Adenocarcinoma Rectum and Low anterior resection using double stapling technique

2. Case Discussion
By
Dr. Muhammad Saifullah
PG Trainee, Surgical Unit V.
Under Supervision of
Assoc. Prof. Dr. Javaid Iqbal

3. CASE HISTORY
Mr. X.Y.Z, 42 years old male, resident of
Toba Tek Singh, presented to us with
complaint of
» Abdominal Pain 5 days
» Vomiting 3 days
» Abdominal Distention 3 days
» Absolute Constipation 2 days

4. History Detail…..
» The patient was in usual state of
health 5 days back when he
developed severe abdominal Pain
which was sudden, colicky in nature,
non-radiating, non shifting, non-
aggravating but relieved by vomiting.

5. History Detail…..
» The patient also had three day history
of non-projectile vomiting, initially
bilious but later it became feculent. It
was associated with abdominal
distension, absolute constipation for 2
days & weight loss. There was also
history of fresh bleeding per rectum
for 5 months. There was no history of
mucous discharge, tenesmus and
altered bowel habits.

6. Systemic inquiry…..
» General….. H/O loss of appetite & significant
weight loss during past 4 months.
» Cardio-vascular System….. No H/O shortness of
breath, palpitations, chest pain or
claudication.
» Respiratory System….. No H/O cough or
hemoptysis.
» Urinary System….. No H/O flank pain, hematuria,
nocturia or dysuria.

7. Systemic inquiry…..
» Nervous System….. No H/O weakness,
numbness, headache, blackouts, fits or
visual loss.
» Locomotor System….. No H/O joint pain, stiffness
or restriction of movements.
» Skin….. No H/O rash, itch or colored spots.

8. Past history…..
» Patient is known diabetic for 15 years but
not taking any treatment.
» No other significant past medical or surgical
history.
» No family history of bleeding per rectum in
first degree relatives, hypertension,
diabetes, tuberculosis or ischemic heart
disease.
» Both parents alive and healthy.
family history…..

9. Personal and social history…..
» Patient is non-smoker with average socio-
economic status.
» No drug or alcohol addiction.

10. Clinical examination…..
An emaciated middle aged man, oriented
in time, space and person, lying on the
couch having following vitals
 B.P 90/60
 Temp 98.6 oF
 Pulse 112/min
 R/R 15/min

11. General physical examination…..
» Nails… Pallor +ve, No clubbing,
koilonychias, splinter hemorrhages or
cyanosis.
» Fingers… No Osler’s, Heberden’s or
Bouchard’s nodes, Joint swelling or
deformity.
» Palm… No sweating, palmar erythema or
dupuytren’s contracture.

12. General physical examination…..
» Face… No puffiness, proptosis, jaundice,
xanthelasmas or central cyanosis. Poor
oro-dental hygeine.
» NECK… No thyroid swelling, engorged
neck veins or palpable cervical lymph
nodes.

13. General physical examination…..
» No palpable axillary or inguinal lymph
nodes.
» FOOT… No edema, cyanosis or loss of hair.

14. Abdominal examination…..
» Abdomen distended with normal shaped
umbilicus, central in position. Peristalsis not
visible. No visible scars, striae or veins.
Hernial orifices are intact.
» Abdomen was tense with generalized
tenderness. No palpable mass or
visceromegaly.
» Abdomen was resonant on percussion with
no area of dullness.
» Bowel sounds 8-10 per minute with no
audible bruits or succussion splash.

15. Digital rectal examination…..
» Inspection showed no skin tags or perianal
abnormality.
» On palpation anal tone was normal with no
palpable hemorrhoids or mass. Finger was
stained with blood mixed with stool.

16. INVESTIGATIONS…..
» Hb 9.2 g/dl
» ESR 40 mm in 1st hour
» TLC 10,400 / mm3
 Neutrophils 70%
 Lymphocytes 26%
 Eosinophils 2%
 Monocytes 2%
» Platelets 2,90,000 / mm3

17. INVESTIGATIONS…..
» RBS 330
» Urea 41
» Creatinine 1.1
» Bilirubin 1.0
 Conjugated 0.7
 Unconjugated 0.3
» Alk. Phosphatase 119
» sGPT 58
» Serum Sodium 140
» Serum Potassium 4.4
» Serum Chloride 100
» Serum Bicarbonate 25
» HBsAg -ve
» Anti-HCV +ve
» PT 14 sec
» APTT 34 sec

18. Radiological examination…..
X-Ray Abdomen Erect Film showed
multiple air fluid levels with air shadows
visible in large gut.

19. Resusitation & pre-op preparation…..
» IV fluids.
» IV Antibiotics.
» Analgesics.
» Insulin therapy.
» N/G intubation & Foley cathetrization.
» Monitoring vitals.

20. Exploratory laparotomy…..
Findings…..
1. A 8 cm growth at the Recto-sigmoid
junction about 10 cm from the anal verge.
2. Fully distended small and large bowel.
3. No Liver mets.
4. No peritoneal seeding.
5. No enlarged intra-abdominal lymph
nodes.

21. Exploratory laparotomy…..
Procedure…..
Transverse Colostomy and small & large
bowel decompression was done. Biopsy of
the recto-sigmoid growth was also taken. As
the patient was not vitally stable, so
resection of the tumor was not done.
Plan…..
To stablize the patient for elective
procedure after histopathology report.

22. Sigmoidoscopy…..
Histopathology of the recto-sigmoid growth…..
Growth in the rectum totally obstructing
the lumen about 12 cm from anal margin.
Further colonoscopy not possible. Mucosal
biopsy taken and preserved for
histopathology.
Signet Ring Cell Adenocarcinoma

23. PLAN…..
Low Anterior Resection of the Recto-
sigmoid growth + TME and subsequent
rectal re-construction using double stapling
technique.

24. Low anterior resection, tme &
rectal re-construction using
double stapling technique…..

26. 1. Midline Abdominal Incision

27. 2. Separation and Mobilization of the tumor
from the surroundings.

28. 3. Mobilization of sigmoid colon and
descending colon upto splenic flexure.

29. 4. Identification of Inferior Mesenteric
Artery.

30. 5. Ligation of Inferior Mesenteric Artery.

31. 6. Ligation of posterior rectal pedicle and
placing of curved cutter stapler across
the rectum and subsequent firing.

32. 7. Application of intestinal clamps and
cutting the colon proximal to the tumor

33. 8. Fixation of anvil in the proximal colon
end.

34. 9. Insertion of curved circular stapler
through the anal verge

35. 10. Fixation of the anvil to the cartridge.

36. 11. Firing of stapler gun and anastomsis of
rectum and colon.

37. 12. Doughnuts of gut after resection and
stapler anastomosis.

39. RESECTED TUMOR

40. Post-operative condition…..
» Recovery….. Uneventfull.
» Mobilization of the patient on 3rd day.
» Patient discharged on the 7th day.
» Follow up.

41. literature review
Overall, colorectal cancer is the
second most common malignancy in
western countries, with approximately
18 000 patients dying per annum in the
UK.

42. Origin & presentation
» Colorectal cancer arises from adenomas in
a stepwise progression in which increasing
dysplasia in the adenoma is due to an
accumulation of genetic abnormalities.
» Usually, these carcinomas present as an
ulcer, but polypoid and infiltrating types
are also common.

43. Dukes’ staging…..
» A: limited to the rectal wall: prognosis excellent.
» B: extended to the extrarectal tissues, but no
metastasis to the regional lymph nodes: prognosis
reasonable.
» C: Secondary deposits in the regional lymph nodes.
a) C1. Pararectal lymph nodes alone are involved
b) C2. Nodes accompanying the supplying blood
vessels are implicated up to the point of division.
Prognosis is poor.
» D: Widespread metastasis… usually hepatic.

45. Diagnosis and assessment of rectal cancer…..
All patients with suspected CA rectum should
undergo:
■ Digital rectal examination
■ Sigmoidoscopy and biopsy
■ Colonoscopy if possible
■ CT colonography or barium enema if
colonoscopy not possible.

46. Diagnosis and assessment of rectal cancer…..
All patients with proven CA rectum require
staging by:
■ Imaging of the liver and chest, preferably by
CT
■ Local pelvic imaging by magnetic resonance
imaging or endoluminal ultrasound.

47. Management of rectal cancer…..
» Radical excision of the rectum, together with
the mesorectum and associated lymph nodes,
should be the aim.
» Rectosigmoid tumours and those in the upper
third of the rectum are removed by ‘high
anterior resection’, in which the rectum and
mesorectum are taken to a margin 5 cm distal
to the tumour, and a colorectal anastomosis is
performed.

48. Management of rectal cancer…..
» Tumours in the middle and lower thirds of the
rectum, complete removal of the rectum and
mesorectum is required, i.e. total mesorectal
excision (TME). A temporary protecting stoma
is usually formed after TME.

49. Colo-rectal anastomosis
stapling technique

54. ADVANTAGES OF STAPLER ANASTOMOSIS…..
LIMITATION…..
» Less time consuming.
» Minimum risk of leakage.
» Low incidence of pelvic sepsis.
» Early recovery.
» High cost.