colon Anorectum

Right and left colon are considered

retroperitoneal

Transverse and sigmoid colon are

intraperitoneal structures

First surgical step is mobilization of the

colon and its mesentery

arterial blood supply to the colon superior mesenteric artery inferior mesenteric arterycommunicate in a watershed area in the

splenic flexure (artery of Drummond)

Arterial blood supply to the rectum Extensive intramural anastomoses between

the superior, middle, and inferior rectal arteries

superior rectal artery originates from the inferior mesenteric artery

middle, and inferior rectal arteries arise from internal iilac artery

Lymphatics of colon

superior mesenteric, and the inferior

mesenteric groups of lymph nodes

Lymphatics of Rectum

inferior mesenteric nodes

iliac nodes

Specific cause of colorectal cancer is not

known many

Genetic and environmental risk factors

have been identified.

GENETIC RISK FACTORSENVIRONMENTAL RISK

FACTORS

Sporadic colon cancer -

Chromosomal deletions, K-

ras, DCC, p53, APC

Familial polyposis

syndromes - Polyps start

after age 10–20, cancer in

100% at age 40

Hereditary nonpolyposis

colon cancer

Inflammatory bowel disease

Geographic variation

Age

Diet

Physical inactivity

Colorectal cancer refers to cancer

originating in the colon or rectum and can

develop in any of the four sections

Colorectal cancer develops slowly over a

period of years (~10-15 yrs)

Colorectal cancer begins usually as a polyp

A polyp is a growth of tissue that starts in the lining and grows into the center of the colon or rectum

Over 95% of colon and rectal cancers are adenocarcinomas

Adenocarcinoma

Mucinous adenocarcinoma

Signet ring cell carcinoma

Small cell carcinoma (oat cell)

Small cell adenosquamous carcinoma

Squamous cell carcinoma

Undifferentiated carcinoma (medullary)

Cancer occurs when cells grow and divide without regulation and order (Stage 0, I, and IIA)

Metastasis occurs when cancer cells break away from a tumor and spread to other parts of the body via the blood or lymph system (Stage IIB, III, and IV)

Staging is a standardized way that describes the spread of cancer in

relation to the layers of the wall of the colon or rectum, nearby lymph

nodes, and other organs

The stage is dependent on the extent of spread through the different

tissue layers affected

The stage is an important factor in determining treatment options and

prognosis

• One of the major staging systems in use is the AJCC (American

Joint Committee on Cancer) staging scheme, which is defined in

terms of primary tumor (T), regional lymph nodes(N), and distant

metastasis (M)

T Categories: Describes the extent of spread of the primary tumor (T) through the layers of tissue that form the wall of the colon and rectum

• Tis: Cancer is in its earliest stage, has not grown beyond mucosa. Also known as carcinoma in situ or intramucosal carcinoma

• T1: Cancer has grown through mucosa and extends into submucosa

• T2: Cancer extends into thick muscle layer

• T3: Cancer has spread to subserosa but not to any nearby organs or tissues

• T4: Cancer has spread completely through wall of the colon or rectum into nearby tissues or organs

N categories: describes the absence or

presence of metastasis to nearby lymph

nodes (N)

• N0: No lymph node involvement

• N1: Cancer cells found in 1-3 regional

lymph nodes

• N2: Cancer cells found in 4 or more

regional lymph nodes

M Categories: describes the absence or

presence of distant metastasis (M)

M0: No distant spread

M1: Distant spread is present

Lymph nodes are

small, bean shaped

structures that form

and store white blood

cells to fight infection.

An iceball in a

patient with a

metastases from

a colon cancer

receiving

cryosurgery

treatment

Stage TNM Category Survival

Rate

Stage 0: Tis, N0, M0 The earliest stage. Has not grown beyond inner layer (mucosa) of colon or

rectum.

Stage I: T1, N0, M0

T2, N0, M0

93% Has grown into submucosa (T1) or muscularis propria (T2)

Stage IIA:

Stage IIB:

T3, N0, M0

T4, N0, M0

85%

72%

IIA: Has spread into subserosa (T3).

IIB: Has grown into other nearby tissues or organs (T4).

Stage IIIA:

Stage IIIB:

Stage IIIC:

T1-T2, N1, M0

T3-T4, N1, M0

Any T, N2, M0

83%

64%

44%

IIIA: Has grown into submucosa (T1) or into muscularis propria (T2) and

has spread to 1-3 nearby lymph nodes (N1)

IIIB: Has spread into subserosa (T3) or into nearby tissues or organs (T4),

and has spread to 1-3 nearby lymph nodes (N1)

IIIC: Any stage of T, but has spread to 4 or more nearby lymph nodes (N2).

Stage IV: Any T, Any N, M1 8% Any T or N, and has spread to distant sites such as liver, lung, peritoneum

(membrane lining abdominal cavity), or ovaries (M1).

Open procedures

Laparoscopic procedures

Robotic surgical procedures

They were started as perineal resection and later were modified to abdominoperineal resection

First perineal resection was done by :: FAGET [ 1739 ]

Later LISFRANC have done 9 perinealresections in series of which 3 died due to sepsis

PAUL KRASKE (1885)

First procedure with resection and

anastomosis

Posterior incision including removal of the

coccyx

Healing was often disturbed and frequently

resulted in rectal fistulas

Maunsell (1892)

Abdominal procedure in which the colon

was pulled through the anus and a

coloanal anastomosis constructed.

Poor anorectal function

KOCHER (1874)

Resection of os coccyx in combination with

perianal phase

Better exposure

Less blood loss

Better lymph node dissection

Less wound infections

MILES (1908) Described abdominoperineal excision

Postoperative mortality of 10% and a local recurrence rate of 30%

It has been treated as gold standard for several decades

But over past 30 years the incidence of APE has decreased due to high recurrence rates

HENRY A HARTMANN (1860-1952)

Rectosigmoid resection and closure of

the rectal stump and colostomy

Still popular

CUTHBERT DUKES - (1890-1977)

Classification of the rectal cancer

Dixon and Best (1940)

Popularised the sphincter saving operation

Anterior resection of the rectum

Lazorthes and Parc (1986)

The J-pouch anastomosis

to improve functional outcome

Z´graggen

Coloplasty

Mechanical staplers

Circular staplers it has become possible to

perform an anastomosis all the way down

to the pelvic floor

Single stapling technique has evolved into

the double stapling and the triple stapling

techniques

Heald (1982)

Total mesorectal excision (TME)

sharp dissection under direct vision in

embryological avascular planes, excising

the rectum together with an intact

mesorectum covered posteriorly and

laterally by the mesorectal fascia

sphincter saving excision

Complication anastomotic leakage

A diverting loop ileostomy was done to

prevent anastomotic leakage

wider lateral excision, aimed at resecting

the so-called lateral lymphnodes was

proposed

Increased urogenital morbidity

Buess (1985)

Transanal Endoscopic Microsurgery

Medically frail patients

Palliative

Primary treatment objective to prevent

local tumor complications, i.e., obstruction,

perforation, bleeding, and pain

Even in the presence of distant

metastases in the liver or lung, resection is

done.

Restoring the intestinal continuity is the

best palliation

Standard Resections of the Colon

Tumor Location Resection Description of Extent Major Blood Vessel Safety Margin

Cecum Right hemicolectomy Terminal ileum to mid transverse colon, right flexure included

Ileocolic artery, Right colic artery, Right branch of mid colic artery

5 cm

Ascending colon Right hemicolectomy Terminal ileum to mid transverse colon, right flexure included

Ileocolic artery, Right colic artery, Right branch of mid colic artery

5 cm

Hepatic flexure Extended right hemicolectomy

Terminal ileum to descending colon (distal to left flexure)

Ileocolic artery, Right colic artery, Mid colic artery

5 cm

Transverse colon Extended right hemicolectomy

Terminal ileum to descending colon (distal to left flexure)

Ileocolic artery, Right colic artery, Mid colic artery

5 cm

(Transverse colon resection)

Transverse colon (including both flexures)

Mid colic artery

Splenic flexure Extended left hemicolectomy

Right flexure to rectosigmoid colon (sigmoid, beginning of rectum)

Mid colic artery, Left colic artery, Inferior mesenteric artery

5 cm

Descending colon Left hemicolectomy Left flexure to sigmoid colon (beginning of rectum)

Inferior mesenteric artery, Left branch of mid colic artery

5 cm

Sigmoid colon Rectosigmoid resection

Descending colon to rectum Superior hemorrhoidal artery, Inferior mesenteric artery

5 cm

open procedures were combined with

radiotherapy

Local recurrence with

Surgery alone : 29%

Surgery combined with radiotherapy : 11%

In late 80’s the success of laparoscopic

gall bladder procedures has laid

foundation for its use in laparoscopic colo

rectal surgeries

Now it has become the main stay of

colorectal surgeries

ADVANTAGES

Less blood loss

Early return of the intestinal motility

Lesser duration of hospital stay

Early ambulation of the patient

In the early post operative period the

patients have shown better reserve of

cellular immune response

DISADVANTAGES

Prolonged duration of surgery

Need for technically expertised people

More costly

Most common – increased chances of

recurrence at the port site

Chances of recurrance if the tumor is handled

many times during the surgery

Risk of vascular injuries as all the

abdominal quadrants are made involved

The laparoscopic approach to colectomy is slowly gaining acceptance for the management of colorectal pathology

Considered reasonable in a palliative setting

Recent studies suggests very less port site recurrences

Moderate quality-of-life benefit but otherwise no difference in outcome and survival between

3 – 4 trocars are inserted

Colon should be mobilized to the same

extent as during open surgery

Vascular pedicle is identified and

transected

Large bowel exteriorized through a small

but sleeve-protected abdominal incision

Extra-abdominal resection and

anastomosis are performed

Preservation of the autonomic nerves is also possible during laparoscopic TME

Technical feasibility of performing laparoscopic TME was demonstrated in several prospective studies

Complete resection of the mesorectumwith intact visceral fascia

For rectal cancer, laparoscopic technique can be more complex depending on the tumor location

In contrast to open and laparoscopic procedures , the robotic surgical procedure gives a high definition 3-D imaging with articulating instruments that mimic human hand

It is more helpful in operating in narrow areas as that for rectum

Hence robotic TME ( TOTAL MESORECTAL EXCISION ) is more safer than open and laparoscopic TME

The acceptance of these MINIMALLY INVASIVE TECHNIQUES by the surgeons and patients has been widely increasing now a days

But due to onchologic concerns application of this techniques to rectum is more slower

THANK YOU