Sugery for olorectal carcinoma and main steps and which all structure removaed and different in table from and with diagram if possible

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I now have comprehensive information from Bailey & Love's and Sabiston's Surgery textbooks. Let me compile the complete, detailed answer.

Surgery for Colorectal Carcinoma (CRC)

Surgery remains the primary curative treatment for colorectal carcinoma. The choice of operation depends on the tumour location (colon vs. rectum), the level within the rectum (upper/middle/lower third), tumour stage, and patient fitness.

Overview Comparison Table

Feature	Right Hemicolectomy	Left Hemicolectomy	Sigmoid Colectomy	High Anterior Resection (HAR)	Low Anterior Resection (LAR)	Abdominoperineal Excision (APE)	Hartmann's Procedure	Pelvic Exenteration
Tumour location	Caecum, ascending, hepatic flexure, proximal transverse colon	Descending colon, splenic flexure	Sigmoid colon	Upper rectum (>12 cm from anal verge)	Middle/lower rectum (5-12 cm)	Low rectum/anus (distal 3rd, <5 cm from verge)	Sigmoid/upper rectum (unfit/frail patients)	Locally advanced rectum invading adjacent organs
Structures removed	Terminal ileum (10-15 cm), caecum, ascending colon, hepatic flexure, proximal transverse colon, associated mesocolon, ileocolic and right colic lymph nodes	Descending colon, splenic flexure, part of transverse colon, associated mesocolon, left colic LNs	Sigmoid colon, mesosigmoid, sigmoid vessels, LNs	Upper rectum (≥3 cm below tumour), mesorectum (partial TME), sigmoid colon, superior rectal vessels, LNs	Upper + middle + lower rectum (complete TME), mesorectum en bloc, sigmoid colon, pelvic LNs	Sigmoid colon, entire rectum, mesorectum, anus, anal sphincters, levator ani, ischiorectal fat, perineal skin, pelvic LNs	Sigmoid colon + rectum (stump closed), no anastomosis	All APE structures PLUS bladder ± prostate (male), or uterus ± posterior vaginal wall (female)
Anastomosis	Ileocolic (ileum to transverse colon)	Colorectal or colo-colic	Colorectal	Colorectal	Colorectal (stapled, low)	None - end colostomy	None - end colostomy (rectal stump closed)	Colostomy ± ileal conduit (if bladder removed)
Stoma	Usually none	Usually none	Usually none	Usually none	Defunctioning loop ileostomy often used	Permanent end-colostomy (left iliac fossa)	Permanent end-colostomy	Permanent colostomy ± urostomy
Anal sphincter preserved?	Yes	Yes	Yes	Yes	Yes	No	Yes	No (if APE component)
TME performed?	No	No	No	Partial (proximal TME)	Complete TME	Complete TME + extralevator excision	No	Complete
Key vessels ligated	Ileocolic artery, right colic artery, right branch of middle colic artery	Left colic artery, inferior mesenteric artery	Inferior mesenteric artery or sigmoid vessels	Superior rectal artery, IMA (high ligation)	IMA at origin or just distal (high ligation)	IMA, middle rectal vessels, pudendal branches	IMA	IMA + internal iliac vessels

1. Right Hemicolectomy

Indication: Tumours of the caecum, ascending colon, hepatic flexure, and proximal transverse colon.

Steps:

Incision - Midline laparotomy or right-sided laparoscopic ports
Exploration - Assess liver, peritoneum for metastases
Mobilisation - Divide peritoneal reflection lateral to ascending colon (white line of Toldt), reflect medially
Ureter and duodenum identification - Protected during dissection (right ureter, second part of duodenum)
Vascular ligation - High ligation of ileocolic artery, right colic artery, and right branch of middle colic artery at their origins (CME principle)
Mesocolon division - En bloc with draining lymph nodes (complete mesocolic excision, CME)
Bowel transection - Terminal ileum (10-15 cm proximal) and mid-transverse colon
Anastomosis - Ileocolic anastomosis (hand-sewn or stapled)

Structures removed: Terminal ileum, caecum, ascending colon, hepatic flexure, proximal transverse colon, mesocolon, ileocolic and right colic lymph nodes.

2. Left Hemicolectomy

Indication: Tumours of the descending colon and splenic flexure.

Steps:

Incision - Midline or laparoscopic approach
Splenic flexure mobilisation - Divide gastrocolic and splenocolic ligaments
Left ureter identification and protection
Vascular ligation - Inferior mesenteric artery (IMA) or left colic artery ligation
Mesocolon division (CME)
Bowel transection - Proximal transverse colon to upper sigmoid/rectosigmoid junction
Anastomosis - Colo-rectal or colo-colic

3. Sigmoid Colectomy

Indication: Sigmoid colon tumours.

Steps:

Mobilise sigmoid colon by dividing lateral peritoneal attachments
Identify and protect left ureter (crosses iliac vessels)
High ligation of IMA or sigmoid branches
Divide sigmoid mesentery with lymph node clearance
Bowel transection: proximal sigmoid to upper rectum
Colorectal anastomosis (stapled or hand-sewn)

4. Anterior Resection (AR) - for Rectal Cancer

This is the sphincter-saving operation for rectal cancers. The key principle is Total Mesorectal Excision (TME).

TME: Sharp dissection in the embryological plane between the investing fascia of the rectum (fascia propria) and the presacral/parietal pelvic fascia, removing the rectum en bloc with its intact mesorectum. This reduces local recurrence from ~25% to ~6% and improves 5-year survival from ~60% to ~73%.

Surgical Steps (Open / Laparoscopic / Robotic):

Midline incision (or laparoscopic port placement)
Full laparotomy - Assess for synchronous lesions, metastases
Sigmoid and descending colon mobilisation - Divide left peritoneal reflection, mobilise to midline; protect left ureter and gonadal vessels
Splenic flexure mobilisation - To achieve tension-free anastomosis
IMA ligation - High ligation at or just below aorta (preserving superior hypogastric plexus where possible)
Posterior rectal dissection - In the TME plane: anterior to presacral fascia, posterior to fascia propria; preserve hypogastric nerves over sacral promontory
Lateral rectal dissection - Divide lateral ligaments; preserve pelvic plexuses (S2, S3, S4 parasympathetics)
Anterior rectal dissection - Anterior to Denonvilliers' fascia (between rectum and prostate/seminal vesicles in male; rectum and vagina in female)
Distal rectal transection - With linear stapler:
- High AR: at least 3 cm below the tumour (upper rectum)
- Low AR: at the anorectal junction (middle/lower rectum - complete TME)
Proximal colonic transection - With adequate proximal margin
Stapled colorectal anastomosis - Circular stapler per anum (end-to-end or end-to-side)
Covering loop ileostomy - Often formed for low anastomoses to protect the join

Structures Removed:

Sigmoid colon and upper rectum (with tumour)
Complete mesorectum (in LAR) with all contained lymph nodes
Superior rectal and inferior mesenteric vessels

Fascial anatomy diagram (Sabiston's Surgery):

Fascial relationships of the rectum showing peritoneum, investing fascia, presacral fascia, rectosacral (Waldeyer's) fascia, and Denonvilliers' fascia - the key dissection planes in TME

Fascial planes of the rectum: The TME dissection plane runs between the investing fascia of the rectum and the presacral fascia posteriorly, and anterior to Denonvilliers' fascia anteriorly.

LAR dissection diagram (Sabiston's Surgery):

Low anterior resection: dotted line shows en-bloc dissection of rectum with mesorectum, preserving bladder anteriorly and following presacral plane posteriorly

Low anterior resection: The dotted line shows the dissection plane removing the rectum and mesorectum en bloc while preserving the bladder anteriorly.

5. Abdominoperineal Excision of the Rectum (APER / Miles' Operation)

Indication: Tumours of the lower third of the rectum (<5 cm from anal verge), tumours invading the external sphincter, poor preoperative sphincter tone.

Surgical Steps:

Abdominal Phase (open or laparoscopic):

Midline laparotomy or laparoscopic access
Identical dissection to anterior resection up to the level of the seminal vesicles (male) or cervix (female) - then stop, do NOT "cone down" onto the tumour
IMA ligation, mobilisation of sigmoid colon
Sigmoid divided proximally; proximal end brought out as end colostomy in left iliac fossa
Dissection purposely stops before reaching pelvic floor (to avoid thin margins)

Perineal Phase:

Patient repositioned (prone jack-knife or Lloyd-Davies lithotomy)
Circumanal incision - Elliptical incision around anus (anus sutured closed prior to incision)
Deepened into ischiorectal fossae bilaterally, extending toward levator muscle attachment at pelvic side wall
Posterior dissection - Waldeyer's (rectosacral) fascia is incised posteriorly; coccyx may be removed to improve access
Anterior dissection - Plane between rectum and prostate/membranous urethra (male - catheter palpated to protect urethra) or between rectum and posterior vaginal wall (female)
Levator ani division - Pubococcygeus and puborectalis divided from pelvic side wall
Specimen retrieved through perineal wound en bloc
Perineal wound closed with drains to pelvis

Perineal dissection in APER: circumanal approach with division of levator ani muscles.

Structures Removed (APER):

Sigmoid colon + entire rectum + mesorectum
Anus + anal canal
Internal AND external anal sphincters
Levator ani muscles (pubococcygeus, puborectalis, iliococcygeus)
Ischiorectal fat bilaterally
Perineal skin (elliptical)
All pelvic lymph nodes
Optional: coccyx (if needed for access/margins)
In females with anterior tumour: posterior vaginal wall

Result: Permanent end-colostomy in left iliac fossa. No anal reconstruction.

6. Hartmann's Procedure

Indication: Frail or elderly patients with poor sphincter tone/anastomotic risk; emergency cases (obstruction, perforation).

Steps:

Same as anterior resection abdominal phase, but:

Rectal stump is stapled closed (Hartmann's pouch)
Proximal colon is brought out as a permanent end-colostomy
No anastomosis is made
Reversal is possible later, but often not undertaken

7. Pelvic Exenteration

Indication: Locally advanced rectal cancer with direct invasion of adjacent organs; locally recurrent rectal cancer.

Type	Structures Removed
Posterior exenteration	Rectum + posterior vagina/uterus
Total exenteration	Rectum + bladder + prostate (male) OR rectum + uterus + bladder (female)
Extended	Above + sacrum, pelvic side wall muscles

Requires colostomy + ileal conduit (urinary diversion if bladder removed)
Perineal defect reconstructed with rectus abdominis or gluteal flap

Key Structures Preserved (Nerves at Risk)

Nerve	Origin	Function	At Risk During
Hypogastric plexus (sympathetic)	L1-L3 (preaortic)	Ejaculation, bladder neck closure	IMA high ligation, sacral promontory dissection
Pelvic plexus (parasympathetic)	S2, S3, S4 (nervi erigentes)	Erection, bladder voiding	Lateral rectal dissection
Pudendal nerve	S2-S4	Anal sphincter tone, perineal sensation	Perineal phase of APER
Left ureter	Retroperitoneal	Urine drainage	Left colon / sigmoid mobilisation
Membranous urethra	-	Urinary continence	Anterior dissection in APER (male)

Comparison: LAR vs. APER

Feature	Low Anterior Resection (LAR)	Abdominoperineal Excision (APER)
Tumour level	Middle/upper rectum	Lower rectum / invades sphincter
Anal sphincters	Preserved	Excised
Stoma	Temporary covering ileostomy	Permanent end-colostomy
TME type	Complete	Complete + extralevator (cylindrical)
Approach	Abdominal only	Abdominal + perineal
Anastomosis	Yes (stapled)	No
Local recurrence risk	Low (with TME)	Low (with extralevator excision)
Positive CRM risk	Lower	Higher if standard (reduced with extralevator APER)

Sources

Bailey and Love's Short Practice of Surgery, 28th Edition, Chapter 79 (pp. 1434-1436)
Sabiston Textbook of Surgery, 21st Edition, Chapter 96 (pp. 2137-2139)
Fischer's Mastery of Surgery, 8th Edition, Chapter 145 (Mesorectal Anterior Excision)
Yamada's Textbook of Gastroenterology, 7th Edition (Surgical treatment for rectal cancer)

Generate a detailed surgical atlas poster showing TME dissection planes

Generating Image

Detailed surgical atlas poster titled "Total Mesorectal Excision (TME) - Dissection Planes" for medical education. Scientific anatomical illustration style with clean white background. Main central illustration: Large sagittal cross-section of male pelvis showing: - Rectum in center with clearly labeled mesorectum (fatty envelope around rectum) - Tumor shown as pink nodule in mid-rectum - Labeled dissection planes with colored dotted/dashed lines: * POSTERIOR plane: between presacral fascia (Waldeyer's fascia) and fascia propria of rectum (mesorectal investing fascia) - shown in blue dotted line * ANTERIOR plane: anterior to Denonvilliers' fascia, between rectum and prostate/seminal vesicles - shown in red dotted line * LATERAL planes: along pelvic side walls - shown in green dotted line - Anatomical labels pointing to: Sacrum, Presacral fascia, Fascia propria of rectum, Mesorectum, Denonvilliers' fascia, Prostate, Seminal vesicles, Bladder, Peritoneum, Levator ani, Waldeyer's rectosacral fascia, Puborectalis, Anal canal, Anococcygeal ligament Top left inset diagram: Axial/cross-sectional view of rectum at mid-pelvis showing: - Concentric layers: rectal wall, mesorectum, investing fascia, parietal fascia - Circumferential resection margin (CRM) indicated - Label: "Holy Plane of TME" with arrow Top right inset: Posterior view showing hypogastric nerves and pelvic plexus with labels: - Superior hypogastric plexus - Left and right hypogastric nerves - Inferior hypogastric (pelvic) plexus - IMA (inferior mesenteric artery) stump - Sacral promontory - Nervi erigentes S2-S4 Bottom panel: Three-step sequential diagrams showing progression of TME dissection: Step 1 - "Posterior Dissection: Enter presacral space at sacral promontory" Step 2 - "Lateral Dissection: Divide lateral ligaments preserving pelvic nerves" Step 3 - "Anterior Dissection: Anterior to Denonvilliers' fascia" Bottom right inset: Completed TME specimen showing intact mesorectal envelope with label "Intact mesorectal fascia = oncologically correct TME" Color-coded legend box: - Blue = Posterior dissection plane - Red = Anterior dissection plane - Green = Lateral dissection planes - Yellow shading = Mesorectum - Orange = Nerves to preserve Title banner at top: "TOTAL MESORECTAL EXCISION (TME) - Surgical Dissection Planes" in bold dark blue Subtitle: "Anatomical Guide for Rectal Cancer Surgery" Footer: "Bailey & Love / Sabiston Surgical Atlas Reference" Professional medical atlas style, anatomically accurate, high detail, suitable for surgical training

Running Command

mkdir -p /home/daytona/workspace/tme-poster && ls /home/daytona/workspace/tme-poster/

Writing File

~/tme-poster/tme_atlas.py

"""
TME Surgical Atlas Poster - Total Mesorectal Excision Dissection Planes
"""

import matplotlib.pyplot as plt
import matplotlib.patches as mpatches
from matplotlib.patches import FancyArrowPatch, Arc, Ellipse, FancyBboxPatch, PathPatch
from matplotlib.path import Path
import matplotlib.patheffects as pe
import numpy as np

# ── Canvas ─────────────────────────────────────────────────────────────────
fig = plt.figure(figsize=(22, 28), facecolor='#F8F6F0')
fig.patch.set_linewidth(6)
fig.patch.set_edgecolor('#1a3a5c')

# Color palette
C = dict(
    bg        = '#F8F6F0',
    title_bg  = '#1a3a5c',
    title_fg  = '#FFFFFF',
    bone      = '#EDE0C4',
    bone_dark = '#C8B89A',
    rectum    = '#C05050',
    rectum_lm = '#8B2020',
    mesrect   = '#F4C4A0',
    bladder   = '#A0B8D8',
    prostate  = '#C4A0C8',
    fascia    = '#8B6914',
    plane_p   = '#1565C0',   # posterior - blue
    plane_a   = '#C62828',   # anterior  - red
    plane_l   = '#2E7D32',   # lateral   - green
    nerve     = '#F57F17',   # nerves    - amber
    lymph     = '#4A148C',   # lymphatics - purple
    section_bg= '#E8F4FD',
    heading   = '#1a3a5c',
    text      = '#2C2C2C',
    tumor     = '#B71C1C',
    levator   = '#5D8A5E',
    label_box = '#FFFFFFCC',
)

# ── Title Banner ────────────────────────────────────────────────────────────
title_ax = fig.add_axes([0, 0.945, 1, 0.055])
title_ax.set_facecolor(C['title_bg'])
title_ax.set_xlim(0,1); title_ax.set_ylim(0,1)
title_ax.axis('off')
title_ax.text(0.5, 0.70, 'TOTAL MESORECTAL EXCISION (TME)',
              ha='center', va='center', fontsize=30, fontweight='bold',
              color='white', fontfamily='DejaVu Sans')
title_ax.text(0.5, 0.20, 'Surgical Dissection Planes — Anatomical Atlas for Rectal Cancer Surgery',
              ha='center', va='center', fontsize=15, color='#B0C4DE',
              fontfamily='DejaVu Sans')

# ═══════════════════════════════════════════════════════════════════════════
# MAIN SAGITTAL DIAGRAM  (left half, tall)
# ═══════════════════════════════════════════════════════════════════════════
main_ax = fig.add_axes([0.02, 0.32, 0.56, 0.60])
main_ax.set_facecolor(C['bg'])
main_ax.set_xlim(-1, 11); main_ax.set_ylim(-1, 14)
main_ax.axis('off')
main_ax.set_aspect('equal')

def filled_curve(ax, xs, ys, color, alpha=1.0, zorder=2, lw=1.5, ec=None):
    ec = ec or color
    ax.fill(xs, ys, color=color, alpha=alpha, zorder=zorder)
    ax.plot(xs, ys, color=ec, lw=lw, zorder=zorder+1)

# ── Sacrum / Coccyx ─────────────────────────────────────────────────────────
sacrum_x = [6.5, 9.5, 9.8, 9.2, 9.4, 8.8, 9.0, 8.4, 8.2, 7.2, 6.5]
sacrum_y = [13.5, 13.5, 12.5, 11.5, 10.5, 9.5, 8.5, 7.5, 6.5, 5.5, 13.5]
filled_curve(main_ax, sacrum_x, sacrum_y, C['bone'], ec=C['bone_dark'], zorder=2)
# Coccyx
coccyx_x = [7.2, 8.2, 8.0, 7.6, 7.2]
coccyx_y = [5.5, 6.5, 5.0, 4.0, 5.5]
filled_curve(main_ax, coccyx_x, coccyx_y, C['bone'], ec=C['bone_dark'], zorder=2)
main_ax.text(8.8, 11.5, 'Sacrum', fontsize=10, color=C['text'], fontweight='bold', zorder=10)
main_ax.text(7.4, 4.5, 'Coccyx', fontsize=9, color=C['text'], zorder=10)

# ── Lumbar vertebra (top) ───────────────────────────────────────────────────
for yi, lbl in zip([13.0], ['L5']):
    main_ax.add_patch(FancyBboxPatch((6.6, yi-0.4), 2.2, 0.8,
                      boxstyle="round,pad=0.05", fc=C['bone'], ec=C['bone_dark'], lw=1.5, zorder=3))
    main_ax.text(7.7, yi, lbl, ha='center', va='center', fontsize=8, color=C['text'], zorder=10)

# ── Presacral fascia ────────────────────────────────────────────────────────
pf_x = [7.0, 8.8, 8.5, 8.0, 7.6, 7.2, 7.0]
pf_y = [13.0, 13.0, 11.2, 9.2, 7.2, 5.8, 13.0]
filled_curve(main_ax, pf_x, pf_y, '#D4B896', alpha=0.6, ec='#8B6914', lw=1.5, zorder=3)
main_ax.text(8.15, 9.8, 'Presacral\nfascia', fontsize=8.5, color=C['fascia'],
             fontstyle='italic', zorder=10, ha='center')

# ── Waldeyer's fascia (rectosacral) ─────────────────────────────────────────
wald_x = np.array([4.8, 5.2, 5.8, 6.5, 7.0])
wald_y = np.array([5.8, 5.5, 5.2, 5.4, 5.8])
main_ax.plot(wald_x, wald_y, color='#5C4000', lw=2.5, ls='--', zorder=6)
main_ax.text(5.0, 5.0, "Waldeyer's fascia\n(rectosacral)", fontsize=8, color='#5C4000',
             fontstyle='italic', zorder=10)

# ── Mesorectum (fatty envelope) ─────────────────────────────────────────────
meso_x = [3.5, 3.2, 3.0, 3.1, 3.4, 3.8, 4.2, 4.5, 4.8, 5.2, 5.8, 6.2,
          6.8, 7.2, 7.5, 7.3, 6.8, 6.0, 5.0, 4.0, 3.5]
meso_y = [12.5, 11.5, 10.0, 8.5, 7.0, 6.0, 5.6, 5.5, 5.4, 5.2, 5.0, 5.2,
          5.8, 6.5, 8.0, 10.0, 11.5, 12.5, 13.0, 12.8, 12.5]
filled_curve(main_ax, meso_x, meso_y, C['mesrect'], alpha=0.85, ec='#CC7733', lw=2, zorder=4)
main_ax.text(4.0, 9.0, 'Mesorectum\n(fatty envelope\nwith lymph nodes)', fontsize=9,
             color='#884400', fontweight='bold', zorder=10, ha='center')

# ── Fascia propria of rectum (investing fascia) ──────────────────────────────
fp_x = [3.8, 3.6, 3.5, 3.6, 3.9, 4.2, 4.6, 4.8, 5.1, 5.5, 5.8, 6.2,
        6.6, 6.9, 7.0, 6.8, 6.4, 5.8, 5.0, 4.2, 3.8]
fp_y = [12.2, 11.2, 9.8, 8.5, 7.2, 6.4, 6.0, 5.9, 5.8, 5.6, 5.5, 5.7,
        6.2, 7.2, 8.5, 10.0, 11.2, 12.0, 12.5, 12.4, 12.2]
filled_curve(main_ax, fp_x, fp_y, '#F8D4B0', alpha=0.9, ec='#CC5500', lw=2.0, zorder=5)

# ── Rectum wall ──────────────────────────────────────────────────────────────
rect_x = [4.2, 4.0, 3.9, 4.0, 4.2, 4.5, 4.7, 5.0, 5.3, 5.6, 5.9, 6.1,
          6.3, 6.5, 6.4, 6.2, 5.8, 5.3, 4.8, 4.2]
rect_y = [12.0, 11.0, 9.8, 8.5, 7.5, 6.8, 6.4, 6.2, 6.0, 5.9, 6.0, 6.2,
          6.8, 7.5, 9.0, 10.5, 11.5, 12.2, 12.3, 12.0]
filled_curve(main_ax, rect_x, rect_y, '#D4706A', alpha=0.9, ec=C['rectum_lm'], lw=2, zorder=6)
main_ax.text(5.15, 9.2, 'RECTUM', fontsize=11, fontweight='bold',
             color='white', ha='center', va='center', zorder=10)

# ── Tumor ────────────────────────────────────────────────────────────────────
tumor_patch = Ellipse((5.1, 7.5), 0.85, 0.65, fc=C['tumor'], ec='#800000', lw=2, zorder=8)
main_ax.add_patch(tumor_patch)
main_ax.text(5.1, 7.5, 'T', ha='center', va='center', fontsize=9, fontweight='bold',
             color='white', zorder=9)

# ── Anal canal ───────────────────────────────────────────────────────────────
anal_x = [4.5, 4.3, 4.2, 4.3, 4.5, 5.0, 5.5, 5.7, 5.6, 5.4, 4.5]
anal_y = [5.5, 4.8, 4.0, 3.3, 2.8, 2.6, 2.8, 3.3, 4.0, 5.0, 5.5]
filled_curve(main_ax, anal_x, anal_y, '#A05050', ec='#703030', lw=1.5, zorder=7)
main_ax.text(5.0, 3.5, 'Anal\ncanal', fontsize=8.5, ha='center', color='white',
             fontweight='bold', zorder=10)

# ── Levator ani ──────────────────────────────────────────────────────────────
lev_x = [3.0, 3.2, 3.6, 4.2, 4.5, 5.5, 6.0, 6.5, 7.0, 7.5, 7.5, 7.0,
         6.5, 5.5, 4.5, 3.8, 3.2, 3.0]
lev_y = [4.5, 4.8, 5.0, 5.2, 5.3, 5.4, 5.3, 5.2, 5.0, 4.8, 4.2, 4.4,
         4.5, 4.6, 4.5, 4.3, 4.0, 4.5]
filled_curve(main_ax, lev_x, lev_y, C['levator'], alpha=0.7, ec='#2E5E2E', lw=2, zorder=5)
main_ax.text(3.0, 4.6, 'Levator ani\n(puborectalis +\npubococcygeus)', fontsize=8,
             color=C['levator'], fontstyle='italic', zorder=10)

# ── Bladder ──────────────────────────────────────────────────────────────────
bladder_patch = Ellipse((1.8, 9.5), 2.4, 3.2, fc=C['bladder'], ec='#1a5276', lw=2, alpha=0.85, zorder=5)
main_ax.add_patch(bladder_patch)
main_ax.text(1.8, 9.5, 'Bladder', ha='center', va='center', fontsize=9,
             fontweight='bold', color='#1a5276', zorder=10)

# ── Prostate / Seminal vesicles ───────────────────────────────────────────────
prostate_patch = Ellipse((2.5, 7.0), 1.8, 1.2, fc=C['prostate'], ec='#6a0dad', lw=1.5, alpha=0.85, zorder=6)
main_ax.add_patch(prostate_patch)
main_ax.text(2.5, 7.0, 'Prostate', ha='center', va='center', fontsize=8.5,
             fontweight='bold', color='white', zorder=10)

sv_patch = Ellipse((2.8, 8.1), 1.4, 0.7, fc='#D0B0E0', ec='#6a0dad', lw=1.5, alpha=0.85, zorder=6)
main_ax.add_patch(sv_patch)
main_ax.text(2.8, 8.1, 'Sem. vesicles', ha='center', va='center', fontsize=7.5,
             color='#4a0078', zorder=10)

# ── Denonvilliers' fascia ─────────────────────────────────────────────────────
den_x = [3.5, 3.6, 3.8, 3.9, 4.0]
den_y = [8.8, 7.8, 7.0, 6.4, 6.0]
main_ax.plot(den_x, den_y, color='#8B0000', lw=3, ls='-.', zorder=8)
main_ax.text(1.5, 7.8, "Denonvilliers'\nfascia", fontsize=8.5, color='#8B0000',
             fontstyle='italic', zorder=10, ha='center')
main_ax.annotate('', xy=(3.55, 8.3), xytext=(2.4, 8.0),
                arrowprops=dict(arrowstyle='->', color='#8B0000', lw=1.5))

# ── Peritoneum reflection ─────────────────────────────────────────────────────
per_x = [0.5, 1.0, 1.5, 2.5, 3.2, 3.5, 3.6, 3.8, 4.0, 4.5, 5.0, 5.5, 5.8, 6.0,
         6.2, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, 9.5, 10.5]
per_y = [13.8, 13.5, 13.0, 12.0, 11.5, 11.2, 10.8, 10.5, 10.4, 10.2, 10.0, 9.8, 9.7, 9.5,
         9.2, 9.0, 9.2, 9.5, 10.0, 10.5, 11.0, 11.5, 12.0]
main_ax.plot(per_x, per_y, color='#2E8B57', lw=2.5, ls=':', zorder=7)
main_ax.text(1.2, 13.2, 'Peritoneum', fontsize=8.5, color='#2E8B57', fontstyle='italic', zorder=10)

# ═══════════════════════════════════════════════════════════════════════════════
# DISSECTION PLANE ARROWS & LABELS
# ═══════════════════════════════════════════════════════════════════════════════

# ── POSTERIOR plane (blue) ────────────────────────────────────────────────────
post_plane_x = np.linspace(6.0, 7.3, 30)
post_plane_y = np.linspace(12.0, 5.8, 30)
main_ax.plot(post_plane_x, post_plane_y, color=C['plane_p'], lw=4, ls='--',
             dashes=(8,4), zorder=9, alpha=0.9)
# Arrow on the plane
main_ax.annotate('', xy=(6.8, 7.5), xytext=(6.5, 10.5),
                arrowprops=dict(arrowstyle='->', color=C['plane_p'], lw=2.5))

# ── ANTERIOR plane (red) ──────────────────────────────────────────────────────
ant_plane_x = [3.8, 3.7, 3.6, 3.6, 3.7, 3.8, 3.9, 4.0]
ant_plane_y = [11.5, 10.5, 9.5, 8.5, 7.5, 6.8, 6.2, 5.8]
main_ax.plot(ant_plane_x, ant_plane_y, color=C['plane_a'], lw=4, ls='--',
             dashes=(8,4), zorder=9, alpha=0.9)
main_ax.annotate('', xy=(3.7, 8.0), xytext=(3.9, 10.5),
                arrowprops=dict(arrowstyle='->', color=C['plane_a'], lw=2.5))

# ── LATERAL planes (green) ────────────────────────────────────────────────────
main_ax.annotate('', xy=(4.0, 6.5), xytext=(2.5, 7.0),
                arrowprops=dict(arrowstyle='->', color=C['plane_l'], lw=2.5,
                                connectionstyle='arc3,rad=0.2'))
main_ax.annotate('', xy=(6.5, 6.5), xytext=(8.0, 7.0),
                arrowprops=dict(arrowstyle='->', color=C['plane_l'], lw=2.5,
                                connectionstyle='arc3,rad=-0.2'))

# ── Nerve paths (amber) ──────────────────────────────────────────────────────
# Hypogastric nerves along sacral promontory
nerve_x = [6.8, 6.5, 6.2, 5.9, 5.6]
nerve_y = [12.5, 12.0, 11.3, 10.5, 9.8]
main_ax.plot(nerve_x, nerve_y, color=C['nerve'], lw=3, zorder=9)
main_ax.plot([n+0.3 for n in nerve_x], nerve_y, color=C['nerve'], lw=3, zorder=9)
# Nervi erigentes
for sx, sy in [(7.5, 9.0), (7.5, 8.0), (7.5, 7.0)]:
    ex, ey = sx - 2.8, sy - 1.0
    main_ax.annotate('', xy=(ex, ey), xytext=(sx, sy),
                    arrowprops=dict(arrowstyle='->', color=C['nerve'], lw=1.8))

# ═══════════════════════════════════════════════════════════════════════════════
# CALLOUT LABELS (right side)
# ═══════════════════════════════════════════════════════════════════════════════
labels = [
    (6.8, 11.0, 12.5, 11.5, 'Hypogastric\nnerves\n(sympathetic L1-L3)', C['nerve']),
    (7.5, 8.5, 10.5, 8.5, 'Nervi erigentes\n(S2,S3,S4)', C['nerve']),
    (7.5, 6.5, 10.5, 6.5, 'Pelvic (inferior\nhypogastric)\nplexus', C['nerve']),
    (7.0, 5.6, 10.5, 5.6, "Waldeyer's\n(rectosacral)\nfascia", '#5C4000'),
]

for lx, ly, tx, ty, txt, col in labels:
    main_ax.annotate(txt, xy=(lx, ly), xytext=(tx, ty),
                    fontsize=8.5, color=col,
                    arrowprops=dict(arrowstyle='-', color=col, lw=1.3),
                    bbox=dict(boxstyle='round,pad=0.3', fc='white', ec=col, alpha=0.9))

# Structures labels (left side)
struct_labels = [
    (3.5, 11.0, -0.5, 11.5, 'Fascia propria\nof rectum\n(investing fascia)', C['plane_a']),
    (3.0, 6.5, -0.5, 6.5, 'Mesorectal\ninvesting\nfascia', '#CC5500'),
]
for lx, ly, tx, ty, txt, col in struct_labels:
    main_ax.annotate(txt, xy=(lx, ly), xytext=(tx, ty),
                    fontsize=8.5, color=col,
                    arrowprops=dict(arrowstyle='-', color=col, lw=1.3),
                    bbox=dict(boxstyle='round,pad=0.3', fc='white', ec=col, alpha=0.9))

# Tumor label
main_ax.annotate('TUMOUR', xy=(5.1, 7.5), xytext=(1.0, 7.3),
                fontsize=9, color=C['tumor'], fontweight='bold',
                arrowprops=dict(arrowstyle='->', color=C['tumor'], lw=1.8),
                bbox=dict(boxstyle='round,pad=0.3', fc='#FFE0E0', ec=C['tumor']))

# Main ax title
main_ax.text(5.0, 13.8, 'SAGITTAL VIEW — Male Pelvis',
             ha='center', fontsize=13, fontweight='bold', color=C['heading'], zorder=12)

# ═══════════════════════════════════════════════════════════════════════════
# TOP-RIGHT: AXIAL CROSS-SECTION
# ═══════════════════════════════════════════════════════════════════════════
ax_ax = fig.add_axes([0.60, 0.72, 0.38, 0.22])
ax_ax.set_facecolor(C['section_bg'])
ax_ax.set_xlim(-5, 5); ax_ax.set_ylim(-5, 5)
ax_ax.axis('off')
ax_ax.set_aspect('equal')

# Background circle (pelvis wall)
pelvis = plt.Circle((0,0), 4.5, fc='#E8D5B5', ec=C['bone_dark'], lw=2.5)
ax_ax.add_patch(pelvis)

# Parietal pelvic fascia
parietal = plt.Circle((0,0), 3.8, fc='#D4C4A0', ec='#9B7A30', lw=2.5)
ax_ax.add_patch(parietal)

# Mesorectum ring
meso_c = plt.Circle((0,0), 2.6, fc=C['mesrect'], ec='#CC7733', lw=3.0)
ax_ax.add_patch(meso_c)

# Fascia propria ring
fp_c = plt.Circle((0,0), 1.7, fc='#F0C0A0', ec='#CC5500', lw=2.0)
ax_ax.add_patch(fp_c)

# Rectum lumen
rect_c = plt.Circle((0,0), 1.1, fc=C['rectum'], ec=C['rectum_lm'], lw=2.0)
ax_ax.add_patch(rect_c)

# Tumor patch
t_c = plt.Circle((0.5, -0.6), 0.45, fc=C['tumor'], ec='#800000', lw=1.5)
ax_ax.add_patch(t_c)
ax_ax.text(0.5, -0.6, 'T', ha='center', va='center', fontsize=7, fontweight='bold', color='white')

# CRM dashed circle
crm = plt.Circle((0,0), 3.0, fc='none', ec='#CC0000', lw=2.5, ls='--')
ax_ax.add_patch(crm)

# Holy Plane arrow
ax_ax.annotate('', xy=(2.6*np.cos(np.radians(45)), 2.6*np.sin(np.radians(45))),
               xytext=(3.5*np.cos(np.radians(45)), 3.5*np.sin(np.radians(45))),
               arrowprops=dict(arrowstyle='<->', color=C['plane_p'], lw=2.5))

# Labels
ax_ax.text(0, 0, 'Rectum\nlumen', ha='center', va='center', fontsize=7,
           color='white', fontweight='bold')
ax_ax.text(0, 1.35, 'Fascia\npropria', ha='center', va='center', fontsize=6.5, color='#883300')
ax_ax.text(0, 2.15, 'Mesorectum', ha='center', va='center', fontsize=7, color='#884400', fontweight='bold')
ax_ax.text(0, 3.0, 'CRM', ha='center', va='center', fontsize=7.5, color='#CC0000',
           fontweight='bold',
           bbox=dict(boxstyle='round,pad=0.2', fc='white', ec='#CC0000', alpha=0.9))
ax_ax.text(-4.2, 3.8, 'Pelvic\nwall', ha='center', fontsize=6.5, color=C['text'])

# Holy plane label
ax_ax.text(4.8, 4.5, '"Holy Plane"\nof TME', ha='right', fontsize=8,
           color=C['plane_p'], fontweight='bold',
           bbox=dict(boxstyle='round,pad=0.3', fc='#E8F0FF', ec=C['plane_p'], alpha=0.95))
ax_ax.annotate('', xy=(2.8, 2.8), xytext=(4.2, 4.0),
               arrowprops=dict(arrowstyle='->', color=C['plane_p'], lw=1.8))

ax_ax.set_title('AXIAL VIEW — Mid-Rectum Cross-Section',
                fontsize=11, fontweight='bold', color=C['heading'], pad=8)

# ═══════════════════════════════════════════════════════════════════════════
# MID-RIGHT: NERVE ANATOMY PANEL
# ═══════════════════════════════════════════════════════════════════════════
nerve_ax = fig.add_axes([0.60, 0.50, 0.38, 0.20])
nerve_ax.set_facecolor(C['section_bg'])
nerve_ax.set_xlim(0, 10); nerve_ax.set_ylim(0, 6)
nerve_ax.axis('off')
nerve_ax.set_title('AUTONOMIC NERVE ANATOMY (Posterior View)',
                   fontsize=11, fontweight='bold', color=C['heading'], pad=6)

# IMA and aorta
nerve_ax.plot([5, 5], [6.0, 4.8], color='#CC2222', lw=5, solid_capstyle='round', zorder=3)
nerve_ax.text(5.3, 5.5, 'Aorta / IMA', fontsize=8, color='#CC2222')

# Superior hypogastric plexus
shp = Ellipse((5, 4.3), 2.5, 0.6, fc='#FFE082', ec=C['nerve'], lw=2, zorder=4)
nerve_ax.add_patch(shp)
nerve_ax.text(5, 4.3, 'Superior hypogastric plexus', ha='center', va='center',
              fontsize=7.5, fontweight='bold', color='#7B5E00')

# Left and right hypogastric nerves
nerve_ax.plot([4.0, 2.5], [4.0, 2.5], color=C['nerve'], lw=2.5, zorder=4)
nerve_ax.plot([6.0, 7.5], [4.0, 2.5], color=C['nerve'], lw=2.5, zorder=4)
nerve_ax.text(2.0, 2.3, 'L hypogastric\nnerve', fontsize=7.5, ha='center', color=C['nerve'])
nerve_ax.text(8.0, 2.3, 'R hypogastric\nnerve', fontsize=7.5, ha='center', color=C['nerve'])

# Nervi erigentes from sacrum
for sx, col_off in [(2.5, -0.3), (5.0, 0), (7.5, 0.3)]:
    nerve_ax.plot([sx + col_off, sx + col_off - 0.5], [0.8, 2.0],
                  color='#1565C0', lw=2, ls='--', zorder=4)
    nerve_ax.text(sx + col_off, 0.5, 'S2-S4', fontsize=7, ha='center', color='#1565C0')

# Inferior hypogastric plexus
ihp_l = Ellipse((2.5, 2.0), 1.8, 0.7, fc='#FFE082', ec=C['nerve'], lw=2, zorder=5)
ihp_r = Ellipse((7.5, 2.0), 1.8, 0.7, fc='#FFE082', ec=C['nerve'], lw=2, zorder=5)
nerve_ax.add_patch(ihp_l)
nerve_ax.add_patch(ihp_r)
nerve_ax.text(2.5, 2.0, 'Pelvic plexus\n(IHP)', ha='center', va='center', fontsize=7, color='#7B5E00')
nerve_ax.text(7.5, 2.0, 'Pelvic plexus\n(IHP)', ha='center', va='center', fontsize=7, color='#7B5E00')

# Rectum schematic
rect_nerve = FancyBboxPatch((3.8, 0.2), 2.4, 3.5, boxstyle="round,pad=0.2",
                             fc=C['rectum'], ec=C['rectum_lm'], lw=2, alpha=0.6, zorder=3)
nerve_ax.add_patch(rect_nerve)
nerve_ax.text(5.0, 2.0, 'RECTUM', ha='center', va='center', fontsize=8,
              fontweight='bold', color='white', zorder=6)

# Legend
nerve_ax.plot([0.2, 0.8], [0.8, 0.8], color=C['nerve'], lw=2.5)
nerve_ax.text(0.9, 0.8, 'Sympathetic', fontsize=7, va='center', color=C['nerve'])
nerve_ax.plot([0.2, 0.8], [0.4, 0.4], color='#1565C0', lw=2.5, ls='--')
nerve_ax.text(0.9, 0.4, 'Parasympathetic', fontsize=7, va='center', color='#1565C0')

# ═══════════════════════════════════════════════════════════════════════════
# BOTTOM PANEL: 3-STEP SEQUENTIAL DISSECTION
# ═══════════════════════════════════════════════════════════════════════════
step_colors = [C['plane_p'], C['plane_a'], C['plane_l']]
step_titles = ['STEP 1: POSTERIOR DISSECTION',
               'STEP 2: ANTERIOR DISSECTION',
               'STEP 3: LATERAL DISSECTION']
step_texts = [
    'Enter presacral space at\nsacral promontory (L5/S1).\nDissect anterior to presacral\nfascia, posterior to fascia\npropria of rectum.\nPreserve hypogastric nerves.\nIncise Waldeyer\'s fascia at\nanorectal junction.',
    'Anterior to Denonvilliers\'\nfascia (between rectum and\nprostate / seminal vesicles\nin male; or posterior vaginal\nwall in female).\nProtect membranous urethra\n(palpate urinary catheter).',
    'Divide lateral ligaments\n("lateral stalks") bilaterally.\nPreserve pelvic plexuses\n(inferior hypogastric plexus)\non pelvic side wall.\nNervi erigentes at greatest\nrisk here (S2, S3, S4).'
]
step_icons = ['⬇ Posterior', '⬆ Anterior', '↔ Lateral']

for i, (col, title, text, icon) in enumerate(zip(step_colors, step_titles, step_texts, step_icons)):
    ax_s = fig.add_axes([0.03 + i*0.325, 0.10, 0.295, 0.20])
    ax_s.set_facecolor('#FFFFFF')
    for spine in ax_s.spines.values():
        spine.set_edgecolor(col); spine.set_linewidth(3)
    ax_s.axis('off')

    # Header strip
    ax_s.add_patch(FancyBboxPatch((0, 0.82), 1, 0.18,
                   boxstyle="square,pad=0", fc=col, ec=col, transform=ax_s.transAxes))
    ax_s.text(0.5, 0.91, title, ha='center', va='center', fontsize=10, fontweight='bold',
              color='white', transform=ax_s.transAxes)

    # Schematic mini-diagram
    ax_s.set_xlim(0, 10); ax_s.set_ylim(0, 10)
    # Sacrum (right)
    sac = FancyBboxPatch((6.5, 2), 2.5, 7, boxstyle="round,pad=0.2",
                          fc=C['bone'], ec=C['bone_dark'], lw=1.5)
    ax_s.add_patch(sac)
    # Rectum
    rec = FancyBboxPatch((3.5, 2), 2.0, 7, boxstyle="round,pad=0.3",
                          fc=C['rectum'], ec=C['rectum_lm'], lw=1.5, alpha=0.85)
    ax_s.add_patch(rec)
    # Mesorectum
    meso_mini = FancyBboxPatch((3.0, 2), 3.0, 7, boxstyle="round,pad=0.2",
                                fc=C['mesrect'], ec='#CC7733', lw=1.5, alpha=0.7, zorder=1)
    ax_s.add_patch(meso_mini)

    # Dissection arrow based on step
    if i == 0:  # posterior
        ax_s.annotate('', xy=(6.3, 5.5), xytext=(5.2, 5.5),
                      arrowprops=dict(arrowstyle='->', color=col, lw=3))
        ax_s.text(5.75, 6.2, 'PLANE', ha='center', fontsize=8, color=col, fontweight='bold')
    elif i == 1:  # anterior
        ax_s.add_patch(FancyBboxPatch((1.0, 3), 2.0, 3.5, boxstyle="round,pad=0.2",
                       fc=C['prostate'], ec='#6a0dad', lw=1.5, alpha=0.8))
        ax_s.text(2.0, 4.75, 'Prostate', ha='center', fontsize=7, color='white')
        ax_s.annotate('', xy=(3.2, 5.5), xytext=(3.2, 5.5),
                      arrowprops=dict(arrowstyle='->', color=col, lw=3))
        ax_s.plot([3.2, 3.2], [2.5, 8.5], color=col, lw=3, ls='--', dashes=(5,3))
        ax_s.text(3.9, 8.8, 'PLANE', ha='center', fontsize=8, color=col, fontweight='bold')
    else:  # lateral
        for xs, xe, ys in [(1.5, 2.9, 5.0), (8.5, 6.1, 5.0)]:
            ax_s.annotate('', xy=(xe, ys), xytext=(xs, ys),
                          arrowprops=dict(arrowstyle='->', color=col, lw=3))

    # Text description
    ax_s.text(5.0, 1.5, text, ha='center', va='top', fontsize=7.5, color=C['text'],
              transform=ax_s.transData,
              bbox=dict(boxstyle='round,pad=0.4', fc='#F0F8FF', ec=col, alpha=0.9))

# ═══════════════════════════════════════════════════════════════════════════
# LEGEND BOX
# ═══════════════════════════════════════════════════════════════════════════
leg_ax = fig.add_axes([0.62, 0.10, 0.35, 0.19])
leg_ax.set_facecolor('#FAFAFA')
for spine in leg_ax.spines.values():
    spine.set_edgecolor(C['heading']); spine.set_linewidth(2)
leg_ax.axis('off')
leg_ax.text(0.5, 0.95, 'LEGEND', ha='center', va='top', fontsize=11, fontweight='bold',
            color=C['heading'], transform=leg_ax.transAxes)

legend_items = [
    (C['plane_p'], '--', 'Posterior dissection plane (blue)'),
    (C['plane_a'], '--', 'Anterior dissection plane (red)'),
    (C['plane_l'], '--', 'Lateral dissection planes (green)'),
    (C['nerve'],   '-',  'Autonomic nerves (amber) — PRESERVE'),
    ('#CC7733',    '-',  'Mesorectum / mesorectal envelope'),
    (C['rectum'],  '-',  'Rectum'),
    (C['tumor'],   '-',  'Tumour'),
    ('#CC0000',    '--', 'Circumferential resection margin (CRM)'),
]
for j, (col, ls, lbl) in enumerate(legend_items):
    y = 0.85 - j * 0.11
    leg_ax.plot([0.03, 0.12], [y, y], color=col, lw=3 if ls == '-' else 2,
                ls=ls, transform=leg_ax.transAxes)
    leg_ax.text(0.15, y, lbl, va='center', fontsize=8, color=C['text'],
                transform=leg_ax.transAxes)

# ═══════════════════════════════════════════════════════════════════════════
# FOOTER
# ═══════════════════════════════════════════════════════════════════════════
foot_ax = fig.add_axes([0, 0, 1, 0.04])
foot_ax.set_facecolor(C['title_bg'])
foot_ax.axis('off')
foot_ax.text(0.5, 0.55,
             'Sources: Bailey & Love\'s Short Practice of Surgery (28e) · Sabiston Textbook of Surgery (21e) · Fischer\'s Mastery of Surgery (8e)',
             ha='center', va='center', fontsize=9, color='#B0C4DE')
foot_ax.text(0.5, 0.15,
             'TME reduces local recurrence from ~25% → ~6%  |  5-year survival improves from ~60% → ~73%',
             ha='center', va='center', fontsize=9.5, color='#FFD700', fontweight='bold')

# ═══════════════════════════════════════════════════════════════════════════
# SAVE
# ═══════════════════════════════════════════════════════════════════════════
out = '/home/daytona/workspace/tme-poster/TME_Surgical_Atlas.png'
plt.savefig(out, dpi=180, bbox_inches='tight', facecolor=C['bg'])
print(f"Saved: {out}")
plt.close()

Running Command

cd /home/daytona/workspace/tme-poster && python tme_atlas.py 2>&1

Reading File

Running Command

ls -lh /home/daytona/workspace/tme-poster/TME_Surgical_Atlas.png

Your surgical atlas poster is ready:

TME Surgical Atlas
Image · PNG
(1.1 MB, 180 dpi)

Here is what the poster contains across its 5 panels:

1. Main Sagittal View (large, left panel)

Full male pelvis cross-section showing: sacrum/coccyx, bladder, prostate, seminal vesicles, rectum, mesorectum, anal canal, levator ani
Color-coded dissection planes drawn in-situ:
- Blue dashed line = posterior plane (between presacral fascia and fascia propria)
- Red dashed line = anterior plane (anterior to Denonvilliers' fascia)
- Green arrows = lateral dissection directions
Fascial layers labeled: presacral fascia, fascia propria of rectum, Waldeyer's (rectosacral) fascia, Denonvilliers' fascia, peritoneum
Nerve pathways: hypogastric nerves, nervi erigentes (S2-S4), pelvic plexus

2. Axial Cross-Section Inset (top-right)

Concentric ring diagram showing: rectal lumen, fascia propria, mesorectum, CRM (circumferential resection margin in red dashes)
The "Holy Plane of TME" labeled with arrow

3. Nerve Anatomy Panel (mid-right)

Posterior view showing the full autonomic nerve map: superior hypogastric plexus → hypogastric nerves → inferior hypogastric (pelvic) plexus + nervi erigentes from S2-S4

4. Three-Step Sequential Dissection (bottom strip)

Step 1: Posterior - enter presacral space, incise Waldeyer's fascia
Step 2: Anterior - Denonvilliers' fascia plane, protect urethra
Step 3: Lateral - divide lateral stalks, preserve pelvic plexus

5. Color Legend + Key Stats

Full color coding guide
Footer stat: TME reduces local recurrence 25% → 6%, improves 5-year survival 60% → 73%

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