7/29/2019 Techniques Offered Rectal Cancer Surgery

1/2

Rectal Cancer Surgery

Surgeons discovered ways to cure rectal cancer nearly a century ago. Until recently thiscure carried with it the loss of the anus and the need for a permanent colostomy. Several

technical advances have allowed us the preserve the sphincter in most patients

undergoing surgery for rectal cancer. A very important one is preoperative staging withultrasound or MRI and neoadyuvant therapy (hyperlink to patient conditions/colorectal

cancer/preop staging rectal cancer). This has allowed doing less extensive surgery in

favorable lesions and preserving the sphincter in low lying rectal cancers by clearing themargins around the tumor so less needs to be removed. Another significant progress is in

instrumentation. The pelvis is a bony structure that hides the rectum away from the

surgeon. The bottom 5 cm of rectum is easily reachable through the anus and the top 5

cm is accessible through the abdomen. The challenge is with the middle 5 cm. Creatingexposure around this middle rectum, controlling blood vessels from bleeding, dividing

the rectum for removal and reconnecting were insurmountable obstacles until proper

instruments were developed. Better exposure of the pelvis, either laparoscopically or

through open surgery, has enabled us to do a more complete dissection and removal ofthe lymph nodes around the rectum, namely a total mesorectal excision.

Two of the instruments are the linear and the circular stapler.

Another advancement in surgery for rectal cancer has been the creation of an internalpouch to provide a reservoir for stool and reduce the frequency of stools. The rectum is

not just the end of the colon. It has distinctive features that allow for adequate continencewhich is defined as the ability to defer bowel movements for when it is sociallyconvenient. In order to accomplish this goal the rectum accepts volume without elicit

expulsion and this is called accommodation. In order for the colon, or ileum, to do the

same we first create a connection between two segments of bowel. In doing so we cutthrough the nerve plexus that elicit the contractions on the colon and threby this new

double segment can accommodate stool and provides better continence.

7/29/2019 Techniques Offered Rectal Cancer Surgery

2/2

Even if a pouch can be created successfully and a connection is made between the pouchand the anus a temporary ileostomy is usually added to the procedure. This is done to

prevent stool and bacteria from traversing the fresh connection before it is completelyhealed. The ileostomy is usually reversed in 8 to 12 weeks.

Tumors in the upper and middle rectum are treated by a low anterior resection of therectum meaning that the rectum is extracted through the abdomen and this can be done

either through the traditional open approach or laparoscopically. I chose to use a hand

port up and down the navel for extraction of the specimen.

Tumors in the lower rectum and even some in the middle rectum can be treated bytransanal excision of the meet certain criteria: on biopsy the cells are not very aggressive

(well differentiated) and preoperative staging by either transrectal ultrasound or MRI

shows a superficial lesion T1 and no regional lymph nodes. Special instruments are used

to created exposure inside the rectum and the tumor is excised with a margin of healthytissue. The gap created by this excision usually involves all layers of the rectum and

usually needs closure with either staples or sutures.