Surgery of Rectum + Anoperineal

etiology anal cancer

SCC associated w/ HPV, tobacco in women

macro aspects of tumours

ulcerative, infiltrative, vegetative

what is more rapid and frequent in rectal vs colon cancer

penetration

most rectal cancers are ________ histopathologically

adenocarcinomas

symptoms based on stages

initial stage - asymptomatic

medium - rectal bleeding (jelly), pain, tenesmus, bowel habit changes (diarrhea if villous, caliber change)

advanced - intense pain (sacral penetration), colicky pain (obstruction), hypogastric + perineal pain, anal incontinence, fistulas, jaundice (metastasis), impregnation signs, compressive edema lower body

physical exam

digital rectal exam

how to assess penetration

tumour mobility on rectal exam

how to physical exam metastasis

groin lymph node palpation

why should vaginal digital exam be done

penetration into post vagina

investigations

rectoscopy w/ biopsy, endocrectal US (for penetration), CT/MRI (for staging), abd us (for metastasis), IV urography (fistula or metastasis), cea (follow up after surgery)

treatment

multimodal - surgical and adjunctive oncotherapy

In cancers located in the lower part of the rectum, what is recommended initially then after

preop radiotherapy for reduction then surgery after 4-6w

surgical treatment

excision of tumoral rectum + lymphadenectomy (total mesorectal excision for tumours in stage II-III)

extension of resection in surgery

tumour should be resected at least 5cm from anal verge, up to inf margin

what if tumour is under 5cm limit

anal sphincter can’t be saved, rectal amputation is major indication

important step in sphincter preserving surgery

introduction staplers for colorectal anastomosis that enabled lowering as much as possible the anastomosis line near anus

the indicated operation in anorectal cancers

abdominoperineal resection (rectal amputation)

types of radical operations

• low ant resection w/ colorectal (Dixon’s) anastomosis w/ or w/o temporary colostomy or ileostomy for anastomosis protection

• ultralow resection w/ peranal or intersphincterian anastomosis (Parks)

• abdominoperineal resection (Miles) w/ l iliac anus colostomy

• pullthrus

• hartmann

• endoluminal excision (early stages)

types of palliative operations

• colostomy, cecostomy, ileostomy

• palliative resection Hartmann I

types of approaches for surgery

classic (median laparotomy), lap, endoluminal (endoscopy)

pull-thru operation procedure

• rectum cut under tumour

• colon pulled thru anus (sphincter preserved)

• exteriorized colon cut and sewn to anal canal

resection of rectum and colorectal anastomosis is more difficult in who

men

cleavage plane (holy plane) facilitates the

total mesorectal excision

operations for tumours under 5-6cm

• abdominoperineal resection

• colo-anal anastomosis (intersphincteric)

• pull thru

advantages of mechanical suture (staplers)

• safe in difficult to reach areas

• less risk rectal amputation

• decreases operation time, blood loss, contamination

postop complications after low ant resection

anastomotic fistula → peritonitis (prevented w/ temp colostomy or ileostomy)

bleeding

intestinal obstructions

transient urinary dysfxn

sex dysfxn

abdominoperineal resection (Miles)

removal entire rectum + anal sphincter + mesorectum + nodes = iliac anus

indications abdominoperineal resection (Miles)

anorectal or very low rectal cancer

2 approaches to abdominoperineal resection (Miles)

• abd - rectum + mesorectum prepared down to levator ani m

• perineal - anorectum completely freed up and removed

transanal excision of rectal tumour can only be performed if

tumour in stage 0 or 1, doesn’t occupy more than 1/3 circumference of rectum, no nodes, no involved sphincter

in ____________, Rectal wall is excised in its entire thickness at least at 1 cm away from the lesion being followed or not by suture of the subperitoneal rectum

transanal excision of rectal tumour

anal fissure symptoms

severe pain during and after defecation, malodorous discharge

causes anal fissure

trauma by constipation/others or repeated diarrhea, stress

location anal fissure

post region, in front in women

evolution anal fissure

usually heal or chronic → intersphincteric abscess, fistula, vicious circle from continuous spasm

complications anal fissure

bleeding, abscess, perianal fistula

diagnosis anal fissure

digital + rectoscopy

treatment anal fissure

conservative - sitz baths, ointments, diet

botulinum toxin

surgical - stop vicious cycle, partial lat int sphincterotomy

______ are located at hrs 3,7,11 in gyno position

hemorrhoids

risk factors hemmorhoids

constipation, diarrhea, prolonged standing/sitting, rectal cancer, htn, pregnancy

internal vs external hemorrhoids

above/below dentate line

hemorrhoid symptoms

only symptomatic if complications - bleeding, prolapse → necrosis, ulcer, suppuration, hemorrhoidal thrombosis, skin tags

diagnosis hemorrhoid ivnestigation

digital exam (check prostate too), anorectoscopy

surgery hemorrhoids

if advanced/complications → rubber band ligation for int, sclerotherapy, laser, cryotherapy

surgery in advanced/complicated cases hemorrhoids

hemorrhoidectomy or hemorrhoidopexy, thrombus removal, transal deartarterialization

anesthesia of most hemorrhoid surgeries

spinal anesthesia

postop complications hemorrhoids

early - acute urinary retention, hemorrhasge

late - secondary hemorrhage, anal stenosis or fissure

anal fissure, hematoma or prolapsed thrombosed int hemorrhoid or following injection anesthesia are causes of

anoperineal abscess

evolution perianal abscess

intersphcinter → perianal → ischiorectal → high interm → pelvirectal

clinical pic perianla abscess

celsian signs, painful, fluctance or ulcerated or fistula skin

fourniers gangrene

abscess progresses to severe form

diagnosis perianal abscess

intrarectal us if deep but otherwise clinical exam

treatment perianal abscess

surgery + atb, if interpshrincteric or supralevator pus discharged

postop evoluation perianal abscess

dressings changed every day, complication perianal fistula

supralevator abscess treatment

transal incision, drainage tube

clinical picture perianal fistula

history of pain or intervention, discharge, ext opening, digital exam shows fibrous tract under skin

investigations anoperineal fistula

anoscopy

most common aanoperineal fistulas

intersphincteric and transsphincteric

goodsall’s rule

anterior fistula has direct track to anal canal, post fistula has curved path

treatment anal fistula

never heals spontaneously

surgery - fistulotomy (cutting tract, most common for simple), fistulectomy (excising tract), seton placement

postop complications anal fistula

early - urinary retention, bleeding hemorrhoidal thrombosis, fecal impaction

delayed - recurrence, anal incontinence or stenosis

to prevent recurrences what conditions must be med in anal fistula

complete fistulectomy, int orifice should be discovered, wound healing must happen (dressing) from depth to surface