OPEN ANTERIOR RESECTION-STEP BY STEP Operative Surgery.pptx

In this presentation, I have shown how to do open anterior resection both high and low varieties in a step-by-step manner with clear pictures as if reading an atlas of operative surgery.

1. OPEN ANTERIOR RESECTION DR.B.Selvaraj MS; Mch ; FICS; “ Surgical Educator” Malaysia OPERATIVE SURGERY

2. OPEN ANTERIOR RESECTION INDICATIONS: Carcinoma of the rectum, where sphincter preservation is possible, high anterior resection is done for tumours of rectosigmoid junction and upper rectum which includes partial mesorectal excision . The anastomosis is made in the region of the junction of the mid and lower third of the rectum. Low anterior resection is done for mid-rectal tumors which includes a total mesorectal excision . The anastomosis is made at the level of the pelvic floor. For low anterior resections defunctioning stoma is made- loop ileostomy

3. OPEN ANTERIOR RESECTION INDICATIONS: Carcinoma of rectum- High anterior resection for rectosigmoid and upper rectal tumors. Low anterior resection for mid rectal tumors. ANESTHESIA: GA/ETT POSITION: Lloyd– Davies- Lithotomy in padded stirrups Diagnosis Confirmed by biopsy Staging by CECT Pre-op preparation Preoperative chemoradiation treatment is indicated for patients with T3, T4 lesions or tumors with enlarged pelvic lymph nodes found on pelvic computed tomography (CT) scan or endorectal ultrasound Adequate mechanical bowel preparation the day before surgery with orthograde enema Prophylactic IV broad spectrum antibiotics VTE prophylaxis with LMWH and pneumatic stockings Bladder catheterization The stoma nurse marks the ileostomy site for defunctioning . Intraoperative rigid proctoscopy is performed to determine the distal extent of the cancer.

4. SURGICAL ANATOMY

5. Incision: Access Midline extending above and below umbilicus Left para-median Position Lloyd-Davies- lithotomy with padded stirrups Surgeon should stand on the right side OPEN ANTERIOR RESECTION

6. Exposure Assess the position and resectability of the tumour. Assess liver and peritoneum for metastatic deposits and colon for synchronous tumours Using diathermy divide the peritoneum along the ‘white line of Toldt ” Exposure Table may be tilted to right side Surgeon stand on right side Abdominal pack over small intestine and retract to right side OPEN ANTERIOR RESECTION

7. Mobilisation of Left Colon Incise the whiteline of Toldt upto splenic flexure Mobilise Lt Colon from retroperitoneal structures Mobilisation of Left Colon Avoid injury to Lt Ureter and Lt Gonadal vessels by placing a right angle clamp or your finger This mobilisation is Mattox Maneuver OPEN ANTERIOR RESECTION

8. Mobilisation of splenic flexure Divide the spleno -colic ligament Mobilisation of greater omentum with Transverse Colon Separate the greater omentum from the distal transverse colon and continue the dissection laterally towards the splenic flexure. OPEN ANTERIOR RESECTION

9. Ligation of blood vessels Elevate the sigmoid colon and isolate the inferior mesenteric artery and left colic artery, which should be spared if appropriate. Ligate the superior hemorrhoidal artery at its take-off from the inferior mesenteric artery. Transaction of Colon Transect the colon to ensure adequate blood supply with GIA stapler OPEN ANTERIOR RESECTION

10. Rectal dissection Trendelenburg position Surgeon on left side Extend the lateral fascial incision upto upper rectum Rectal dissection The peritoneum is incised medial to the right ureter and extended around the rectum to join the pelvic peritoneal incision on the left meeting anterior to the rectum. OPEN ANTERIOR RESECTION

11. Posterior Rectal dissection Carry on the dissection in the avascular plane between the meso-rectum and the pre-sacral fascia posteriorly. Carry the dissection through Waldeyer’s fascia to the level of the coccyx. The mesorectum is mobilized laterally toward both the right and left pelvic side wall, preserving the hypogastric nerves on the sacrum Posterior Rectal dissection The mesorectum is divided laterally either with clamps and sutures or with a vessel sealer device, such as LigaSure . Aim for a 2cm clearance below the distal margin of the tumour and a 5cm clearance of the mesorectum. High anterior resection Partial mesorectal excision Low anterior resection Total mesorectal excision OPEN ANTERIOR RESECTION

12. Anterior Rectal dissection The rectum is mobilized ventrally by dividing the rectovaginal septum in females or the recto-vesicle space in males. In males, the dissection plane is ventral to Denonvillier fascia, preserving the seminal vesicles. OPEN ANTERIOR RESECTION

13. Transaction of Rectum The distal rectum is closed with a linear stapler- TA55, approximately 2 to 5 cm distal to the tumor at the pre-selected area. Apply a right-angle clamp 2 cms proximal to the staple line Transaction of Rectum Divide the rectum with a scalpel in between the stapler line and the right-angle clamp OPEN ANTERIOR RESECTION

14. Stapler Colo-rectal anastomosis Prior to creation of the anastomosis, the proximal colon is tested to determine that adequate length is available In selected cases, division of the inferior mesenteric vein near its origin can facilitate the colonic mobilization The anvil is detached and placed within the proximal colon, and the purse-string is tied around the anvil OPEN ANTERIOR RESECTION Stapler Colo-rectal anastomosis After careful deployment of the spike just posterior to the staple line in the rectum , the stapler is coupled and fired, completing the anastomosis Integrity of the anastomosis can be evaluated by gentle insufflation of the rectum with saline to rule out any leak and by examining the tissue doughnuts

15. Hand sewn Colo-rectal anastomosis Can do for high anterior resection but difficult for low anterior resection OPEN ANTERIOR RESECTION Alternate Colo-rectal anastomosis J pouch colorectal anastomosis also can be created

16. Great omental cover M obilise greater omentum with vascularity, bring it down and keep it over the anastomosis to prevent any leak OPEN ANTERIOR RESECTION Defunctioning /Diverting Ileostomy Create a loop ileostomy to divert fecal stream to protect the anastomosis

17. Closure of Laparotomy By mass closure with 1-0 prolene or PDS OPEN ANTERIOR RESECTION

18. Post-op Care No need to continue antibiotics postoperatively unless there is intraabdominal infection. Ambulation and incentive spirometry on postoperative day 1 is important for the prevention of postoperative atelectasis. Clear liquids are started on postoperative day 1, and diet is advanced as tolerated. The Foley catheter is left in place for a few days because of the high incidence of urinary retention in male patients. DVT prophylaxis should be continued until the time of discharge and can be considered as an outpatient in certain subsets of patients. OPEN ANTERIOR RESECTION

19. Pearls & Pitfalls The mesorectal dissection should be performed sharply under direct vision and not bluntly with the hand. The colorectal anastomosis must be tension free, and this may require division of the sigmoid artery at its origin and mobilization of the splenic flexure of the colon. In T3 and T4 rectal cancers, preservation of the pelvic autonomic nerves may not be possible. In most patients, the 29-mm circular stapler works well. Using the maximum-size circular stapler may create radial tension, leading to anastomotic leak. If the anastomosis fails the “bubble test,” the anastomotic defect must be identifi ed and repaired primarily. A protection loop ileostomy may be indicated for diffi cult or low anastomosis (<5 cm) and for patients who underwent preoperative chemoradiation treatment. OPEN ANTERIOR RESECTION

20. THANK YOU