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The first 25 slides, exactly as they appear. The full deck has 123 content slides.
General Surgery
Perspective on Rectal Cancer (A)
Built from Maingot's Abdominal Operations
What’s inside
10 sections · 123 slides
Overview
- What this deck covers
- Terms used throughout
- Terms used throughout (continued)
Cancer of the Rectum
The standard operation, and what changed it
- The long-standing operation for rectal cancer
- Sphincter preservation versus permanent colostomy
- Advances that widened the surgical options
- Factors that determine the surgical approach
- Stage and location lead the decision
Patient Evaluation
Examination and imaging before any plan is made
- Aims of pretreatment evaluation
- Complete colonoscopy before treatment
- Information gained from digital rectal examination
- Proctoscopy and distance from the anal verge
- Endorectal ultrasound in early rectal cancer
- Cross-sectional imaging of the pelvis
- MRI in locally advanced rectal cancer
- CT for locoregional staging
- Tests for distant metastasis
- Course of the rectum through the pelvis
- The rectum's neighbours in the male pelvis
- Levator muscle and the anal sphincters
- The mesorectum and the fascia propria
- Depth of invasion through the bowel wall
- Deciding between local therapy and radical surgery
Local Excision
Taking out the tumour without taking out the rectum
- Patients suitable for local excision
- Two ways of excising a tumour through the anus
- Reach and outcome of the two techniques
- Restricting local excision to distal early cancers
- Clinical selection before local excision
- Pathological criteria for accepting local excision alone
- Findings that mandate radical surgery after local excision
- Chemoradiation after local excision of T2 tumours
- Clinically staged T2N0 tumours
- Chemoradiation before local excision
Total Mesorectal Excision
Removing the rectum inside an unbroken envelope
- Indications for total mesorectal excision
- Sharp dissection in the areolar plane
- Consequences of blunt dissection
- Protecting the hypogastric nerves and pelvic plexuses
- Rectal perforation during dissection
- Completeness of the mesorectal excision and recurrence
- Distal mesorectal spread and the 5-cm rule
- Tumour-specific mesorectal excision
- The mesorectum ends above the anorectal ring
- Restoring bowel continuity after excision
- Distal resection margin in the bowel wall
- Circumferential resection margin and the need for APR
- When removal of the anus becomes necessary
- The intersphincteric plane in an infiltrated sphincter
- Assessing levator and sphincter involvement
- Local recurrence after abdominoperineal resection
- Tumour left behind at the levator hiatus
- Cylindrical abdominoperineal resection
- Rationale and result of the cylindrical operation
- Prone jackknife position for the perineal dissection
- Permanent colostomy after removal of the rectum and anus
- Candidates for a hand-sewn coloanal anastomosis
- The transanal approach to the distal rectum
- Dissection in the intersphincteric space
- Sequencing the transanal and abdominal stages
- Diverting loop ileostomy after a low anastomosis
Minimally Invasive Excision
Keyhole and robotic routes to the same operation
- Aims of minimally invasive rectal surgery
- What dictates the length of the incision
- Effect of a keyhole or robotic mesorectal dissection
- Patient position and access for laparoscopic excision
- Steps of the laparoscopic vascular dissection
- Structures at risk during vascular division
- Mobilising the left colon and splenic flexure
- Reasons for full left colon mobilisation
- Opening the areolar plane at the promontory
- Completing the pelvic dissection
- Denonvilliers' fascia and the anterior plane
- Technical difficulties of laparoscopic excision
- What the robotic platform adds
- Limitations of the robotic approach
Radiation and Chemotherapy Before Surgery
Improving local control before the knife
- Pelvic radiation and local tumour control
- Radiation before surgery rather than after
- United States guideline schedule
- Which patients the United States guideline covers
- European risk stratification on MRI
- The three European treatment groups
- Extended surgery for the highest-risk group
- Linear accelerator in a radiotherapy treatment room
Patients With Metastatic Disease
When the cancer has already spread
- 1 in 3
- Factors that shape treatment in metastatic disease
- Multimodality therapy for resectable metastases
- Treatment sequence in the asymptomatic patient
- Radiation for a high-risk primary tumour
- Synchronous versus staged resection
- Order of operations in a staged resection
- Symptomatic patients with resectable metastases
- Asymptomatic patients with unresectable metastases
- Palliative options for symptomatic unresectable disease
- Choosing among palliative procedures
Cancer of the Anus
A disease that moved from the operating theatre to the radiotherapy suite
- Change in the primary treatment of anal cancer
- The surgeon's role in anal cancer
- Breadth of knowledge the surgeon needs
- Tumours grouped by location, not by biology
- Boundaries of the anal canal and anal margin
- Classifying a tumour as canal or margin
- Treatment follows histology, not the label
- Overlapping epithelia in the anorectal region
- Squamous carcinoma found only in mesorectal nodes
- Squamous cell carcinoma of the anus under the microscope
- Keratin pearl in anal squamous cell carcinoma
- Anal cytology and high-resolution anoscopy
- Ablation of high-grade squamous intraepithelial lesions
- Vaccination against the causative virus
- Assessment after chemoradiation for anal cancer
- Current follow-up practice
- 20-30%
- Salvage surgery after failed chemoradiation
- Planning the salvage operation
- Extent of resection in salvage removal of the anus
- Perineal wound problems and reconstruction
Summary
What to carry away
- Key points on rectal cancer
- Key points on treatment sequence and anal cancer
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition