2. Anatomy of The Rectum
The rectum begines at the level of the middle of the sacrum,
as continuation to sigmoid .
The rectum, about 15 cm long , follows the sacrococcygeal
curve at the anorectal junction, the gut curves backward and
its concavity is held by the puborectal sling.
The rectum presents three or more lateral curvatures, which
correspond to transverse rectal folds
The rectum has neither mesentery nor haustra, and it has an
almost complete outer longitudinal muscular coat rather than
teniae
4. Approaching the rectum remains challenge for
colorectal surgeons
Dissection of the lower rectum in some low rectal
and pararectal pathologies can be technically
difficult
8. Approaches to the rectum
Posterior approaches:
Tans sphincteric
Trans sacral
Trans perineal
Trans anal approach(TEM)
Intersphincteric approach
Laproscopic Approach
11. Intersphincteric approach
Schiessel and colleagues initially described this approach in19
Dissection is done in the intersphincteric plane between(EAS –
IAS ) .
The intersphincteric groove (ISG) exists between the terminal
part of the internal sphincter (IS) and the subcutaneous part of
the external sphincter (ES).
It was described mainly for distal cancer involving the anal ring
12. Technique of inter sphincteric approach
Good exposure of the anal canal via self-retaining retractor
(Lone Star Retractor)
Injection of 1 mg diluted epinephrine in 20 mL of saline
solution to minimize bleeding and facilitate intersphincteric
dissection
The mucosa and internal sphincter are circumferentially
incised at least 1 cm distance from the distal edge of the tumor
13. Technique of inter sphincteric approach
The anal orifice is then closed transanally with pursestring
sutures to prevent tumor cell dissemination.
Dissection continues through intersphincteric plane to
connect with dissection from abdomen
After the rectum is totally separated from prostate or vagina,
the specimen is removed per anally
14. Indications of ISA
The most common indication for ISA is cancer within 1 cm of
the anorectal ring.
When to avoid ISA?
Avoid ISA in distal cancer in followig cases
Malignant infiltration of other organs or of the striated
muscles of the pelvic floor (such as levator ani muscle or
external sphincter)
If tumors displayed low differentiation on histopathology, or
if preoperative anal function demonstrated marked
insufficiency
16. Transacral approach to the rectum(Kraske)
It was originally described by Paul Kraske and it allows
exposure of the mid rectum after removal of the coccyx and
a portion of the left sacral wing
Kraske described his technique 1884 for patient with rectal
cancer
In the past the results of the treatment of mid rectal tumors by
the Kraske’s procedure were disappointing due to the
development of local complications such as proctocutaneous
fistulas, wound infection, stricture and incontinence
however operation also offers an alternative approach for mid
rectal lesions that cannot be treated transanaly
17. Technicqe of kraske approach
The patient placed in prone jackknife position with the chest
and pelvis supported and the abdomen free.
The skin incised in the midline from the level of the lower
part of the sacrum to 2-3cm from the anus. The coccyx was
dissected free by dividing the muscular and ligamentus
attachments to the sides of the coccyx and the whole length of
the anococcygeal raphe was incised. The coccyx was removed
The levator ani muscles and the Waldeyer’s fascia divided in
the midline exposing the posterior rectal wall
19. Indications
The Kraske’s posterior approach is a viable option and its
success is largely dependent on its indications.
It should be considered in benign mid rectal lesions as in
adenomatus polyps, leiomyomas, endometriosis, benign
strictures, localized rectal hemangiomas, rectovaginal and
rectoprostatic fistulas as well as in pre malignant lesions
(villous adenomas, recurrent dysplasias in endoscopic
polypectomy site) which cannot be excised transanally
20. POST. KRASKE APPROACH in rectal cancer
T1 ,t2 T3 stage of lesion without nodal metastatic involvement
Kraske’s approach in selected cases such as extensive co-
morbid disease, informed patient decision about the
undesirability of a colostomy
21. POSTERIOR TRANS SPHINCTERIC APPROACH
1969, Kilpatrick and York—Mason described a posterior
approach, transrectal, and transsphincteric - York-Mason
technique—in which all layers of the anorectal sphincter are
divided
The York Mason transsphinteric exposure was conceived to
treat rectourinary fistulae, benign strictures, benign and
malignant tumours of the lower two-thirds of the rectum
22. Technicqe
jack-knife position with the gluteus muscles separated with
tape.
A paracoccigeal incision is made which is extended to the
anal margin.
The incision passes through the subcutaneous tissue until
reaching the gluteus maximus at its proximal end and the
levator ani and the external sphincter at its distal end .
After separately identifying the levator ani, external sphincter
and the internal sphincter, they are sectioned by using sutures
at their extremes, which will later facilitate reconstruction
Then the posterior wall of the inferior rectum is exposed
24. TRANS PERINEAL APPROACH
This technique was described to allow colorectal surgeons to
approach the rectum in ultra low rectal pathologies.
It was described ultra low recta resection
In U.C,CHRONS,R.V FISTULA,ULTRALOW RECTAL
CANCER,DIFFICULT REVERSAL OF HARTMAN
25. Technicqe of TRANSPERINEAL APPROACH
Convex crescentric skin incision made in the perineum
midway between the vagina or base of the scrotum and the
anal verge .
The skin and subcutaneous tissue were dissected from the
underlying external anal sphincter and transverse perinei
muscles
The dissection continued upwards until the plane created
from above by the abdominal operator was reached
32. Transanal endoscopic microsurgery (TEM)
Transanal endoscopic microsurgery (TEM) is a minimally
invasive technique that was conceived almost 30 years ago as
an alternative to abdominal rectal resection and conventional
transanal techniques, for the removal of large polyps
localized in the rectum and not amenable to endoscopic
resection
The equipment includes a 7 or 15 cm rectal tube which has a
4 cm diameter and three working channels (12, 5 and 5 mm)
This system is used with conventional laproscopic approach
34. INDICATIONS
TEM for rectal adenomas Endoscopic resection represents
the treatment of choice for pre-malignant lesions of the
gastrointestinal tract. However, conventional endoscopic
mucosal resection (EMR) cannot provide an en-bloc resection
in case of large lesions and incomplete or piecemeal resection
may occur in up to 50% of cases
Also , TEM has been shown to be an important therapeutic
option even in the treatment of recurrent adenoma, when the
endoscopic resection is not feasible