Main surgical approaches and methods
The choice of the optimal surgical technique in the surgical treatment of benign neoplasms of the terminal digestive tract strictly relies on topical diagnostics and the anatomical features of the specific affected area. In the modern arsenal of the operating surgeon, there are four basic technical approaches, each of which has its own strict indications. These include:
- Transanal excision — performed through the natural anal opening when the pathology is located low.
- Electrocoagulation — performed using endoscopic equipment through a rectoscope tube.
- Posterior proctotomy — a surgical approach that involves longitudinal dissection of the tissues of the posterior wall of the rectum.
- Transperitoneal colotomy — a radical approach from the abdominal cavity side.
Tactics for low location (up to 10 cm)
The surgical algorithm and choice of instruments naturally change as the pathological focus moves proximally away from the anocutaneous line.
- Involvement of the anal region: For adequate visualization of the surgical field and to ensure convenient access, a standard rectal speculum is used. After exposing the area of interest, the neoplasm is securely fixed and pulled down with a surgical clamp, after which its complete resection is performed. The mucosal defect formed after removal requires mandatory closure. For this purpose, surgeons place interrupted catgut sutures, which ensure complete hemostasis and precise alignment of the mucosal wound edges.
- Localization at a distance of 6–10 cm from the anus: The basic surgical technique remains completely analogous to transanal excision in the anal canal. The key difference lies exclusively in the instrumentation used for the operation. Due to the significantly greater depth of the pathological focus, instead of a regular rectal speculum, the surgical team uses a large gynecological speculum. This instrument allows for a more effective retraction of the rectal walls at this given depth and provides the surgeon with the necessary viewing angle and freedom of manipulation.
Tactics for high location (11–25 cm)
In clinical cases where the neoplasm is localized at a considerable distance — from 11 to 25 centimeters from the anal sphincter — direct transanal access using any specula becomes technically unfeasible. In such situations, electrocoagulation becomes the alternative-free method of choice.
This surgical intervention is carried out under constant visual control through the lumen of an inserted rectoscope. To perform precise manipulations in the bowel lumen at such a significant depth, specialized elongated instruments are required. According to the classical technique, surgeons use a sturdy steel forceps holder, which is originally designed for bronchoesophagoscopy. At the distal end of this holder, various interchangeable working tips can be securely fixed, the choice of which is dictated by the shape, size, and density of the grasped tissues. The standard set of such tips includes fenestrated attachments, sharp tenacula for maximum rigid fixation, as well as cup-shaped elements.
Features of removing large polyps on a broad base
A particular and most complex surgical problem is represented by massive neoplasms that have a broad base and are located in the upper (proximal) sections of the rectum. The main clinical danger of such large structures lies in the extremely high risk of their malignant transformation (malignancy).
It is precisely due to this high oncological vigilance that simple superficial resection or standard electrocoagulation in this particular case are categorically unacceptable. A large polyp on a broad base must be removed exclusively en bloc together with the underlying section of the rectal wall. To perform such a radical scope of surgical intervention, surgeons are forced to use more complex and traumatic approaches:
- Posterior proctotomy, during which the surgeon performs a longitudinal dissection of the posterior wall of the rectum to directly reach the base of the formation.
- Transperitoneal colotomy, which requires full opening of the abdominal cavity to provide access to the affected intestinal segment.
Briefly: answers to topical questions
Which arteries supply blood to the rectum in the area where transanal excision is performed?
The blood supply to the rectum involves:
- Superior rectal artery (a. rectalis superior) — the terminal branch of the inferior mesenteric artery, running toward the ampulla of the rectum.
- Middle rectal arteries (aa. rectales mediae) — located on the pelvic diaphragm.
- Inferior rectal arteries (aa. rectales inferiores) — pass through the ischioanal fossa in the frontal plane.
Which autonomic nerve plexuses can be damaged during bowel mobilization during transperitoneal colotomy?
The innervation of the rectum involves:
- Inferior mesenteric plexus (plexus mesentericus inferior).
- Superior hypogastric plexus (plexus hypogastricus superior), also called the presacral nerve (n. presacralis).
- Inferior hypogastric plexuses (plexus hypogastrici inferiores dexter et sinister), which are joined by the pelvic splanchnic nerves.
- Myenteric plexus of Auerbach and submucosal plexus of Meissner.
The "10-25-Broad" rule: up to 10 cm — specula and excision, 11–25 cm — rectoscope and coagulation, Broad base — proctotomy/colotomy and removal with the wall.
Class and exam questions
What suture material is used to close the mucosa after excision of an anal polyp?
Interrupted catgut sutures are used to close the mucosal defect after the neoplasm is excised.
What is the difference in surgical technique when a polyp is localized 8 cm from the anus compared to the anal region?
The core excision technique remains the same, however, for adequate access and visualization at a depth of 6–10 cm, a large gynecological speculum is used instead of a rectal speculum.
What instruments are used for electrocoagulation of formations at a depth of 11–25 cm?
The manipulation is performed via a rectoscope. The working instrument used is a steel forceps holder for bronchoesophagoscopy with interchangeable tips (fenestrated, tenaculum, or cup-shaped).
Why do large polyps on a broad base require excision together with a section of the bowel wall?
Radical removal en bloc with the bowel wall is necessary due to the extremely high risk of malignant transformation (malignancy) of such large formations.
What else to study on this topic
- Topographic anatomy of the rectum and anal canal
- Technique of posterior proctotomy: layer-by-layer access
- Transperitoneal colotomy: indications and stages of surgery
- Endoscopic equipment: design of the rectoscope and bronchoesophagoscope
- Types of surgical sutures on the wall of a hollow organ
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