the surgery for rectal cancer
DESCRIPTION
Nick RiegerAssociate ProfessorUniversity of AdelaideSouth AustraliaTRANSCRIPT
The Surgery for Rectal Cancer
Nick RiegerAssociate Professor
University of Adelaide
South Australia
Surgical considerations“What is a surgeon thinking”
• The patient
• The tumour
• Preoperative chemoradiotherapy
• The Operation (TME)
• Postoperative dysfunction
• Postoperative chemoradiotherapy
The Patient
• Age
• Sex Male vs Female
• Build (BMI)
• Co-morbidities
• Cognition
• Ability to manage a Stoma
The Tumour
• Height from anal verge• Circumferential relationships• Size• Tumour depth (T stage)• Distant metastasis• Rectal examination• Imaging
CT, MRI, ENUS
Rectal Anatomy15
cm
High Anterior Resection
Low Anterior Resection
Ultralow Anterior Resection
Abdominoperineal Resection
Endorectal Ultrasound
MRI
Rectal cancer
• Cooperative trials
• Local recurrence rates 25-35%
• NIH consensus adjuvant chemotherapy and radiotherapy for T3 and N1 rectal adenocarcinoma
• Wide surgeon variability for Local Recurrence and Survival.
Pre-operative Chemoradiotherapy
Before After
Pre-operative Chemoradiotherapy
• T3 / T4 Tumours
• Down stage tumour
• Long course (5-6 weeks)
• Short course (1 week)
• Reduced local recurrence
• Improved survival
Total Mesorectal Excision
• An operation for Rectal Cancer
• Low rate of Local Recurrence after “curative” resection.
• The term initially introduced by Bill Heald (UK) in 1982
• Many surgeons had practised this concept of surgery prior to the introduction of the term “TME”
Bill Heald
• Archives of Surgery 1998
• 405 curative resections / No radiotherapy
• Local Recurrence 3% at 5 years
• Local Recurrence 4% at 10 years
• Disease free survival 80% at 5 years
• Disease free survival 78% at 10 years
Local RecurrenceWhat is Important?
• Circumferential margins
• Distal margin
• Removal mesorectal envelope containing all the lymph nodes
• Cytocidal rectal washout
• Radiotherapy - pre and post operative
• YOUR SURGEON
TME
• Rectal cancer spreads to lymph nodes in the mesorectum
• This may be in nodes below the inferior margin of the cancer
• Particularly relevant in cancers of the middle and lower thirds of the rectum
TME
TME
TME Leak Rate
• Karanjia, Heald et al BJS 1994• 219 LAR with TME• Major leak (abscess or
peritonitis) 11%• Minor leak (contrast enema)
6.4%
TME
• Nerve preservation (sexual and bladder function)
• Low anastomosis - Reduced APR
• Low anastomosis - Colonic pouch
• Higher anastomotic leak rate
• Higher rate covering stoma
• ? Negates the need for routine use of radiotherapy
Modified TME• Distal spread of adenocarcinoma either in the
rectal wall or mesorectum greater than 2-3 cm is rare.
• When it occurs it is with advanced tumours and associated with a poor prognosis.
• The need to remove the mesorectum more than 5 cm below the tumour is not proven and unnecessary and will increase the rate of anastomotic leakage (devascularised rectal stump)
Modified TME
5 cm
5 cm
Rectal Ultrasound
The TechniquePre-operative
• Consent
• Bowel preparation
• Stomal therapy and siting for stoma
• DVT prophylaxis
• Antibiotics
• Urinary catheter
The TechniqueSet-up
• Extended Lloyd-Davies position
• Good assistance
• Long midline incision
• Wide retraction
• Small bowel packed out of the way
• Full laparotomy (liver etc)
Operative Position
The TechniqueColonic Mobilisation
• Transverse, Splenic flexure and Descending colon mobilised
• High ligation inferior mesenteric artery on the aorta
• High ligation inferior mesenteric vein at the lower border of the pancreas
• Preservation of ureter, gonadal vessels, and hypogastric nerves
Mobilisation Sigmoid Colon“Ureter”
Splenic Flexure Mobilised
High Ligation Inferior Mesenteric Artery
Ligation Inferior Mesenteric Vein and Exposure of the Spleen
Full Bowel Mobilisation
The TechniquePosterior Rectal Dissection
• Develop the plane at the pelvic brim anterior to the hypogastric nerves and posterior to the superior rectal artery.
• Enter the areolar space between the mesorectal fascia and the sacral fascia.
• Do not “cone in” on the mesorectum
• Sharp dissection or diathermy
• Avoid blunt dissection
• St Marks retractor
St Mark’s Retractor
The TechniquePosterior Rectal Dissection
The TechniquePosterior Rectal Dissection
The TechniqueAnterior Rectal Dissection
• Divide the anterior peritoneum of rectovesical or rectouterine pouch above and anterior to its apex
• Develop the plane between the seminal vesical or vagina anterior to Denonvilliers fascia
• Continue dissection to pelvic floor
The TechniqueAnterior Rectal Dissection
The TechniqueTransection of Rectum
• Mesorectum at least 5 cm below tumour (modified TME) or at pelvic floor.
• Cross clamp or staple below tumour
• Rectal cytocidal washout
• 30 mm stapler at least 2 cm below the tumour
• Haemostasis
Transverse Staple Line Rectal Stump
The TechniquePreparation Proximal Bowel
• Ligation mesocolon vessels preserving the marginal artery
• Avoid using the sigmoid colon
• Use the descending colon
• Fashion colonic pouch if ULAR
• Insert purse-string suture and head of circular staple gun
The TechniquePreparation Proximal Bowel
The TechniquePreparation Proximal Bowel
The TechniquePreparation Proximal Bowel
Transected Bowel
Staple Gun Head
The TechniqueAnastomosis
• Ensure colon not twisted
• Ensure vagina excluded
• Double staple anastomosis
• Check donuts and Air test
• Haemostasis
• Drain pelvis
• Loop ileostomy
Mid-rectal AnastomosisInserting the Staple Gun
Midrectal Anastomosis
Resected Specimen
Low anterior resection Abdominoperineal resection
Summary
• TME associated with low rate of local recurrence
• Requires meticulous technique and a surgeon familiar with operating in the pelvis
• Modified TME acceptable for high and mid rectal tumours.
TEMPORARY STOMA(Ileostomy)• Dependant on:• Height of anastomosis• Ease and technical success
of operation• Well being of the patient
(co-morbidities)• Surgical conservatism• Radiation
PERMANENT STOMA(Colostomy)• Dependant on:• Height of tumour from
anal canal• Likelihood of continence
Laparoscopy
Postoperative Adjuvant Therapy
• Multi-disciplinary meeting
• Chemotherapy
• Radiotherapy
• Age and well-being of the patient
• Tumour factors
Postoperative Bowel Function
• Rectum acts as a reservoir• Removal leads to replacement with
a colonic conduit (neorectum) • “Anterior resection syndrome”• Frequent loose stool, stool
clustering, urgency, occasional incontinence
• Colonic “J” Pouch
Conclusions
• Results of surgery operator dependent
• “Good” surgery must account for the nuances of the patient and the tumour
• Multidisciplinary approach