Orris

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

Reading File
Finding Sources
Finding Sources
Searching the Web

colorectal carcinoma surgery types steps structures removed comparison

Finding Sources
Finding Sources
Finding Sources
Reading File
Finding Sources
Reading File
Reading File
Reading File
Reading File
Finding Sources
Reading File
Loading Image
Loading Image
Loading Image
Finding Sources
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

FeatureRight HemicolectomyLeft HemicolectomySigmoid ColectomyHigh Anterior Resection (HAR)Low Anterior Resection (LAR)Abdominoperineal Excision (APE)Hartmann's ProcedurePelvic Exenteration
Tumour locationCaecum, ascending, hepatic flexure, proximal transverse colonDescending colon, splenic flexureSigmoid colonUpper 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 removedTerminal ileum (10-15 cm), caecum, ascending colon, hepatic flexure, proximal transverse colon, associated mesocolon, ileocolic and right colic lymph nodesDescending colon, splenic flexure, part of transverse colon, associated mesocolon, left colic LNsSigmoid colon, mesosigmoid, sigmoid vessels, LNsUpper rectum (≥3 cm below tumour), mesorectum (partial TME), sigmoid colon, superior rectal vessels, LNsUpper + middle + lower rectum (complete TME), mesorectum en bloc, sigmoid colon, pelvic LNsSigmoid colon, entire rectum, mesorectum, anus, anal sphincters, levator ani, ischiorectal fat, perineal skin, pelvic LNsSigmoid colon + rectum (stump closed), no anastomosisAll APE structures PLUS bladder ± prostate (male), or uterus ± posterior vaginal wall (female)
AnastomosisIleocolic (ileum to transverse colon)Colorectal or colo-colicColorectalColorectalColorectal (stapled, low)None - end colostomyNone - end colostomy (rectal stump closed)Colostomy ± ileal conduit (if bladder removed)
StomaUsually noneUsually noneUsually noneUsually noneDefunctioning loop ileostomy often usedPermanent end-colostomy (left iliac fossa)Permanent end-colostomyPermanent colostomy ± urostomy
Anal sphincter preserved?YesYesYesYesYesNoYesNo (if APE component)
TME performed?NoNoNoPartial (proximal TME)Complete TMEComplete TME + extralevator excisionNoComplete
Key vessels ligatedIleocolic artery, right colic artery, right branch of middle colic arteryLeft colic artery, inferior mesenteric arteryInferior mesenteric artery or sigmoid vesselsSuperior rectal artery, IMA (high ligation)IMA at origin or just distal (high ligation)IMA, middle rectal vessels, pudendal branchesIMAIMA + internal iliac vessels

1. Right Hemicolectomy

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

Steps:

  1. Incision - Midline laparotomy or right-sided laparoscopic ports
  2. Exploration - Assess liver, peritoneum for metastases
  3. Mobilisation - Divide peritoneal reflection lateral to ascending colon (white line of Toldt), reflect medially
  4. Ureter and duodenum identification - Protected during dissection (right ureter, second part of duodenum)
  5. Vascular ligation - High ligation of ileocolic artery, right colic artery, and right branch of middle colic artery at their origins (CME principle)
  6. Mesocolon division - En bloc with draining lymph nodes (complete mesocolic excision, CME)
  7. Bowel transection - Terminal ileum (10-15 cm proximal) and mid-transverse colon
  8. 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:

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

3. Sigmoid Colectomy

Indication: Sigmoid colon tumours.

Steps:

  1. Mobilise sigmoid colon by dividing lateral peritoneal attachments
  2. Identify and protect left ureter (crosses iliac vessels)
  3. High ligation of IMA or sigmoid branches
  4. Divide sigmoid mesentery with lymph node clearance
  5. Bowel transection: proximal sigmoid to upper rectum
  6. 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):

  1. Midline incision (or laparoscopic port placement)
  2. Full laparotomy - Assess for synchronous lesions, metastases
  3. Sigmoid and descending colon mobilisation - Divide left peritoneal reflection, mobilise to midline; protect left ureter and gonadal vessels
  4. Splenic flexure mobilisation - To achieve tension-free anastomosis
  5. IMA ligation - High ligation at or just below aorta (preserving superior hypogastric plexus where possible)
  6. Posterior rectal dissection - In the TME plane: anterior to presacral fascia, posterior to fascia propria; preserve hypogastric nerves over sacral promontory
  7. Lateral rectal dissection - Divide lateral ligaments; preserve pelvic plexuses (S2, S3, S4 parasympathetics)
  8. Anterior rectal dissection - Anterior to Denonvilliers' fascia (between rectum and prostate/seminal vesicles in male; rectum and vagina in female)
  9. 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)
  10. Proximal colonic transection - With adequate proximal margin
  11. Stapled colorectal anastomosis - Circular stapler per anum (end-to-end or end-to-side)
  12. 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):
  1. Midline laparotomy or laparoscopic access
  2. 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
  3. IMA ligation, mobilisation of sigmoid colon
  4. Sigmoid divided proximally; proximal end brought out as end colostomy in left iliac fossa
  5. Dissection purposely stops before reaching pelvic floor (to avoid thin margins)
Perineal Phase:
  1. Patient repositioned (prone jack-knife or Lloyd-Davies lithotomy)
  2. Circumanal incision - Elliptical incision around anus (anus sutured closed prior to incision)
  3. Deepened into ischiorectal fossae bilaterally, extending toward levator muscle attachment at pelvic side wall
  4. Posterior dissection - Waldeyer's (rectosacral) fascia is incised posteriorly; coccyx may be removed to improve access
  5. Anterior dissection - Plane between rectum and prostate/membranous urethra (male - catheter palpated to protect urethra) or between rectum and posterior vaginal wall (female)
  6. Levator ani division - Pubococcygeus and puborectalis divided from pelvic side wall
  7. Specimen retrieved through perineal wound en bloc
  8. Perineal wound closed with drains to pelvis
Perineal phase of APE: separation and division of pubococcygeus and puborectalis muscles during circumanal dissection
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.
TypeStructures Removed
Posterior exenterationRectum + posterior vagina/uterus
Total exenterationRectum + bladder + prostate (male) OR rectum + uterus + bladder (female)
ExtendedAbove + 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)

NerveOriginFunctionAt Risk During
Hypogastric plexus (sympathetic)L1-L3 (preaortic)Ejaculation, bladder neck closureIMA high ligation, sacral promontory dissection
Pelvic plexus (parasympathetic)S2, S3, S4 (nervi erigentes)Erection, bladder voidingLateral rectal dissection
Pudendal nerveS2-S4Anal sphincter tone, perineal sensationPerineal phase of APER
Left ureterRetroperitonealUrine drainageLeft colon / sigmoid mobilisation
Membranous urethra-Urinary continenceAnterior dissection in APER (male)

Comparison: LAR vs. APER

FeatureLow Anterior Resection (LAR)Abdominoperineal Excision (APER)
Tumour levelMiddle/upper rectumLower rectum / invades sphincter
Anal sphinctersPreservedExcised
StomaTemporary covering ileostomyPermanent end-colostomy
TME typeCompleteComplete + extralevator (cylindrical)
ApproachAbdominal onlyAbdominal + perineal
AnastomosisYes (stapled)No
Local recurrence riskLow (with TME)Low (with extralevator excision)
Positive CRM riskLowerHigher 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
Running Command
Writing File
Running Command
Reading File
Running Command
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%
This is a shared conversation. Sign in to Orris to start your own chat.