1. Carcinoma Rectum
A CASE PRESENTATION
DR. JOY ZAKHARIA RAB
ASSISTANT REGISTRAR
SURGERY UNIT – I
SBMCH,BARISAL.

2. Mr. Aiub Ali
65 yrs
Before operation

3. Case presentation
1. PARTICULARS OF THE PATIENT:
Name: Ayub Ali Date Admission: 29/08/09
Father’s name: Late Abdul Ali Hospital : SBMCH
Age: 65 years. Department : SU-I
Sex: male. Ward : 11
Marital status: married . Bed : 16
Religion: Islam.
Occupation: farmer
Social status : Poor
Address: Kawer Char
Barisal Sadar
Dist- Barisal

4. Case presentation
2. PRESENTING COMPLAINTS :
Weakness for 6 months
Feeling of incomplete defecation for 3 months
Pain or discomfort during defecation for same duration
Per rectal bleeding for 3 months

5. Case presentation
3. HISTORY OF PRESENT ILLNESS:
According to the statement of the patient he was quite
well 6 months back. Since then he developed nausea
and found himself unwilling to do any daily activities
due to unusual weakness. He went to village doctor
who advised him some vitamin tablets but these were
not very fruitful to overcome his weakness or nausea.
Then after 3 months he noticed passing of hard stool
followed by small amount of bleeding at end of
defecation.

6. Case presentation
3. HISTORY OF PRESENT ILLNESS:
He ignored this bleeding and thought this may
be due to constipation. But after few days he
felt abdominal cramp which made him to get up
early in the morning due to urge for defecation
but only some amount of muciod watery stool
came out which could not satisfy his defecation
urge, as well as passage of rectal bleeding didn’t
stop. And for last 15 days rectal bleeding
worsened so he came to our hospital for better
management.

7. Case presentation
4. HISTORY OF PAST ILLNESS:
HTN.
5. PERSONAL HISTORY:
Diet habit :
He took high fibre and roughage
Vegetables almost daily
Less animal fat
Red meat usually once in a month
Nonsmoker
Nonalcoholic .
6. FAMILY HISTORY:
None of His family members were suffering from this type of disease

8. Case presentation
7. DRUG HISTORY:
Anti-hypertensive:
Tenoren
Amdocal
Syp. Antacid
8. HISTORY OF IMMUNIZATION: Not Completed.

9. Case presentation
9. GENERAL EXAMINATION:
Appearance: ill looking Anemia : present
Height : 5 ft. 2 inches Jaundice : absent.
Weight : 50 kg. Edema : absent.
Body build : Below average. Pulse : 80/min.
Decubitus : on patient’s choice. B.P :160/100mm/Hg.
Dehydration: absent
Temp. : 98`F
Enlarged lymph node: absent.
Nutrition : below average. RR : 22 breaths/min.

10. Case presentation
10. SYSTEMIC EXAMINATION:
THE ABDOMEN
A. INSPECTION:
Shape : Scaphoid
Flanks : not full.
Umbilicus : normal, centrally placed.
Visible vein : absent.
Visible pulsation : absent.
Visible peristalsis : absent.
Visible swelling : absent.
Hernial orifices : intact.
Scar : absent.

11. Case presentation
The Abdomen cont ...
B. PALPATION:
1. SUPERFICAL PALPATION:
Local temperature : not raised.
Tenderness : absent.
Muscle guard/Rigidity : absent
2. DEEP PALPATION:
Liver : not enlarged.
Gallbladder : non palpable.
Spleen : non palpable .
Kidneys : kidneys were nonballotable.

12. Case presentation
The Abdomen cont ...
C. PERCUSSION :
Percussion note : Normal.
D. AUSCULTATION :
Bowel sound : normal.
E. DRE FINDINGS : an annular growth encircling the whole
circumference of the rectum which was hard in consistency with
irregular margin associated with multiple small polypoid lesion
around the growth which seems to be fixed with the surrounding
muscles and involving the anal sphincter was found about 3 cm
from the anal verge.

13. Case presentation
11. OTHER SYSTEMS EXAMINATION :
Cardiovascular system : normal.
Respiratory system : normal.
Nervous system : normal.
Genito Urinary System : normal.

14. Case presentation
12. CLINICAL DIAGNOSIS:
Carcinoma of rectum

15. Case presentation
13. INVESTIGATIONS :
A. COMPLETE BLOOD COUNT:
 Total Count : 8000/ cmm of blood
 Differential Count :
Neutrophil – 57%
Lymphocyte count – 37%
Mono cyte- 01%
Eosinophil – 05%
Basophil – 00%
 Hb% : 50%.
 ESR : 40 mm in 1st hour.
(anaemia was corrected by 2 unit blood transfusion)
B. BLOOD FOR RBS AND SERUM CREATININE:
RBS – 310 mg/dl
112 mg/dl after control with inj. insulin
Creatinine – 0.9mg/dl

16. Case presentation
Investigations cont …
C. URINE FOR RME:
Color – Straw
Appearance – Clear
Albumin – absent
Epithelial cells – (2-4) / HPF
RBC – Nil
Pus Cells – (1-2) /HPF
D. PLAIN X-RAY OF CHEST P/A VIEW: Normal

17. Case presentation
Investigations cont …
F. USG OF WHOLE ABDOMEN (01/09/2009)
Liver: An echogenic area with surrounding halo is seen in
posterior superior quadrant of right lobe of liver near
gall bllader.
All other viscera were normal and no lymphadenopathy or
ascites
Impression: suggestive of SOL of liver.
most possibly 2ndary

18. Case presentation
Investigations cont …
G. Proctoscopic biopsy:
 Proctoscopic biopsy was taken from the
annular rectal growth and after proper
preservation and labelling was sent for
hislogical examiantion.
 Histological examination revealed –
adenocarcinoma, moderately differentiated.
( Colonoscopy & CEA – not done)

19. Case presentation
15. TREATMENT
Plan Of Treatment :
Abdominoperineal excision
Ratinonale: The growth was 3 cm from the anal verge and
involving the sphincter
Pre Operative Preparation :
The pt. was made fit for general anesthesia with proper
diet, nutrition , blood transfusion and adequate glycaemic control
with inj. insulin and control of BP with anti- hypertensive and
required investigations were done.
Two units of fresh human blood were arranged for operation.

20. Case presentation
15. TREATMENT
 Bowel preparation:
 NPO from 10 pm (day before surgery)
 Inf. Hartman’s solution 1000 ml: IV @ 10 drop/min
 Inj. Ciprofloxacin 500 mg: IV bd
 Inj. Metronidazole 400 mg: IV tds
 Inj. Mannitol: 250 ml orally at 5pm
125 ml orally if necessary at 6 pm
 Enema Simplex: at 10 pm (day before surgery)
at 7 am ( on day of surgery)
 Consent :
1. An informed written consent was taken from the pt. and his wife for
abdomenoperineal excision along with permanent colostomy in left iliac
fossa under general anesthesia.
2. Patient and his wife was briefed about management of colostomy.

21. Case presentation
Treatment ( Surgical management ) cont …
OPERATION NOTE :
Venue : General OT in SBMCH, Barisal.
Date : 25/10/2009.
Time : 11:30 am.
Indication : carcinoma rectum.
Name of operation : abdomenoperineal excision
with permanent end colostomy.
Name of anesthesia : GA with endotracheal intubation.
Name of Surgeon : Prof. A M S M Sharfuzzaman.
FCPS, MRCS (Edin)
Dr. Zahurul Haq FCPS (surgery)
Assistant Professor, Surgery

22. Case presentation
Treatment ( operation note ) cont …
 Position:
Trendelenburg lithotomy position (with urinary catheter in
situ)
 Incision:
Abdominal surgeon – made a midline incision
Perineal surgeon – made an elliptical incision between
the coccyx and the central perineal point, around anus.

23. Case presentation
15. TREATMENT
Procedure and findings :
 With all aseptic precaution abdominal surgeon opened the
abdomen through a midline incision. Liver and peritoneal
cavity was assessed for any metastasis. Which was not found.
So decision for curative Total mesorectal excision was taken
 Coils of small intestine was packed using mops to keep them
away from the pelvic cavity. Retractors were used for proper
exposure and sigmoid colon was freed by dividing the
peritoneal reflection on the left side.
 The sigmoid colon was mobilized to the midline on its
mesentry, and the left ureter and testicular vessels were
identified and secured.

24. Case presentation
Treatment ( operation note ) cont …
 The mesocolon was divided at the site of proposed
division of the colon and the inferior mesenteric artery
ligated and divided distal to the first sigmoidal branch.
 Then the sigmoid colon at this point, is cut in between the
intestinal clumps. Peritoneal fold over the rectosigmoid
junction is divided to make it free. Middle rectal artery
was ligated and divided. Median sacral artery were also
secured. Sigmoid colon and rectum were freed from the
pelvic cavity by both sharp and blunt dissection
preserving the nerves of sacral plexus.

25. Case presentation
Treatment ( operation note ) cont …
 The perineal surgeon closed the anus with purse-string sutures
using no. 1 cutting body silk.
 An elliptical shaped incision around the anus through the
transverse perineal muscle anteriorly and levator ani muscle
posteriorly and keeping the dissection line away from the
prostate and urethra through Denonviller’s fascia.
 The left forefinger was insinuated into the levator ani, which was
divided lateral to the finger, first on one side then on another
side. Dissecting the Waledeyer’s fascia by diathermy and
scissors, then contact was made with the abdominal surgeon.
The apex of the skin anterior to the anus was grasped by artery
forceps acting as a retractor. The wound was deepened by
dissection by diathermy, scissors and gauge. When the catheter
within the membranous urethra was felt, a plane of cleavage was
formed between the rectum and prostate.

26. Case presentation
Treatment ( operation note ) cont …
 Denonviller’s fascia was divided after which the rectum
was separated from the prostate. The abdominal surgeon
freed the rectum from pelvic cavity. Whole of the
anus, rectum and part of the sigmoid colon was drawn
downwards and removed through the perineal wound.
 Haemostasis was done using diathermy, ligation and hot
mopping. The perineal muscle was closed in layers with
1/0 round body vicryl. Skin was closed with 2/0 cutting
body silk. A drain was applied in the peritoneal cavity
through the right ischeorectal fossa.

27. Case presentation
Treatment ( operation note ) cont …
 A permanent end colostomy was made 2.5 cm above the
left spino-umbilical line.
 Peritoneal defects were sutured with 1/0 round body
catgut. Abdomen was closed in layers. Peritoneum
sutured by 1/0 catgut ,Linea alba by no. 1 prolene and skin
by 2/0 silk.
 Sterile dressings were placed on the abdominal and
perineal wound

28. Video of APER

29. Case presentation
Treatment ( operation note ) cont …
16. Postoperative period:
 NPO for 48 hours then food was given orally
 IV fluid for 48 hours
 IV antibiotic for 5 days
 IM analgesic for 48 hours then switched to oral formulation
 Colostomy was managed by colostomy bag
 Catheter – removed on 5th POD
 Perineal wound infection was noticed on 6th POD, stitches
were removed , and wound was managed by Seitz bath

31. Figure showing :
midline incision mark
colostomy bag in place (covering
The colostomy in left iliac fossa)

32. Figure showing:
Gap in the perineal wound
Which was later on managed by
Seitz bath

33. Case presentation
Treatment ( operation note ) cont …
18. DISCHARGE AND ADVICE :
Patient was advised to contact with radiotherapy
department on 15th post operative day for further
oncological surveillance.

34. THANK YOU ALL