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By
Yasser Mohamed
Lecturer of General Surgery
Unusual Approaches to
the Rectum
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
Why it is difficult to approach the rectum?
 Approaching the rectum remains challenge for
colorectal surgeons
 Dissection of the lower rectum in some low rectal
and pararectal pathologies can be technically
difficult
Anatomical difficulties
1. The rectum is present within
complex bony pelvis
Anatomical difficulties
2.The rectum has complex visceral
anatomical relations within the pelvi
How to reach the rectum?
Approaches to the rectum
 Posterior approaches:
Tans sphincteric
Trans sacral
 Trans perineal
 Trans anal approach(TEM)
 Intersphincteric approach
 Laproscopic Approach
Intersphincteric approach
Anatomy of intersphincteric plane
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
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
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
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
Posterior approaches to the rectum
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
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
Unusual approaches to rectum
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
 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
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
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
Unusual approaches to rectum
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
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
Abou-Zeid and Makki, 2007
Incision and Anterior dissection
Lateral and posterior dissection
Resection of the specimen
Anastomosis
Perineal wound
Covering ileostomy
Unusual approaches to rectum
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
Unusual approaches to rectum
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
Unusual approaches to rectum

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Unusual approaches to rectum

  • 1. By Yasser Mohamed Lecturer of General Surgery Unusual Approaches to the Rectum
  • 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
  • 3. Why it is difficult to approach the rectum?
  • 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
  • 5. Anatomical difficulties 1. The rectum is present within complex bony pelvis
  • 6. Anatomical difficulties 2.The rectum has complex visceral anatomical relations within the pelvi
  • 7. How to reach the rectum?
  • 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
  • 27. Incision and Anterior dissection
  • 28. Lateral and posterior dissection
  • 29. Resection of the specimen
  • 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