Prolapse rectum

etiology,clinical features & management of prolapse rectum

1. PROLAPSE RECTUM DR.SUNIL KAMBLE ASSISTANT PROFESSOR DEPT.OF GEN.SURGERY MNR MEDICAL COLLEGE,SANGAREDDY

2. INTRODUCTION Prolapse is circumferential descent of the rectum through the anus. Partial prolapse -the mucous membrane and submucosa of the rectum protrude outside the anus for approximately 1-4cm. Complete prolpase - circumferential , full-thickness protrusion of the rectum through the anus. A lso called as first-degree prolapse or procidentia .

3. EMBRYOLOGY DEVELOPMENT OF THE DISTAL PART OF THE LARGE BOWEL. The left colic flexure, descending colon, sigmoid colon, rectum, and upper half of the anal canal are developed from the hindgut.

4. Distally, this terminates as a blind sac of entoderm , which is in contact with a shallow ectodermal depression called the proctodeum .

5. The apposed layers of ectoderm and entoderm form the cloacal membrane, which separates the cavity of the hindgut from the surface.

6. The hindgut sends off a diverticulum, the allantois, that passes into the umbilical cord. Distal to the allantois, the hindgut dilates to form the entodermal cloaca.

7. In the interval between the allantois and the hindgut, a wedge of mesenchyme invaginates the entoderm . With continued proliferation of the mesenchyme, a septum is formed that grows inferiorly and divides the cloaca into anterior and posterior parts. The septum is called the urorectal septum, the anterior part of the cloaca becomes the primitive bladder and the urogenital sinus, and the posterior part of the cloaca forms the anorectal canal.

8. On reaching the cloacal membrane, the urorectal septum fuses with it and forms the future perineal body. The anorectal canal forms the rectum and the superior half of the anal canal.

9. SURGICAL ANATOMY The rectum is about 5 in. (13 cm) long and begins in front of the third sacral vertebra as a continuation of the sigmoid colon. Passes downward, following the curve of the sacrum and coccyx, and ends in front of the tip of the coccyx by piercing the pelvic diaphragm and becoming continuous with the anal canal.

10. The lower part of the rectum is dilated to form the rectal ampulla. The rectum deviates to the left, but it quickly returns to the median plane.

11. LATERAL VIEW The rectum follows the anterior concavity of the sacrum before bending downward and backward at its junction with the anal canal . The puborectalis portion of the levator ani muscles forms a sling at the junction of the rectum with the anal canal and pulls this part of the bowel forward, producing the anorectal angle.

12. The peritoneum covers the anterior and lateral surfaces of the first third of the rectum and only the anterior surface of the middle third, leaving the lower third devoid of peritoneum . The muscular coat of the rectum is arranged in the usual outer longitudinal and inner circular layers of smooth muscle.

13. The three teniae coli of the sigmoid colon, however, come together so that the longitudinal fibers form a broad band on the anterior and posterior surfaces of the rectum. The mucous membrane of the rectum, together with the circular muscle layer, forms two or three semicircular permanent folds called the transverse folds of the rectum; they vary in position.

14. RELATIONS POSTERIORLY The rectum is in contact with the sacrum and coccyx; the piriformis , coccygeus , and levatores ani muscles; the sacral plexus; and the sympathetic trunks.

15. ANTERIORLY M ale -the upper two thirds of the rectum, which is covered by peritoneum, is related to the sigmoid colon and coils of ileum that occupy the rectovesical pouch . The lower third of the rectum, which is devoid of peritoneum, is related to the posterior surface of the bladder, to the termination of the vas deferens and the seminal vesicles on each side, and to the prostate.

16. F emale -the upper two thirds of the rectum, which is covered by peritoneum, is related to the sigmoid colon and coils of ileum that occupy the rectouterine pouch (pouch of Douglas ). The lower third of the rectum, which is devoid of peritoneum, is related to the posterior surface of the vagina.

17. BLOOD SUPPLY The superior, middle, and inferior rectal arteries supply the rectum. The superior rectal artery is a direct continuation of the inferior mesenteric artery and is the chief artery supplying the mucous membrane. E nters the pelvis by descending in the root of the sigmoid mesocolon and divides into right and left branches, which pierce the muscular coat and supply the mucous membrane.

18. They anastomose with one another and with the middle and inferior rectal arteries. The middle rectal artery is a small branch of the internal iliac artery and is distributed mainly to the muscular coat. The inferior rectal artery is a branch of the internal pudendal artery in the perineum. It anastomoses with the middle rectal artery at the anorectal junction.

19. VENOUS DRAINAGE The veins of the rectum correspond to the arteries. The superior rectal vein is a tributary of the portal circulation and drains into the inferior mesenteric vein. The middle and inferior rectal veins drain into the internal iliac and internal pudendal veins, respectively. The union between the rectal veins forms an important portalsystemic anastomosis

20. LYMPHATIC DRAINAGE The lymph vessels of the rectum drain first into the pararectal nodes and then into inferior mesenteric nodes . Lymph vessels from the lower part of the rectum follow the middle rectal artery to the internal iliac nodes.

21. NERVE SUPPLY The nerve supply is from the sympathetic and parasympathetic nerves from the inferior hypogastric plexuses. The rectum is sensitive only to stretch.

22. PHYSIOLOGY OF RECTUM The anorectum is mainly responsible for maintaining continence and for evacuation. These are highly complex and coordinated processes, the dysfunction of which can be distressing . Incontinence and constipation can limit patient’s lifestyles severely and have devastating effects on their quality of life .

23. FECAL CONTINENCE Fecal continence is maintained by several factors, both mechanical and neurologic.

24. STOOL VOLUME AND CONSISTENCY Stool volume and consistency play an important role in maintaining anal continence . Some patients are variably continent to solid, liquid, or gas. By changing the stool consistency and volume, some patients may be made continent.

25. RECTAL CAPACITY AND COMPLIANCE Another mechanical factor is the reservoir function of the rectum . The valves of Houston slow down the progression of stool and provide a barrier effect. Rectal capacity and adaptive compliance are also important for an effective reservoir. Urgency is usually felt after instilling 200 mL of saline into the rectum.

26. This transiently causes an increase in the intrarectal pressure, but then the pressure returns to baseline and the feeling of urgency disappears . This is called receptive relaxation .

27. ANORECTAL ANGLE Another important factor for maintaining continence is the angulation of the anorectal angle. This is normally maintained at 80 to 90 by the continuous tonic activity of the puborectalis muscle.

28. ANAL RESTING PRESSURE Anal resting pressure is maintained by the aid of the internal anal sphincter, the external anal sphincter, and the hemorrhoidal complex. The resting pressure is between 40 and 80mmHg and is higher than the baseline intrarectal pressure.

29. ANORECTAL MANOMETRY Anal manometry is used to measure the anal resting pressure. One of the instruments used is a four-channel probe, with each probe oriented 90 apart. This instrument can provide resting pressure measurement on four quadrants.

30. ANORECTAL SENSIBILITY Anorectal sensibility is the ability to discriminate between gas , liquid, or solid . By allowing awareness, the external sphincter can contract in order to postpone defecation.

31. RECTOANAL INHIBITORY REFLEX When feces reaches the rectum with colonic mass movements, the rectal wall stretches and this causes reflexive relaxation of the internal sphincter. This is called the rectoanal inhibitory reflex.

32. DEFECATION REFLEX The process of defecation is a highly coordinated and complex process. Distention of the rectum stimulates contractions of the colon and rectum. This is known as the defecation reflex and involves the sacral segments of the spinal cord. When the rectum is distended, the rectoanal inhibitory reflex is initiated and the internal anal sphincter relaxes whereas the external anal sphincter contracts.

33. If it is not a socially acceptable time, the external anal sphincter is voluntarily contracted while rectal compliance allows accommodation and the urge passes. On the other hand, if it is determined that it is an appropriate time and place, a voluntary increase in abdominal pressures assists the defecation reflex to evacuate the rectum.

34. RECTAL PHYSIOLOGY TESTING Anorectal physiology testing is an important part of evaluating patients with anorectal dysfunction such as incontinence and constipation. Anal manometry , Electromyography, Nerve stimulation, and Sensation measurements.

35. ETIOLOGY Rectal procidentia is the protrusion of the entire thickness of the rectal wall through the anal sphincter . T wo theories concerning the etiology of rectal procidentia . The first was proposed in 1912 by Moschcowitz . CONCEPT -A rectal procidentia is a sliding hernia through a defect in the pelvic fascia. Based on the observation that an abnormally deep rectovaginal or rectovesical pouch is a striking and constant feature in most patients with complete rectal prolapse.

36. The second theory Broden and Snellman , who demonstrated through cineradiography that the initial step in the genesis of prolapse is circumferential intussusception of the rectum, with its starting point approximately 3 inches from the anal verge.

37. CLASSIFICATION Altemeier et al.believed that either a sliding hernia or an intussusception is present in different patients. Type I :Is a protrusion of the redundant mucosal layer ( labeled as a false prolapse and usually associated with hemorrhoids ). Type II :Is an intussusception with an associated culde -sac sliding hernia. Type III: Is a sliding hernia of the cul-de-sac and is the one that they believed occurs in the vast majority of cases.

38. BEAHRS et al. CLASSIFICATION 1 . INCOMPLETE (MUCOSAL PROLAPSE) 2. COMPLETE (FULL-THICKNESS WALL PROLAPSE) First degree High or early, ‘‘concealed,’’ ‘‘invisible’’ Second degree Externally visible on straining, sulcus evident between rectal wall and anal canal. Third degree Exernally visible.

39. PREDISPOSING FACTORS Straining associated with intractable constipation-52% D iarrhea 15% P regnancy P revious operations N eurologic disease P sychiatric illness P rogressive systemic sclerosis

40. PATHOLOGIC ANATOMY The anatomic defects described as occurring with prolapse of the rectum include the following : ( A ) a defect in the pelvic floor with diastasis of the levator ani muscles and a weakened endopelvic fascia ( B ) an abnormally deep cul-de-sac of Douglas ( C ) a redundant rectosigmoid colon ( D ) a patulous weak anal sphincter (E) loss of the normal horizontal position of the rectum caused by its loose attachment to the sacrum and pelvic walls .

41. PHYSIOLOGIC DYSFUNCTION Pre-existing fecal incontinence ranges from 35% to 100% of cases. The etiology of incontinence;in some cases it is secondary to sphincter damage resulting from the prolapse itself while in others it occurs as a result of internal anal sphincter relaxation induced by the prolapse .

42. F ecal incontinence and severe incontinence may be clinically present in association with internal (‘‘occult’’) rectal prolapse unassociated with morphological sphincter damage. In some patients, there is difficulty in the elicitation of the rectal anal inhibitor reflex (a measure of innate internal sphincter function ),accompanied by an absence of internal anal sphincter electromyographic trace.

43. Chronic internal anal sphincter relaxation (secondary to the presence of a prolapse itself) affects the inherent internal anal sphincter activity . R eduction in rectal tone and compliance is noted (a ‘‘rectal adaptation’’), following rectal distention in patients with full thickness rectal prolapse.

44. INCIDENCE SEX Women predominate among patients with rectal procidentia with a ratio of 6:1, as previously mentioned.

45. AGE In women, the incidence of this disorder is maximal in the fifth and subsequent decades, but in men, it is evenly distributed throughout the age range. I n men, the peak incidence declines after the age of 40 years, whereas in women, it climbs steadily to reach its maximal incidence in the seventh decade .

46. CLINICAL FEATURES SYMPTOMS Prolapse of the rectum vexes patients with the misery it causes them. The presenting complaints may be related to the prolapse itself or to the disturbance of anal continence that frequently accompanies it. Initially the mass may extrude only with defecation, but in a more advanced form, extrusion occurs with any slight exertion, such as coughing or sneezing.

47. In the early stage-difficulty in bowel regulation, discomfort, the sensation of incomplete evacuation, and tenesmus . Permanently extruded rectum that is excoriated and ulcerated, leading to mucous discharge and bleeding, which cause soiling of the underclothes . Fecal incontinence. Constipation with straining . Impairment of anorectal sensation- incontinence . U rinary incontinence with uterine prolapse. The psychologic trauma-because of embarrassment, many patients with rectal prolapse avoid all social contact.

48. PHYSICAL EXAMINATION INSPECTION Large red mass. I nitial examination-prolapse is frequently reduced. Anal orifice is quite patulous . If the patient is asked to bear down, the full thickness of the rectal wall will prolapse, and the concentric folds can be noted readily . This pattern is in marked contrast to the radial folds seen in patients with prolapsing internal hemorrhoids . The mucosa shows superficial ulceration caused by repeated trauma . The patient is asked to sit in the squatting position and bear down to demonstrate the prolapse . Aassociated uterine prolapse or cystocele.

49. PALPATION Digital examination usually demonstrates a diminished tone of the sphincteric muscle . Voluntary contraction of this muscle on the examining finger is either deficient or absent. Lack of discomfort experienced by the patient for such an examination. Bidigital palpation of the prolapsing tissue will reveal that the entire bowel wall thickness is involved.

50. SIGMOIDOSCOPY The first 8 to 10 cm on the anterior wall of the rectum may appear red and inflamed, which may be mistaken as a sign of inflammatory bowel disease . Granuloma formation-early telltale sign of so-called hidden, or occult, rectal procidentia . Malignancy, should be ruled out . Prevalence of rectosigmoid carcinoma with prolapse was 5.7% as opposed to 1.4% in a comparative group. The relative risk for carcinoma was 4.2-fold over the comparative group .

51. DIFFERENTIAL DIAGNOSIS When the mucosa appears hesitatingly at the anal orifice, distinguishing between a mucosal prolapse or prolapsing internal hemorrhoids from a complete rectal procidentia may be difficult. W ith complete procidentia the furrows are in a concentric ring, whereas with mucosal prolapse they are radial ; with complete procidentia the anus is in a normal anatomic position whereas with mucosal prolapse it is everted ; and with complete prolapse there is a sulcus between the anus and the protruding bowel , whereas no sulcus is present with only a mucosal prolapse. L arge polypoid neoplasm of the rectum or colon. A ssociated symptoms, digital examination, sigmoidoscopy , colonoscopy, or a barium enema will confirm this diagnosis.

52. INVESTIGATION & RADIOLOGIC EXAMINATION BARIUM ENEMA A colonic evaluation is indicated to assess for the possible association of another disease process such as a neoplasm, inflammatory bowel disease, or diverticular disease . SPINE Radiographs of the lumbar spine and pelvis may provide a clue to frank neurologic disease (e.g., spina bifida occulta ).

53. CINERADIOGRAPHY S uspected procidentia but not demonstrable. Cine- defecography may demonstrate an internal intussusception that starts 6 to 8 cm upward in the rectum. Defecography-33 % incidence of occult rectal prolapse in patients, with clinical rectoceles and defectory dysfunction. Balloon proctography - loss of the anorectal angle and lax squeeze pressures .

54. ENDORECTAL ULTRASONOGRAPHY The thickness and area of the internal sphincter and submucosa will be measured at three levels . Qualitatively , patients with rectal prolapse will show a characteristic elliptical morphology in the anal canal with anterior/posterior submucosal distortion accounting for most of the change . Quantitatively, internal anal sphincter and submucosal thickness and area will be greater in all quadrants of the anal canal (especially upper) in patients with rectal prolapse compared with controls. I ncreases in all measured variables-rectal prolapse .

55. The cause of sphincter distortion in rectal prolapse is may be due to a response to increased mechanical stress placed on the sphincter from the prolapse or an abnormal response by the sphincter complex to the prolapse. There is no correlation between internal anal sphincter thickness and function . Sphincter defects are not the cause of incontinence. Patients with this feature on endo -anal ultrasound may benefit from defecography to look for rectal wall abnormalities.

56. MAGNETIC RESONANCE IMAGING MRI clearly shows pelvic visceral prolapse and pelvic floor configuration on straining . Dynamic MRI defecography -underlying anatomic and pathophysiologic background of pelvic floor disorders with main diagnoses such as rectal prolapse or intussusception, rectocele, descending perineum, fecal incontinence, outlet obstruction, and dyskinetic puborectalis muscle.

57. MRI defecography - clinical results in 77.3% and defects in addition to clinical diagnoses in combined pelvic floor disorders in 34%. MRI represents a convenient diagnostic procedure in females and to a lesser extent in males in terms of dynamic imaging of pelvic floor organs during defecation. MR defecography -bladder descent, vaginal descent.

58. Evacuation proctography remains the first line investigation for the diagnosis of rectal intussusception but may not distinguish mucosal from full thickness descent . MR defecography further complements evacuation proctography by giving information on movements of the whole pelvic floor, 30% of the patients studied having associated abnormal anterior and/or middle pelvic organ descent .

59. If operation is planned for patients with rectal intussusception, MR defecography provides useful information regarding the presence and degree of anterior pelvic compartment descent that may need to be addressed if a good functional outcome is to be achieved.

60. TRANSIT STUDIES A bnormal transit time- the choice of operation . If the patient should suffer from total colonic inertia, they would consider performing a proctopexy with total abdominal colectomy and ileorectal anastomosis in a continent patient.

61. COLONOSCOPY A growing number of colorectal surgeons have adopted colonoscopy to rule out other colonic disease rather than use of barium enema . Certainly for patients 50 years, screening for colorectal carcinoma would be appropriate in any event.

62. ANORECTAL MANOMETRY P atients with rectal procidentia have specific abnormalities detectable through manometry , and such studies may help in the earlier diagnosis of this condition. P hysiologic abnormalities included an impaired sphincteric function as manifested by reduced resting and maximal voluntary squeeze pressures and a reduced physiologic rectal capacity as measured by the critical volume and constant relaxation volume.

63. ELECTROMYOGRAPHIC STUDIES Electromyographic studies have demonstrated abnormalities in patients with rectal prolapse . Although it is appropriate to conduct these studies in patients with rectal procidentia in an effort to understand the disease better, the information gathered to date is not sufficient enough to define a treatment strategy based on these physiologic studies alone. Investigations using cineradiography, transit studies, anorectal manometry , and electromyography are all of interest but, in the usual case of rectal procidentia , do not change the operative plan.

64. OPERATIVE REPAIR The Ripstein technique involves mobilization of the rectum down to the tip of the coccyx by opening the lateral peritoneal folds and freeing the bowel from the sacrum. It may be necessary to divide the upper portion of the lateral stalks to allow secure placement of the sling . The free ends of a 5-cm band of rectangular mesh (Teflon or Marlex ) are placed around the rectum at the level of the peritoneal reflection and are sutured firmly to the presacral fascia approximately 5 cm below the promontory. Nonabsorbable sutures are placed approximately 1 cm from the midline,while presacral blood vessels are carefully avoided.

65. RIPSTEIN TECHNIQUE

66. CONCLUSIONS The recurrence rate for this operation, 2.3 %. The reported complication rate of 16.5% is related to the specific placement of the sling; if to this are added nonspecific complications such as Urinary problems Pulmonary problems and W ound infections which were reported as approximately 13 %, the overall complication rate may approximate 30%.

67. IVALON SPONGE WRAP OPERATION

68. ABDOMINAL PROCTOPEXY AND SIGMOID RESECTION

69. RECTOPEXY

70. PERINEAL PROCEDURES PERINEAL RECTOSIGMOIDECTOMY

71. PERINEAL PROCTECTOMY, POSTERIOR RECTOPEXY, AND LEVATOR ANI MUSCLE REPAIR

72. DELORME PROCEDURE

73. MODIFIED DELORME TECHNIQUE

74. THIERSCH OPERATION

75. COMPLICATIONS I ncarceration, strangulation, and gangrene

76. RUPTURE OF PROLAPSE

77. ULCERATION AND HEMORRHAGE Minor ulceration of the exposed mucosa may cause minimal bleeding , but more extensive ulcerations on very rare occasions may cause a severe hemorrhage .

78. PROLAPSE IN CHILDREN In children, the incidence of prolapse is highest in the first2 years of life and declines thereafter. Boys are affected slightly more frequently than girls. The condition is usually the mucosal type. P redisposing factor-absence of the sacral curve, causing the patient’s rectum and anal canal in the sitting or standing position to form an almost vertical straight tube . Prolapse may be associated with any illness that leads to excessive straining at stool such as diarrhea , over-purgation, constipation, frequent coughing , or malnutrition . Mucoviscidosis also may be associated with rectal prolapse.

79. The parent may complain that when the child defecates,the rectum projects from the anus. Associated with a slight discharge of mucus or blood. Examination may reveal that the ring of prolapsing mucosa projects 2 to 4 cm beyond the anal orifice. Palpation of the prolapsing tissue reveals that only two layers of mucosa are present. Rarely , complete rectal procidentia may occur. Sphincteric tone may be lax .

80. D ifferential diagnosis -prolapsed rectal polyp or the apex of an intussusception protruding through the anus. In children, prolapsing rectal mucosa is a selflimiting disease. Treatment -correcting constipation and instituting proper habits of defecation. Correction of malnutrition. Strapping the buttocks -only buys time until the self-limiting disease resolves. In patients who do not respond to the above forms of therapy, submucosal injection of a sclerosing agent, such as phenol in almond oil, has proved effective.

81. C omplete rectal prolapse-perirectal injections of sclerosing agents to stimulate periproctitis and to fix the rectum to the sacrum. other treatments -excision of a mucosal prolapse, presacral packing with gauze or Gelfoam , linear cauterization of the anorectum , transsacral rectopexy , transcoccygeal rectopexy , puborectalis plication , perineal proctosigmoidectomy , and transanal rectopexy . Actual surgical resection for prolapse in children is a very rare necessity, but emergency rectosigmoidectomies for large irreducible prolapses in children can be done. Long-standing prolapse - rectopexy can be performed as it is done in the adult, but rarely is this indicated .

82. RECURRENT RECTAL PROLAPSE In 41 % of cases,most often attributable to problems with the mesh following the Ripstein procedure. Preoperative incontinence and constipation-unchanged by the operation for recurrent prolapse . B owel dysfunction still remains in 60% of patients. The average time for recurrence-14 months. Initial operations were perineal proctectomy and levatorplasty , anal encirclement , Delorme’s procedure , and anterior resection .

83. Operative procedures for recurrence - perineal proctectomy and levatorplasty , sacral rectopexy (abdominal approach), anterior resection with rectopexy , Delorme’s procedure, and anal encirclement . The operative management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence.

84. There were no differences between the groups in preoperative incontinence score in mortality, in mean hospital stay , in anastomotic complications, in wound infection, and in postoperative incontinence or recurrence rate between the two groups. The overall success rate for recurrent rectal prolapse- 85.2%. T he outcome of operation for rectal prolapse is similar in cases of primary or recurrent prolapse and the same surgical operations are valid in both scenarios.

85. In the selection of operations for recurrent rectal procidentia , the surgeon must be cautious not to perform an Altemeier procedure following a previous sigmoid resection unless the anastomosis is integrated in the resection and similarly should not perform a sigmoid resection following an Altemeier procedure because of the risk of creating a devascularized segment of bowel . Perineal proctectomies can be safely repeated. Non- resectional procedures such as Delorme’s procedure should be considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed.

86. HIDDEN PROLAPSE (INTERNAL PROCIDENTIA ) ‘‘Hidden’’ prolapse refers to the earliest stage of procidentia , when the intussuscepting rectum occupies the rectal ampulla but has not yet continued through the anal canal. The most common complaint is difficulty in emptying the bowel , often described as a sensation of incomplete evacuation or obstruction. The second most common symptom is incontinence (33%). Other symptoms include bloody mucus (51%), perineal pain (16%), and soiling (24 %). Digital rectal examination reveals anterior rectal wall prolapse in 84 %. Sigmoidoscopic findings include a solitary ulcer (49%) or hyperemia and edema of the mucosa of the anterior rectal wall for a distance of 8 to 10 cm from the anus .

87. Bulging edematous mucosa may be seen. Colitiscystica profunda may be found, and hidden prolapse, a solitary rectal ulcer, and colitis cystica profunda may represent a spectrum of one syndrome. Defecography is probably the most useful diagnostic procedure for identifying internal intussusception. Abnormalities may include small residual folds occurring 3 to 7cm from the anal canal located mainly in the posterior wall, anterior rectal wall prolapse, and circular prolapse creating a funnel like configuration as seen in complete rectal prolapse.

88. SUMMARY Bachoo et al . tried to determine the best choice of operation for rectal procidentia . The following specific issues were addressed . 1. Whether surgical intervention is better than no treatment. 2. Whether an abdominal approach to surgery is better than a perineal approach. 3. Whether one method for performing rectopexy is better than another. 4. Whether laparoscopic access is better than open access for operation. 5. Whether resection should be included in the procedure.

89. REFERENCES MAINGOT’S ABDOMEN OPERATIONS,11 TH EDITION. SABISTON TEXTBOOK OF SURGERY 20 TH EDITION. SCHWARTZ PRINCIPLES OF SURGERY 10 TH EDITION. BAILEY & LOVE’S SHORT PRACTICE OF SURGERY 26 TH EDITION. FARQUHARSON’S TEXTBOOK OF OPERATIVE GENERAL SURGERY 9 TH EDITION. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT 6 TH EDITION. PRINCIPLES AND PRACTICE OF SURGERY FOR THE COLON, RECTUM, AND ANUS 3 RD EDITION BY PHILIP H. GORDON .

90. MODERN SURGICAL CARE-PHYSIOLOGIC FOUNDATIONS AND CLINICAL APPLICATIONS BY THOMAS A.MILLER 3 RD EDITION SNELL’S ANATOMY 8 TH EDITION MASTERY OF SURGERY 5 TH EDITION