Gross presentation –bowel loop

Anatomy Large bowel

• Forms three sided frame around SI leaving inferior area open to the pelvis.

• Approx. 1.5 m in length & extend from lleum to anus.

• Diameter dec from caecum (7cm) to sigmoid colon (2.5cm).

• Divided into 4 segments-cecum,colon,rectum & anus.

Types of bowel resection

• Total colectomy.• Right hemicolectomy.• Transverse colectomy. • Left hemicolectomy.• Low anterior resection.• Abdominoperineal resection.

Procedure

• Weigh & measure the specimen• Sample lymph nodes, & remove the mesentry

while the specimen is fresh.• Two options are there:-

A) Open the bowel longitudinally, pin on a corkboard & fix it overnight.

B)Injecting formalin through one end when the other end is tied, then tying off the injected end.

• Take photographs .• In cases with deep penetration by tumor,

dissect the veins carefully for possible tumor invasion.

Description • Part of bowel removed & length of specimen .• Mucosa- type of lesion,extent,ulceration(linear or

transverse),depth, pseudoplyps,hemorrhage,fissures.• Wall thickening (focal or diffuse),atrophy ,fibrosis,

necrosis.• Serosa- fibrin, pus,fibrosis,adherence of mesentry.• Diverticulum- number, size, location in relation to

teniae,content, evidence of inflammation, hemorrhage or perforation.

Description for tumor

Tumor • size (including thickness).• Shape (fungating,flat,ulcerating)• Extent through bowel wall• Serosal involvement,satellite nodules.• Areas of necrosis & hemorrhage.• Evidence of blood vessel invasion & invasion of

adjacent organs.

• Distance of tumor to each line of resection. • Estimate the no. of lymph nodes found,

whether or not nodes appear to be involved by tumor, size of largest node.

Sections for histology

For non tumoral conditions:-• As many as necessary to sample abnormal areas.• Proximal & distal lines of resection in cases of colitis.• Appendix, if included in specimen.

For tumoral conditions:-• 3 sections from tumor.• Representative section of subserosal connective

tissue, fat & blood vessel around tumor.• Both surgical margins.• Bowel b/w tm & distal line of resection.

• Appendix if included in the specimen.

• Lymph nodes:-

A) around tumor.

B)distal to tumor.

C)proximal to tumor.

D)at high point of resection(areas surrounding ligated vessels)

• In abdominoperineal resections:- anorectal junction.

Meckels diverticulum

Crohns disease

Ulcerative colitis Pseudo polyps

Tuberculosis Typhoid

Mesentric embolism Carcinoid tumor

Diverticular disease Diverticulitis

Chronic ischaemic colitis

Pseudomembranous colitis

Amebic dysentery

Tubular adenoma

Villous adenoma

Familial polyposis coli

MELANOSIS COLI

Endometriosis

Ulcerating rectal carcinoma

Fungating rectal carcinoma

Annular stenosing rectal carcinoma

Caecal carcinoma

Hirschsprung disease

SPEAKER DR N. P. TIWARITHANK YOU