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