ca recti miles operation abdominalperinealresection
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• Czarny (1884) Reseksi rektum pertama kali dengan teknik abdominoperineal resection (APR).
• Kraske (1885) Transacral approach untuk reseksi anastomosis rektum.
• Miles (1908) zone of upward spread eksisi luas perineal, termasuk rektum di rongga pelvis, rektum intra abdomen dengan pengikatan arteri tinggi, serta kgb iliaca (mortalitas >42%)
• William Heald total mesorectal excision
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• Panjang rektum 15 cm, berawal dari rectosigmoid junction, ditandai dengan bergabungnya taeniae coli dalam lapisan otot sirkuler, sampai dengan anal canal.
• Bertransisi dari organ intraperitoneal menjadi ekstraperitoneal, 6–8 cm dari anus.
• Difiksasi di bagian posterior dan lateral oleh fascia Waldeyer. • Pada laki-laki, bagian anterior rektum terfiksir ke fascia
Denonvillier, sebuah lipatan dari 2 lapis peritoneum yang memisahkan rektum dari prostat posterior dan vesicula seminalis.
• Pada perempuan, kavum peritoneum berlanjut menjadi kavum Douglas yang anteriornya berbatasan dengan cervix dan posterior berbatasan dengan pertengahan rektum.
• Bila dilihat dengan endoskopi, rektum mempunyai 3 valves of Houston, dimana bagian tengahnya berhubungan dengan refleksi peritoneum anterior.1.2.3
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• Kebanyakan ahli bedah mendeskripsikan kanker rektum berdasarkan jarak lesi dari anal verge
• Landmark yang lebih dapat dipercaya adalah dentate line, ujung distal dari rektum.
• Anal canal dimulai dari high-pressure zone yaitu proksimal dari cincin anorektal, sebuah struktur muskuler yang terdiri dari sfingter interna, sfingter eksterna, dan puborektalis.
• Zone ini melanjutkan diri ke linea dentata sampai perbatasan mukosa anus dan kulit perianal (anal verge).
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• A. Rectalis superior a. Meseterika inferior. memperdarahi mesorektum dan rektum proksimal dan medial.
• A. Rectalis media a.iliaca interna, hanya ditemukan pada 22% kadaver. Bila ada, a.rectalis media ini berada dekat lateral rektum, yang sering sulit dibedakan dengan persarafan.1,3
• A. Rectalis inferior a. Pudendalis interna berjalan posterolateral dan memperdarahi sfingter ani dan epitelium.
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• V. rectalis superior rektum proksimal dan
medial sistem portal melalui v. Mesenterica inferior.
• V. rectalis media rektum distal v. Iliaca interna.
• V. Rectalis inferior anal canal menglairkan darah ke v. Iliaca interna melalui v. pudenda.
• Karena adanya hubungan antara sistem vena, maka kanker rektum distal dapat menyebar melalui sirkulasi portal dan sistemik.
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• KGB dari rektum proksimal dan medial mengalir ke KGB mesenterium inferior.
• KGB dari rektum distal mengalir ke sistem mesentrium inferior atau ke KGB sekitar a. Rectalis medial dan inferior, di posterior a. Sacralis medial, dan di anterior melalui celah septum retrovesical atau rectovaginal, menuju KGB iliaca dan akhirnya menuju KGB paraaorta.
• Kelenjar limfe dari anal canal diatas linea dentata mengalir ke KGB rectalis superior menuju KGB mesenterium inferior dan ke lateral menuju KGB obturator dan iliaca interna.
• Dibawah linea dentata, cairan limfe mengalir ke KGB inguinalis dan mungkin mengalir juga ke KGB rektalis inferior atau superior.1,3,4
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Fascial planes. (from Michelassi F, Milsom JW (eds). Operative Strategies in Inflammatory Bowel Disease. New York: Springer-Verlag, 1999.)
Fascial planes. (from Michelassi F, Milsom JW (eds). Operative Strategies in Inflammatory Bowel Disease. New York: Springer-Verlag, 1999.)
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B. Mobiliation of sigmoid (L-side)
C. Identify (L) spermatic or
ovarian vein & ureter
D. Mobiliation of sigmoid (R-side)
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E, F. Identify & Divide the IMA
G. Identify the presacral nerve
At the level just below the promontory, these nerves
bifurcate
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K. Anterior mobilization of Rectum
Men : plane between the seminal vesicles & Denonviller fascia
Women : plane between rectum & vagina
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MSV : Middle sacral vein
LSV : Lateral sacral vein
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