various surgeries and how they developed

1. BY
Dr. G .MADHU KUMAR
UNDER THE GUIDANCE OF
DR. P. NANCHARAIAH

2.  The large intestine
is formed by the
following anatomic
entities:
 Ileocecal valve
 Appendix
 Cecum
 Ascending colon
 Hepatic flexure
 Transverse colon
 Splenic flexure
 Descending colon
 Sigmoid colon
 Anorectum

3. Right and left colon are considered
retroperitoneal
Transverse and sigmoid colon are
intraperitoneal structures
First surgical step is mobilization of the
colon and its mesentery

4.  arterial blood supply to the colon
 superior mesenteric artery
 inferior mesenteric artery
 communicate in a watershed area in the
splenic flexure (artery of Drummond)
 Arterial blood supply to the rectum
 Extensive intramural anastomoses between
the superior, middle, and inferior rectal
arteries
 superior rectal artery originates from the
inferior mesenteric artery
 middle, and inferior rectal arteries arise from
internal iilac artery

5. Lymphatics of colon
 superior mesenteric, and the inferior
mesenteric groups of lymph nodes
Lymphatics of Rectum
 inferior mesenteric nodes
 iliac nodes

6. Specific cause of colorectal cancer is not
known many
Genetic and environmental risk factors
have been identified.

7. GENETIC RISK FACTORS
ENVIRONMENTAL RISK
FACTORS
 Sporadic colon cancer -
Chromosomal deletions, K-
ras, DCC, p53, APC
 Familial polyposis
syndromes - Polyps start
after age 10–20, cancer in
100% at age 40
 Hereditary nonpolyposis
colon cancer
 Inflammatory bowel disease
 Geographic variation
 Age
 Diet
 Physical inactivity

8. Colorectal cancer refers to cancer
originating in the colon or rectum and can
develop in any of the four sections
Colorectal cancer develops slowly over a
period of years (~10-15 yrs)

9.  Colorectal cancer
begins usually as a
polyp
 A polyp is a growth of
tissue that starts in the
lining and grows into
the center of the colon
or rectum
 Over 95% of colon
and rectal cancers are
adenocarcinomas

10. Adenocarcinoma
Mucinous adenocarcinoma
Signet ring cell carcinoma
Small cell carcinoma (oat cell)
Small cell adenosquamous carcinoma
Squamous cell carcinoma
Undifferentiated carcinoma (medullary)

11.  Cancer occurs when
cells grow and divide
without regulation and
order (Stage 0, I, and
IIA)
 Metastasis occurs
when cancer cells break
away from a tumor and
spread to other parts of
the body via the blood
or lymph system (Stage
IIB, III, and IV)

12.  Staging is a standardized way that describes the spread of cancer in
relation to the layers of the wall of the colon or rectum, nearby lymph
nodes, and other organs
 The stage is dependent on the extent of spread through the different
tissue layers affected
 The stage is an important factor in determining treatment options and
prognosis
• One of the major staging systems in use is the AJCC (American
Joint Committee on Cancer) staging scheme, which is defined in
terms of primary tumor (T), regional lymph nodes(N), and distant
metastasis (M)

13.  T Categories: Describes the extent of
spread of the primary tumor (T)
through the layers of tissue that form
the wall of the colon and rectum
• Tis: Cancer is in its earliest stage,
has not grown beyond mucosa.
Also known as carcinoma in situ or
intramucosal carcinoma
• T1: Cancer has grown through
mucosa and extends into
submucosa
• T2: Cancer extends into thick
muscle layer
• T3: Cancer has spread to
subserosa but not to any nearby
organs or tissues
• T4: Cancer has spread completely
through wall of the colon or rectum
into nearby tissues or organs

14.  N categories: describes the absence or
presence of metastasis to nearby lymph
nodes (N)
• N0: No lymph node involvement
• N1: Cancer cells found in 1-3 regional
lymph nodes
• N2: Cancer cells found in 4 or more
regional lymph nodes
 M Categories: describes the absence or
presence of distant metastasis (M)
 M0: No distant spread
 M1: Distant spread is present
Lymph nodes are
small, bean shaped
structures that form
and store white blood
cells to fight infection.
An iceball in a
patient with a
metastases from
a colon cancer
receiving
cryosurgery
treatment

15. Stage TNM Category Survival
Rate
Stage 0: Tis, N0, M0 The earliest stage. Has not grown beyond inner layer (mucosa) of colon or
rectum.
Stage I: T1, N0, M0
T2, N0, M0
93% Has grown into submucosa (T1) or muscularis propria (T2)
Stage IIA:
Stage IIB:
T3, N0, M0
T4, N0, M0
85%
72%
IIA: Has spread into subserosa (T3).
IIB: Has grown into other nearby tissues or organs (T4).
Stage IIIA:
Stage IIIB:
Stage IIIC:
T1-T2, N1, M0
T3-T4, N1, M0
Any T, N2, M0
83%
64%
44%
IIIA: Has grown into submucosa (T1) or into muscularis propria (T2) and
has spread to 1-3 nearby lymph nodes (N1)
IIIB: Has spread into subserosa (T3) or into nearby tissues or organs (T4),
and has spread to 1-3 nearby lymph nodes (N1)
IIIC: Any stage of T, but has spread to 4 or more nearby lymph nodes (N2).
Stage IV: Any T, Any N, M1 8% Any T or N, and has spread to distant sites such as liver, lung, peritoneum
(membrane lining abdominal cavity), or ovaries (M1).

16. Open procedures
Laparoscopic procedures
Robotic surgical procedures

17. They were started as perineal resection
and later were modified to
abdominoperineal resection
First perineal resection was done by ::
FAGET [ 1739 ]
Later LISFRANC have done 9 perineal
resections in series of which 3 died due to
sepsis

18. PAUL KRASKE (1885)
First procedure with resection and
anastomosis
Posterior incision including removal of the
coccyx
Healing was often disturbed and frequently
resulted in rectal fistulas

19. Maunsell (1892)
Abdominal procedure in which the colon
was pulled through the anus and a
coloanal anastomosis constructed.
Poor anorectal function

20. KOCHER (1874)
Resection of os coccyx in combination with
perianal phase
 Better exposure
 Less blood loss
 Better lymph node dissection
 Less wound infections

21.  MILES (1908)
 Described abdominoperineal excision
 Postoperative mortality of 10% and a local
recurrence rate of 30%
 It has been treated as gold standard for
several decades
 But over past 30 years the incidence of APE
has decreased due to high recurrence rates

22. HENRY A HARTMANN (1860-1952)
Rectosigmoid resection and closure of
the rectal stump and colostomy
Still popular

23. CUTHBERT DUKES - (1890-1977)
Classification of the rectal cancer
Dixon and Best (1940)
Popularised the sphincter saving operation
Anterior resection of the rectum

24. Lazorthes and Parc (1986)
 The J-pouch anastomosis
 to improve functional outcome
Z´graggen
 Coloplasty

25. Mechanical staplers
Circular staplers it has become possible to
perform an anastomosis all the way down
to the pelvic floor
Single stapling technique has evolved into
the double stapling and the triple stapling
techniques

26. Heald (1982)
Total mesorectal excision (TME)
sharp dissection under direct vision in
embryological avascular planes, excising
the rectum together with an intact
mesorectum covered posteriorly and
laterally by the mesorectal fascia
sphincter saving excision

27. Complication anastomotic leakage
A diverting loop ileostomy was done to
prevent anastomotic leakage
wider lateral excision, aimed at resecting
the so-called lateral lymphnodes was
proposed
Increased urogenital morbidity

28. Buess (1985)
Transanal Endoscopic Microsurgery
Medically frail patients
Palliative

29. Primary treatment objective to prevent
local tumor complications, i.e., obstruction,
perforation, bleeding, and pain
Even in the presence of distant
metastases in the liver or lung, resection is
done.
Restoring the intestinal continuity is the
best palliation

30. Standard Resections of the Colon
Tumor Location Resection Description of Extent Major Blood Vessel Safety
Margin
Cecum Right hemicolectomy Terminal ileum to mid transverse
colon, right flexure included
Ileocolic artery, Right colic artery, Right
branch of mid colic artery
5 cm
Ascending colon Right hemicolectomy Terminal ileum to mid transverse
colon, right flexure included
Ileocolic artery, Right colic artery, Right
branch of mid colic artery
5 cm
Hepatic flexure Extended right
hemicolectomy
Terminal ileum to descending colon
(distal to left flexure)
Ileocolic artery, Right colic artery, Mid
colic artery
5 cm
Transverse colon Extended right
hemicolectomy
Terminal ileum to descending colon
(distal to left flexure)
Ileocolic artery, Right colic artery, Mid
colic artery
5 cm
(Transverse colon
resection)
Transverse colon (including both
flexures)
Mid colic artery
Splenic flexure Extended left
hemicolectomy
Right flexure to rectosigmoid colon
(sigmoid, beginning of rectum)
Mid colic artery, Left colic artery,
Inferior mesenteric artery
5 cm
Descending colon Left hemicolectomy Left flexure to sigmoid colon
(beginning of rectum)
Inferior mesenteric artery, Left branch
of mid colic artery
5 cm
Sigmoid colon Rectosigmoid
resection
Descending colon to rectum Superior hemorrhoidal artery, Inferior
mesenteric artery
5 cm

31. open procedures were combined with
radiotherapy
Local recurrence with
Surgery alone : 29%
Surgery combined with radiotherapy : 11%

32. In late 80’s the success of laparoscopic
gall bladder procedures has laid
foundation for its use in laparoscopic colo
rectal surgeries
Now it has become the main stay of
colorectal surgeries

33.  ADVANTAGES
Less blood loss
Early return of the intestinal motility
Lesser duration of hospital stay
Early ambulation of the patient
In the early post operative period the
patients have shown better reserve of
cellular immune response

34. DISADVANTAGES
 Prolonged duration of surgery
 Need for technically expertised people
 More costly
 Most common – increased chances of
recurrence at the port site
 Chances of recurrance if the tumor is handled
many times during the surgery
 Risk of vascular injuries as all the
abdominal quadrants are made involved

35. The laparoscopic approach to colectomy is
slowly gaining acceptance for the
management of colorectal pathology
Considered reasonable in a palliative
setting
Recent studies suggests very less port site
recurrences
Moderate quality-of-life benefit but
otherwise no difference in outcome and
survival between

36. 3 – 4 trocars are inserted
Colon should be mobilized to the same
extent as during open surgery
Vascular pedicle is identified and
transected
Large bowel exteriorized through a small
but sleeve-protected abdominal incision
Extra-abdominal resection and
anastomosis are performed

37. Preservation of the autonomic nerves is
also possible during laparoscopic TME
Technical feasibility of performing
laparoscopic TME was demonstrated in
several prospective studies
Complete resection of the mesorectum
with intact visceral fascia
For rectal cancer, laparoscopic technique
can be more complex depending on the
tumor location

39.  In contrast to open and laparoscopic
procedures , the robotic surgical procedure
gives a high definition 3-D imaging with
articulating instruments that mimic human
hand
 It is more helpful in operating in narrow areas
as that for rectum

40. Hence robotic TME ( TOTAL
MESORECTAL EXCISION ) is more safer
than open and laparoscopic TME
The acceptance of these MINIMALLY
INVASIVE TECHNIQUES by the surgeons
and patients has been widely increasing
now a days
But due to onchologic concerns application
of this techniques to rectum is more slower

41. THANK YOU