Classification and types of interventions
All surgeries for rectal cancer are divided into radical (complete removal of the tumor block) and palliative (e.g., creation of an artificial anus for fecal diversion without tumor removal).
Radical interventions are performed via abdominal, abdominosacral, or combined approaches. There are three main types of surgeries:
- Resection — excision of the affected segment while preserving the sphincter and restoring bowel continuity (or bringing out a stoma).
- Extirpation — complete removal of the rectum along with the sphincter apparatus and creation of a permanent stoma on the anterior abdominal wall.
- Amputation — removal of the distal part with pull-through of the central stump into the perineal wound.
Basic radical operations include abdominoperineal extirpation, intraperitoneal ("anterior") resection, Hartmann's operation, abdominoanal pull-through resection, and perineal amputation.
Hartmann's operation
Intraperitoneal resection according to Hartmann is used when restoring the continuity of the intestinal tract is impossible or inexpedient.
- Essence: Removal of a portion of the rectum and sigmoid colon.
- Distal end: Closed blindly, forming a blind pouch in the pelvic cavity.
- Proximal end: Brought out onto the abdomen as a single-barreled artificial anus (anus praeternaturalis).
Abdominoperineal extirpation (Miles' operation)
This is a single-stage operation aimed at the total removal of the rectum, anal canal, sphincter, and surrounding adipose tissue with lymph nodes. It consists of two stages.
I. Abdominal stage: A lower midline laparotomy is performed. The sigmoid colon is retracted to the left. The peritoneum is incised with a lyre-shaped incision: starting 4 cm above the promontorium (L4 level), extending down along the right edge of the bowel to the pelvic floor, and returning upwards. The mesenteric vessels are ligated below the origin of the left colic artery (a. colica sinistra). The bowel is separated bluntly and sharply from the sacrum, and anteriorly from the vagina/uterus in women or urinary bladder/prostate in men. The sigmoid colon is transected, the distal end is placed at the bottom of the pelvis and reperitonealized. The proximal end is brought out as a colostomy, suturing the mesentery to the parietal peritoneum (to prevent internal herniation).
II. Perineal stage: The patient is in the lithotomy position. The anus is closed with a purse-string suture. The tissues around the anus are incised with two elliptical incisions. The levator ani muscles (m. levator ani) are suture-ligated and transected. The specimen is removed en bloc, and the wound is partially closed with sutures and packed.
Abdominoanal resection (pull-through operation)
Used to preserve the natural sphincter apparatus. The affected rectum is removed, and the mobilized sigmoid colon is pulled down to replace it.
Mobilization features: It is critical to assess the blood supply of the graft. To ensure adequate blood supply to the pulled-through bowel, preservation of the marginal arcade is mandatory. If the length is insufficient, the splenic flexure of the colon is mobilized. Pull-through into the pelvis is performed strictly without tension.
Anal stage and completion: The rectal mucosa is incised at the mucocutaneous junction and dissected upward for 4 cm. A transverse skin incision is made anterior to the coccyx, and the anococcygeal ligament is transected. The muscular wall of the bowel is cut with Cooper's scissors above the internal sphincter. The stretched anal ring is pulled down. The seromuscular layer of the sigmoid colon is sutured to the edges of the anal wound. The affected segment is resected, and the bowel lumen is left open. The wound above the coccyx is loosely packed.
Briefly: answers to topical questions
Which pelvic floor and perineal muscles are suture-ligated and transected during the perineal stage of Miles' operation?
During the perineal stage of one-stage abdominoperineal extirpation, the levator ani muscles are suture-ligated and transected. Dissection during this stage also involves cutting the skin, subcutaneous fat, and ischioanal fossa fat.
- Levator ani muscle (m. levator ani) — suture-ligated and transected after approximating the wound edges for subsequent en-bloc removal of the rectum.
To remember the essence of Hartmann's operation: "Hartmann cut, but did not anastomose" — the distal end is closed blindly (blind pouch), and the proximal end is brought out as a colostomy; there is no anastomosis.
Class and exam questions
How does a radical surgery differ from a palliative one in rectal cancer?
Radical surgery aims to remove the tumor en bloc with lymph nodes and surrounding tissue. Palliative surgery (e.g., creation of a colostomy) merely relieves symptoms by diverting feces in cases of an unresectable tumor.
What is a lyre-shaped incision?
This is a specific type of pelvic peritoneum incision during the abdominal stage of extirpation. It begins above the sacral promontory, extends down along the bowel to the pelvic floor, and returns upward on the other side.
Why is the mesentery of the brought-out bowel sutured to the peritoneum during stoma formation?
Fixation of the mesentery to the parietal peritoneum of the lateral abdominal wall (usually 2–3 sutures) is necessary to prevent internal herniation of bowel loops into the resulting pocket.
What else to study on this topic
- Topography of the sigmoid and rectal mesenteric vessels (marginal arcade)
- Technique of pelvic floor reperitonealization after rectal excision
- Features of rectal mobilization in men and women (relations to the prostate gland and vagina)
- Anatomy of the pelvic floor muscles (m. levator ani, sphincters)
Master the complete topic in the "Topographic Anatomy" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Radical surgeries for rectal cancer" and 2,777 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 91 video lessons on the subject
Other topics in the section «Pelvic and Perineal Surgery»
Free video lessons: topographic anatomyShort lessons with study notes — no registration required.
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.