Removal of the rectum consequences of removal of the tube. Anterior rectal resection Using Levitra after anterior rectal resection

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low anterior resection of the rectum for malignant neoplasms

A.I. Abelevich, State Educational Institution of Higher Professional Education "Nizhny Novgorod State medical Academy Ministry of Health and Social Development"

Abelevich Alexander Isakovich - e-mail: [email protected]

The article summarizes the experience of 240 low anterior resections performed at the Nizhny Novgorod Surgical Clinic named after. A.I. Kozhevnikov regional hospital for 2003-2009. The criteria for choosing proximal, lateral and distal resection boundaries, indications for mobilization of the left flexure of the colon, and technical features of hardware sigmoidal anastomosis are shown. Indications for the application of a discharge stoma and a rational option for diversion of intestinal contents were determined. The use of the complex of technical and tactical techniques described above makes it possible to perform low anterior resections of the rectum with a minimum number of postoperative complications and a mortality rate of less than 1%.

Key words: low anterior resection, mobilization, lymph node dissection, resection boundaries, sigmoidal anastomosis, unloading stoma.

The experience of 240 low anterior rectum resections performed at Nizhny Novgorod surgical clinic named after A.I. Kozhevnikov of Regional hospital at 2003-2009 is summarized in the article. The criteria of choosing of proximal, lateral and distal borders of resection, indications for mobilization of left flexure of colon, technical features of hardware-based sigmoidorectal anastomosis are described. The indications for application of protective stoma and a rational variant of diversion of intestinal contents are defined. The use of the described above combination of technical and tactical ways gives an opportunity to perform low anterior rectum resections with minimal number of post operation complications and lethality less than 1%.

Key words: low anterior resection, mobilization, lymphodissection, borders of resection,

sigmoidorectal anastomosis, protective stoma

Anterior rectal resection was developed in the 30s of the twentieth century by Dixon and gradually became the operation of choice for upper ampullary rectal cancer. However, with mid-ampullary tumor localization, abdominal-anal resection of the rectum was performed for a long time, characterized by radicalism and relative simplicity of execution. At the same time, the unsatisfactory functional results of this operation increasingly forced surgeons to resort to a more functionally effective low anterior rectal resection. In the General Surgery Clinic of the Nizhny Novgorod Regional Hospital, both abdominal-anal resection of the rectum and standard anterior resection have been performed by several generations of surgeons for 46 years, but low anterior resections have become widespread only in the last decade. This paper summarizes the experience of 240 low anterior resections performed in the clinic in 2003-2009.

An important component of successful surgical treatment is the rational choice of proximal, lateral and distal resection boundaries. They are mainly determined based on the location of the tumor and the stage of the disease.

The proximal resection line usually runs along the sigmoid colon quite far from the tumor and is mainly determined not by the distance to the tumor, but by the length of the sigmoid colon, the option of the upcoming lymph node dissection and the architectonics of the vessels in the inferior mesenteric artery basin. High is preferred

ligation of the superior rectal artery immediately below the origin of the left colon, which ensures mobility of the sigmoid colon and practically does not disrupt its blood supply thanks to the vessels of the left and middle colon artery system. In addition, high ligation facilitates extended aortoiliac lymph node dissection.

One of the key steps that determines the choice of the proximal resection margin is the mobilization of the left flexure of the colon. We highlight the following indications for it:

1. the need for aortoiliac lymph node dissection due to the presence of pathologically altered retroperitoneal lymph nodes. Extended lymph node dissection, performed without the use of endoscopic technology, itself requires a wide median laparotomy and intersection of the inferior mesenteric artery at the origin, which makes mobilization of the left half of the colon more reasonable and logical;

2. the presence of fecal stones in the colon due to tumor obstruction. It becomes possible to move fecal stones to the removed part of the colon and perform a primary anastomosis even with subcompensated intestinal obstruction;

3. pathologically altered sigmoid colon. Any organic changes in the intestine, for example, diverticulosis, require at least a sigmoidectomy and, therefore, mobilization of the overlying parts of the colon;

4. doubt about adequate blood supply to the sigmoid colon after its mobilization. In the presence of even slight changes in the color of the serous cover and weak marginal pulsation of the vessels, the application of a sigmorectal anastomosis becomes risky. In these cases, we resort to additional mobilization of the overlying sections of the intestine, which allows us to cut off an area with questionable microcirculation;

5. short sigmoid colon. Attempts to move it into the pelvis by mobilizing only the descending colon without releasing the left flexure can lead to tissue tension in the area of the sigmoidal anastomosis.

With a sufficient length of the sigmoid colon, good blood supply and the absence of intestinal contents in its lumen, it is possible to form a reliable sigmoid anastomosis without additional mobilization of the overlying parts of the intestine. In this case, the operation can be performed from a low-traumatic inferomedial approach.

The lateral border of resection, as a rule, runs between the visceral and parietal fascia along the avascular zone. Preparation in this layer ensures minimal bleeding and low-traumatic mobilization of the rectum. Going beyond the layer may be necessary if the primary tumor or its regional metastases spread beyond the boundaries of the mesorectal tissue. Manipulation in these areas often leads to bleeding from the veins of the sacrum, the lateral walls of the pelvis or the Santorini plexus. Preliminary ligation of the internal iliac arteries and work with electrosurgical instruments can reduce blood loss. Expansion of the resection margin can also lead to damage to autonomic nerve fibers. Nerve-saving technique of extended and combined operations in the absence of involvement of the sympathetic and parasympathetic trunks in pathological process is a necessary component of modern surgical technology.

The distal margin of resection mainly depends on the location of the pathological focus. For tumors whose lower edge is located 7-10 cm from the anus, the level of intestinal intersection is determined by indenting 3-4 cm distal to the visible or palpable boundaries of the tumor. Difficulties may arise with small, difficult to palpate tumors. In these cases, preoperative marking of the distal border of the bowel under optical control is preferable. coherence tomography by applying a mark to the mucous membrane with an electrocoagulator or using a graduated indicator of the level of anastomosis inserted into the anus during surgery. The role of such a determinant can also be played by an ordinary rectoscope, on which centimeter marks are applied.

ditch marks, however, its use is less convenient and more traumatic for the rectal mucosa. Low anterior resection provides that after cutting off the mobilized complex, the rectum is subtotally resected and the mesorectal tissue is completely removed. Next, either a supralevator sigmorectal anastomosis or an anastomosis is formed between the sigmoid colon and the surgical anal canal at the level of the levator ani muscle.

For tumors whose lower edge is located 11-13 cm from the anus, the choice of the distal resection margin depends on the presence or absence of tumor invasion of the mesorectal tissue. Stages T1^0M0 allow for the possibility of an indentation of 3 cm in the distal direction, transsection of the mesorectum and a relatively high sigmoidal anastomosis, which, in fact, means the abandonment of low anterior resection in favor of the traditional extent of the operation. At the stage of the disease T3^0-2M0, it is advisable to perform a mesorectumectomy, which means low anterior resection with a supralevator anastomosis. We proved this by comparing the results of anterior and low anterior rectal resections performed in the clinic over the period from 1997 to 2003. The analysis showed that after operations accompanied by complete removal of mesorectal tissue, a smaller number of locoregional relapses are recorded than after “high” anterior resection, in which part of the mesorectum remains not removed. In this case, the substrate for relapse can be both regional The lymph nodes, and the mesorectal tissue itself, due to implantation metastasis.

Implantation of tumor cells is most typical for tumors growing outside the intestine. Careful handling of tissues, isolation with tampons or other material can only partially solve the problem, since it is usually not possible to achieve complete absence of contact of the tumor with surrounding tissues. Cells lying freely in the lumen are another source of implantation when the intestine is crossed and anastomosis is performed. They are removed by intraoperative lavage of the rectal stump. In this case, the nature of the liquid used for lavage does not matter; only the complete mechanical removal of neoplastic cells from the intestinal lumen is important. Rinsing the pelvic cavity with antiseptic solutions after anastomosis is another measure to prevent implantation metastasis. However, all these measures do not guarantee complete ablastics, especially when leaving mesorectal tissue as a substrate for implantation. This proves the need for its complete removal, and therefore, the wider use of low anterior resection for locally advanced cancer of the upper ampullary rectum.

In some cases, sigmorectal anastomosis with low anterior resection of the rectum can be performed manually, but most surgeons tend to use staplers. Unfortunately, hardware anastomosis is not without its drawbacks, the main ones being less reliability than with manual suture and higher price, which was the basis for our limited use of mechanical suture in the period before 2003. However, subsequent comparative analysis showed that anastomosis on an open rectal stump is accompanied by a large number of locoregional relapses, which, apparently, is associated with the same implantation of tumor cells during the process of anastomosis.

The operations that use hardware anastomosis in the form of a double suturing technique are characterized by the greatest aplasticity and asepticity. We perform this type of intervention as follows. After mobilization is completed, an L-shaped clamp is applied to the rectum, the stump is sanitized and stitched across with a linear stapler. After removing the mobilized complex, a hardware rod is inserted into the sigmoid colon, fixed with a wrapping or purse-string suture, and the device itself is inserted into the rectum. By rotating the cylinder, a spear is pulled out of the apparatus, piercing the tissue near the linear staple seam, and a rod with the sigmoid colon is put on the spear. By reverse rotation of the cylinder, the device is brought as close as possible to the rod and a squeezing movement of the handle forms a mechanical anastomosis, after which the device, together with the rod and the tissues cut with a circular knife, is removed from the anus. Comparative characteristics of various staplers showed the advantages of circular staplers from Autosuture and Ethicon with a working part diameter of 28, 29, 31, 33, 34 mm. Unfortunately, domestically produced devices, both circular staplers and compression ones, turned out to be less reliable and last years are not used by us.

During the operation, you must pay attention to the following technical features:

1. In cases where the distance from the intended anastomosis to the zone of maximum sphincter pressure, previously measured during anorectal manometry, does not exceed 2 cm, it is preferable to perform a side-to-end anastomosis, which will subsequently minimize the manifestations of low anterior resection syndrome.

2. If the length of the linear suture exceeds the diameter of the circular apparatus, then excess intestine remains on the sides of the anastomosis, called “dog ears” or “dog ears” in foreign literature. If possible, they are immersed with semi-purse string sutures. In the non-immersed version, the “weak spots” at the junction of the linear and circular sutures are strengthened with seromuscular sutures.

3. One or two drainage tubes are installed behind the rectal stump, and it is preferable to use an original device for pelvic drainage, which is a metal rod curved along the curvature of the sacrum and sharpened in a special way, onto the base of which drainage is placed. The diameter of the rod corresponds to the outer diameter of the drainage, which allows you to quickly and atraumatically pass it through the perineal tissue.

4. The tightness of the hardware anastomosis is confirmed by an air sample. If there is no tightness, the air introduced into the anus appears in the form of bubbles in the antiseptic liquid, which is previously poured into the basin. The defect, if possible, is sutured with an atraumatic thread.

5. The pelvic peritoneum is restored hermetically. If it is deficient, it is possible to use uterine appendages, a flap of the greater omentum, or an allograft.

6. The anastomosis is temporarily turned off by applying a discharge stoma, which we use in approximately 80% of cases. A stoma is not indicated only under favorable conditions, when the above technical details are easily achievable, and the adequacy of the blood supply to the sutured organs is beyond doubt.

To divert intestinal contents from the anastomosis, a loop transversostomy, or loop ileostomy, is used. The choice depends on the patient’s physique, the length of the mesentery of the transverse colon and the completeness of mobilization of the left half of the colon. In general, we give preference to transversostomy, characterized by smaller electrolyte disturbances and making it possible to use cheap non-hermetic colostomy bags. However, in obese patients with a short mesentery of the transverse colon, transversostomy is often technically more difficult, deforms the abdominal wall, and, ultimately, care for such a stoma is less convenient. In such cases, we resort to applying an ileostomy, placing it in the right iliac region. In addition, ileostomy appears to be more justified in those patients in whom the left flexure of the colon was mobilized and retracted for colorectal anastomosis. With an alternative transversostomy with removal of the right flexure of the colon, the discharge from the stoma is comparable in aggression to the chyme, but the large deformation of the abdominal wall, characteristic of a transversostomy, complicates skin care and can lead to severe parastomal dermatitis.

In cases where the sigmoid colon is excessively long and the intestine is filled with feces, a discharge sigmoid stoma can be applied. It is brought out in the form of a loop in the left iliac region. With a smooth course of the postoperative period, unloading stomas

close after one and a half to two months, and in case of complications, the possibility and timing of their closure are determined individually.

The use of the complex of technical and tactical techniques described above makes it possible to perform low anterior resections of the rectum with a minimum number of postoperative complications and a mortality rate of less than 1%. At the same time, radicalism and quality of life allow us to consider this type surgical intervention as the operation of choice in patients with neoplasms of the upper and middle ampullary sections of the rectum.

LITERATURE

1. Alexandrov V.B. Rectal cancer. M.: University Book, 2001. 208 p.

2. Vorobyov G.I. Surgery for colon cancer/50 lectures on surgery, ed. Savelyeva V.S. M.: Media Medica, 2003. 408 p.

3. Vorobyov G.I., Odaryuk T.S., Sevostyanov S.I. Immediate results of anterior rectal resection for cancer in elderly and senile people (history of the issue and own data). Clinical gerontology. 2002. T. 8. No. 12. P. 13-18.

4. Abelevich A.I., Snopova L.B. A method for preoperative determination of the distal border of rectal resection for cancer. Patent for invention No. 2290070 dated May 5, 2004, register. December 27, 2006

5. Reynolds J.V., Joyce W.P., Dolan J. et al. Pathological evidence in support of total mesorectal excision in the management of rectal cancer. Br J Surg. 1996. No. 83. R. 1112.

6. Knysh V.I. Colon and rectal cancer. M.: Medicine, 1997. 304 pp.

7. Yamana T., Oya M., Komatsu J. Preoperative anal sphincter high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity predict early postoperative defecatory function after low anterior resection for rectal cancer. Dis Colon Rectum. 1999. Sep. No. 42 (9). R. 1145-1151.

8. Corman Marvin L. Handbook of colon and rectal surgery. Philadelphia, USA.: Lippincott Williams and Wilkins. 2002. 934 p.

9. Vasiliev S.V., Grigoryan V.V., Yem A.E., Sednev A.V., Vasiliev A.S. The use of protective ileostomy in the surgical treatment of rectal cancer. Current problems of coloproctology. Materials of a scientific conference with international participation dedicated to the 40th anniversary of the State Research Center of Coloproctology. Moscow, February 2-4. 2005. pp. 176-177.

The operation to completely remove the rectum is a difficult surgical procedure to perform. It is carried out in the most advanced cases of cancer, when it is impossible to restore the tissues and functions of this part of the intestine and when methods conservative therapy do not provide a therapeutic effect. Read on to find out when such an operation is indicated, how it is performed and what its possible complications are.

In what cases is resection indicated?

The most common indications for rectal removal are:

cancer in advanced cases;
tissue necrosis;
prolapse of the intestine, which cannot be reduced.

Rectal resection is a slightly more complex operation than, for example, colon surgery. This is due to the peculiarities of the location of this part of the intestine. The rectum is tightly adjacent to the pelvic walls and the lower part of the spinal column.

In close proximity to it are the genitals, ureters, major arteries, and there is some risk of damage during the operation. It is larger for patients with significant excess weight and for those who have a naturally narrow pelvis.

In addition, due to the complexity of rectal resection, there is some likelihood that the tumor will grow again.

Diagnosis before resection

Malignant tumor is the main disease. which may lead to the need for rectal resection. Signs of cancer most often make themselves felt in the later stages, the symptoms are as follows:

disturbances in the regularity of bowel movements;
pain that is felt during defecation;
the presence of pus, mucus and blood in the stool;
tenesmus, or false and painful urge to defecate.

As the disease progresses, it becomes difficult to pass stool, constipation and serious bowel dysfunction occur. A blood test determines the presence of anemia, which is a low concentration of red blood cells.

Diagnostic procedures used to detect cancer:

examination by a proctologist;
anoscopy;
sigmoidoscopy;
ultrasonography.

Types of operations and methods of their implementation

Resection of the rectum is carried out to the border of tissues unaffected by cancer. During the operation, the nearest lymph nodes are also eliminated. If the tumor spreads widely, it is necessary to remove the anal sphincter, which performs the function of retaining feces. In this case, the surgeon creates a stoma for bowel emptying, which means wearing a colostomy bag in the future. During the operation, the fatty tissue that surrounded the tumor and some unaffected clean tissue are also removed in order to minimize the possibility of cancer growing again.

The extent of resection depends on how much the tumor has spread; according to this, the following types of operations to remove the rectum are distinguished:

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sphincter-preserving, which include transanal excision and two types of anterior resection;
abdominal-perineal extirpation, when the anal sphincter is removed and a colostomy is formed.

Anterior resection

This type of surgery involves removing only part of the rectum through the abdominal wall. This option is applicable if the tumor is localized in the upper part of the intestine. The essence of the operation is as follows. The lower part of the sigmoid and the upper part of the rectum are removed, and their edges are subsequently sutured together. This results in a kind of shortening of these sections of the intestine while maintaining the sphincter.

Low anterior resection

This option of partial removal of the rectum is performed by a surgeon if the tumor is located in its lower and middle zone. The affected parts are eliminated along with the mesentery, and the edge of the overlying colon and the remaining small lower part of the rectum are sutured. This type of sphincter-sparing operation is the most common in surgical practice and carries a minimal risk of tumor re-development.

Transanal excision

This technique is applicable for small, non-aggressive tumors located in the lower rectum. The essence of this surgical intervention is the excision of a certain area on the intestinal wall and its subsequent suturing.

Abdominoperineal extirpation

This method of removing the rectum is accompanied by the removal of the sphincter muscles and the formation of a permanent stoma inserted into the abdominal wall. Resection is carried out from both sides - through the peritoneum and from below through the perineum. Surgery is indicated for extensive tumors of the lower rectum.

Preparatory stage

The day before the resection, it is necessary to clear the intestines of feces. For this purpose, enemas and special laxatives are prescribed. Thorough bowel cleansing significantly reduces the risk of complications. You are not allowed to eat solid food the entire day before surgery. Only water, broth, teas, compote are allowed.

You should also take all medications prescribed by your doctor strictly according to schedule. It can be:

beta blockers - reduce the risk of heart complications in patients with vascular atherosclerosis;
diuretics – reduce the risk of a heart attack that can occur due to excess fluid in the body;
Antihypertensive drugs help stabilize blood pressure during surgery.

Do not take before surgery medicines, affecting blood clotting. These are NSAIDs (in particular ibuprofen and aspirin), anticoagulants. Taking medications for diabetes must be discussed with your doctor.

Possible complications

The percentage of cases of adverse consequences of surgery to remove the rectum is about 10-15%. TO possible complications include:

suppuration of the postoperative suture;
secondary growth of a cancerous tumor;
infection abdominal cavity;
in case of damage to the nerve responsible for the work Bladder and sexual desire, problems with urination and sexual function.

Some patients with rectal cancer are afraid of surgery and do not agree to have it. Most often this occurs due to the fear of not being able to control bowel movements and having to walk with a colostomy in the abdominal wall for the rest of your life (in the case of the perineal-peritoneal method).

There is no other way to completely cure a rectal tumor other than surgery. Other methods, such as radiation and chemotherapy, never guarantee a 100% result and act more often as supportive measures and are used before and after removal of the rectum.

Resection of the rectum is the excision of its affected part. The rectum continues the colon and is located from the sigmoid to the anus. This is the final part of the digestive tract, the length of which is 13-15 cm. Feces accumulate in it and are subsequently excreted. It got its name because it has no bends. The main ailments of the rectum are: various processes of inflammation, Crohn's disease, obstruction, ischemia, cancer. The main treatment for such diseases is surgery.

Types of operations

To eliminate rectal cancer, the most best treatment- operation. In medical practice, depending on the location of the tumor and its size, there are several methods of excision:

Polypectomy is the simplest operation to remove polyps and minor tumors. During this procedure, nearby tissues are minimally damaged. Surgery is performed using an endoscope if the tumor is located near the anus.
Anterior resection of the rectum - is done by removing its upper part and the lower end of the sigmoid colon. The remaining part of it is connected to the sigmoid colon. At the same time, the nervous apparatus and anus are preserved. For fast healing sometimes a temporary colostomy is applied, which is removed after a second operation after about two months.

Low anterior resection - is performed when removing pathology in the middle part of the rectum. In this case, the damaged part of the sigmoid and the entire rectum, except the anus, are excised. The reservoir function of the intestine is lost. The place for the accumulation of feces is formed from the lowered intestine, which is located above. The sigmoid colon is connected to the rectum by anamostosis. In almost all cases, an ostomy is performed to relieve the load over a period of several months.
Abdominal-anal resection - performed from the abdominal cavity and anus. Resection of the rectum is done when the pathology is located close to the anus, but does not affect it. The part of the sigmoid colon that is completely straight with the anal sphincter portion is subject to removal. The remaining sigmoid colon is used to form an anastomosis with part of the anal sphincter.
Abdominal-intermediate extirpation - through two incisions, one of which is on the abdomen, and the other around the anal canal. In this case, the rectum, anal canal and anal sphincter muscles are subject to resection. Feces are drained through the formed stoma.

Resection technique

Surgery to remove part of the rectum can be performed in two ways: using laparotomy or laparoscopy. During a laparotomy, an incision is made along the lower abdomen. The surgeon receives good review for all manipulations performed. The laparoscopic method involves several small holes for inserting surgical instruments into the abdominal cavity. The technique of open rectal resection is as follows:

The surgical field is processed and an incision is made in the abdominal wall. The abdominal cavity is carefully examined and the affected area is located.
This area is isolated by applying clamps and removed to healthy tissue. At the same time, part of the mesentery with the vessels feeding the intestine is excised. Before removal, the vessels are ligated.
After excision of the tumor, the ends of the intestine are sutured, and it can function again.

When moving from one stage of the operation to another, the surgeon changes instruments to avoid infection with intestinal contents.

Laparoscopic anterior rectal resection

As mentioned earlier, resection can be performed not only openly, but also using laparoscopy. In this case, several holes are made into which laparoscopic instruments are inserted. The proven technique for carrying out such operations is becoming increasingly popular due to the low level of trauma to the patient and a number of other advantages. The operation of anterior resection of the rectum in the upper sections begins with the intersection of the vessels. Then the affected part of the intestine is isolated and brought out through a small hole in the anterior abdominal wall, where resection is performed and the ends of the intestine are sutured.

The same steps are followed for resection of the lower colon. Anastomosis (connection of two parts of the intestine) is carried out based on anatomical conditions. If the loop is long enough, the area with the tumor is brought out through the hole, it is excised, and the ends are sutured. Otherwise, when the length of the intestine does not allow it to be brought out, resection and joining of the ends is performed in the abdominal cavity, using a special circular stapler.

Advantages of laparoscopic surgery

It has been experimentally established that the results of operations performed using the laparoscopic method are not inferior in quality to the results of rectal resection performed using laparotomy (open access). In addition, they have the following advantages:

cause fewer injuries;
short period of rehabilitation and recovery of the patient after surgery;
minor pain symptom;
absence of suppuration and postoperative hernias;
a small percentage of complications in the initial and long-term period.

Disadvantages of laparoscopy

The disadvantages include:

The laparoscopy method is not always technically possible. It may be safer for the patient to perform the operation with an open approach.
Resection requires expensive instruments and equipment.
The operation has its own specifics and is performed by highly qualified specialists, whose training requires certain funds.

In some cases, during the operation, which began using laparoscopy, they switch to laparotomy.

What will happen after the operation?

After rectal resection, the patient is transferred to the intensive care unit, where he will recover from anesthesia. The patient is then admitted to the surgical ward for further rehabilitation. During the first time after the surgical period, nutrition is administered to the patient intravenously using a dropper. After seven days, you are allowed to switch to eating regular food, prepared in liquid form. Gradually the transition to solid food is carried out. For a quick recovery, physical activity has a great influence, so the patient is recommended to walk and do exercises for respiratory system. After about ten days, the patient is discharged, but treatment will continue in the oncology department.

Resection for polyps

Rectal polyps are tumor-like formations, mostly benign in nature. But sometimes their nature changes and they become malignant tumors. In this case, the radical treatment method is resection of rectal cancer.

If there are polyps with symptoms of malignancy, part of the rectum is excised or it is completely removed. The length of the area to be removed depends on the degree of damage to the polyp. If the cancer process spreads to nearby areas of the rectum, the entire affected part is removed. And if metastases appear, then the lymph nodes must also be excised.

Types of intestinal connections after resection

After removing the abnormal section of intestine, the doctor must connect the remaining ends or perform an anastomosis. The opposite ends of the intestine may differ in diameter, so technical difficulties often arise. Surgeons use three types of connections:

End to end is the most physiological and frequently used method for recreating intestinal integrity.
Side to side - used to connect ends when their diameters do not match.
Side to end - used to connect different parts of the intestine.

For stitching, a manual or machine stitch is used. If it is technically impossible to restore the intestines or to quickly recreate its functions, a colostomy (outlet) is used on the anterior wall of the abdomen. With its help, feces are collected in a special colostomy bag. A temporary colostomy is removed after a few months, but a permanent one remains for the rest of your life.

Consequences of rectal resection

An operation to remove part of the rectum sometimes has negative consequences:

If sterility in the operating room or instruments is compromised, wound infection occurs. In this case, redness and suppuration of the suture forms, the patient’s temperature rises, chills and weakness are observed.
The occurrence of internal bleeding. It is dangerous because it does not appear immediately.
When intestinal scarring occurs, intestinal obstruction may occur. In this case, a repeat operation will be required to eliminate it.
Anastomositis is the occurrence of an inflammatory process at the junction of the ends of the rectum. The causes of inflammation are the body’s reaction to the suture material, poor adaptation of the stitched mucous membranes, tissue trauma during surgery. The disease has a chronic, catarrhal or erosive form.

After resection of the rectum, the operated organs continue to function and can be injured by feces. To prevent injury, the patient must strictly follow the diet recommended by the doctor and avoid physical activity for six months.

Nutrition in the postoperative period

IN postoperative period It is especially important to follow a special diet so that it does not injure the intestines or cause fermentation and diarrhea. On the first day after surgery, the patient fasts; the necessary vitamins and minerals are administered intravenously. Fermented milk products, legumes, raw vegetables and fruits are excluded for two weeks. Subsequently, the diet does not greatly limit the diet of the operated patient. Sample menu after rectal resection:

In the morning, drink a glass of boiled clean water. After half an hour, eat oatmeal prepared in water, adding a small amount of walnuts to it, and drink a cup of jelly.
After three hours, use applesauce for a snack.
For lunch, soup with buckwheat and fish quenelles, and tea brewed with herbs are suitable.
The afternoon snack consists of a handful of crackers and a glass of kefir.
Can be used for dinner rice porridge, chicken cutlets steamed and compote.

There are many different recipes for preparing dishes, so you can use them to have a varied diet.

Prevention of colorectal cancer

To prevent rectal cancer, you should healthy image life, breathe fresh, clean air, drink quality water, eat more plant-based foods and limit the use of animal fats. An important factor is secondary prevention, timely detection of polyps and their removal. There is a high probability of detecting cancer cells in a polyp whose size is more than five centimeters. The polyp develops very slowly over 10 years. This time is used for preventive examinations, which begin to be carried out from the age of fifty in people who do not have risk factors for developing colorectal cancer. For those who are predisposed to developing cancer, preventive measures begin ten years earlier. It is important to immediately consult a doctor if suspicious symptoms appear in the bowel function and undergo an examination so as not to undergo rectal resection.

Other reasons for the development of a tumor are a chronic inflammatory process in the intestines, as well as the presence of papillomas. Human nutrition plays an important role in the development of cancer. An unbalanced diet leads to a decrease in the body's protective functions, obesity, and vitamin deficiency, which contribute to the occurrence of intestinal pathology.

Features of tumor treatment

It is very difficult to independently diagnose an oncological process in the intestines. As a rule, this happens during a routine examination with a proctologist. However, cancer still makes itself felt with some symptoms: mucous, purulent, bloody discharge, causeless disturbances in bowel movements, pain during the passage of stool. The presence of such symptoms is a reason to seek emergency care. medical care. The consequences of such a condition can be the most dire.

Treatment of rectal cancer is comprehensive, aimed at improving the patient’s condition, restoring intestinal patency, and eliminating the painful symptoms of the disease. Rectal tumors require surgical treatment, the goal of which is to completely remove the pathological focus. Only in this case the likelihood of subsequent relapses is reduced and a complete cure for the disease occurs. Surgery for rectal cancer can be different, depending on the stage of the disease, the presence/absence of secondary foci of malignant growth (metastases), the location of the tumor, general condition the patient’s health, the presence of complications of the disease. Surgery for rectal cancer is performed exclusively by experienced surgeons who know all the intricacies of such an intervention. Surgical removal of the tumor is often accompanied by radiation or chemotherapy. Such additional procedures facilitate the process of eliminating the formation, greatly reduce the likelihood of relapse, and speed up the patient’s recovery process.

Types of surgical therapy

Thanks to modern technologies, surgery for rectal cancer does not involve complete removal of the organ. Complete elimination was done to prevent the spread of metastases, as well as to reduce the likelihood of relapses in the future. Removing stage 2 and higher colorectal cancer using modern technical equipment is easier, faster and more effective.

Surgery to remove a cancerous tumor

Surgery for rectal cancer is of the following types:

Abdominal-perineal extirpation. Indicated for the treatment of malignant neoplasms at a distance of less than 7-6 centimeters from the anus. It consists of complete elimination of the affected organ along with pararectal tissue, sphincter apparatus and lymph nodes. Includes two stages: intraperineal and intraabdominal. Typically performed by two surgical teams. It is prescribed strictly according to indications, without the possibility of performing more gentle types of surgical intervention.
Palliative surgery. Intended for the treatment of cancerous tumors when it is impossible to eliminate the area of the intestine involved in the tumor process. It consists of restoring intestinal patency above the cancerous formation by applying an unnatural double-barreled anus. Part of the organ is brought out and fixed on the peritoneum, forming a spur. In the presence of acute intestinal obstruction, the lumen is opened immediately after the formation of the outlet. Palliative surgery is prescribed in the presence of an unremovable tumor formation.
Resection. It can be abdominal-anal (according to Hochsisg), anterior or obstructive (according to Hartmann):

Abdominal-anal surgery for rectal cancer is based on partial elimination of a section of the intestine while sparing the anal sphincter and anal canal. It is supplemented by two- or one-stage restoration of the integrity of the organ. Indicated for the elimination of a cancer focus at a distance of 8 centimeters up from the anus. Subsequently, an additional procedure is performed to restore intestinal patency (anastomosis, colostomy, suturing the colon to the anal canal);
Anterior type resection is characterized by the elimination of the affected area through a hole made in the abdominal cavity. Indicated for the destruction of a lesion at a distance above 10 centimeters from the anus. After eliminating the tumor, an anastomosis is established (connecting two parts of the intestine to restore its integrity). There may be several types, depending on the location of the cancer focus;
surgery for rectal cancer according to Hartmann is based on the selective elimination of the lower parts of the large intestine through an opening in the abdominal cavity. Subsequently, a suture is placed and the colostomy is removed. Obstructive resection is indicated in emergency cases, for example, in the presence of acute intestinal obstruction. Allows you to destroy cancer at a distance above 10 centimeters from the anus.

Consequences of surgical therapy

Not everyone can overcome rectal cancer after surgery. Reviews of people who have overcome their illness claim that rectal cancer (stage 2 and above) is successfully treated in a complex way, including surgery and chemotherapy ( radiation exposure). It is almost impossible to do without surgery. Surgery for rectal cancer without chemotherapy often leads to a rapid relapse, which becomes more and more difficult to overcome each subsequent time. To avoid repeated exacerbations, it is recommended to undergo comprehensive treatment aimed at the complete destruction of cancer cells and affected parts of the organ.

After surgery, rectal cancer goes away with all the painful symptoms. In addition to following a diet, each patient must undergo a regular medical examination by a proctologist, undergo a series of tests, and periodically ultrasound diagnostics abdominal cavity. This will allow timely detection of repeated rectal cancer (relapse). If there are no signs of recurrent cancer cell damage within 5 years after surgery, almost all previously established restrictions are lifted.

Rectal operations

The rectum is operated on for a variety of reasons, depending on which the appropriate technique is selected. Excision of the rectum is technically more difficult to perform than operations on other parts of the intestine. Undesirable consequences or complications appear more often due to the high risk of damage to nearby structures in a narrow space. Regardless of the type of resection used, preparation of the organ is necessary before surgery. To do this, several methods of cleansing the intestines are used: cleansing enemas, taking drugs that improve motility, diet.

When are surgeries needed?

Frequent reasons that necessitate operations on the rectal ampulla are:

haemorrhoids;
cracks in the mucous membrane of the anal canal.

Surgical intervention is necessary for the development of:

cancer, polyposis, to prolong the patient’s life;
diverticulitis - inflammation of hernial protrusions on the intestinal walls due to infection;
pathological inflammation causing erosive damage or death of areas of the rectum;
bleeding and intestinal blockages;
Crohn's disease - chronic pathology of the transmural type;
insufficient blood supply to the rectal part due to the presence of blood clots in the main arteries of the organ.

The reason for surgery may also be explained by:

abdominal injuries of various types;
complications after other attempts at intestinal restoration.

Types of resection

There are several ways:

Anterior rectal resection. This method removes rectal cancer located at the top. To do this, an incision is made in the lower abdomen, part of the rectum and S-shaped section is removed. After excision, an anastomosis is created to connect the ends of the intestine.
Lower anterior abdominal resection. The method is used when operating on the middle and lower part of the rectum. The entire rectum, mesentery, anal canal, and sphincter muscle are removed through the lower abdomen. This approach is often necessary to completely remove the cancer while preventing possible relapse. Partial excision of the rectal ampulla involves the creation of an anastomosis between the bottom of the rectum and the anal canal. At the same time, the sphincter muscle is preserved, so there is no problem with fecal incontinence after the intervention.
Abdominal perineal extirpation of the rectum. It is performed by making an incision in the abdomen and perineum near the anus. The rectal ampulla, anal canal, and sphincter muscles are completely excised. To ensure the normal passage of stool with emptying, a colostomy is formed. Previously, this operation was performed for any type of tumor in the rectum.
Complete extirpation (excision) of an organ. This type of surgery is used for tumors located in the rectum no further than 50 mm from the anus. To make it easier for stool to pass after the intervention and to correct stool incontinence, an artificial stoma is created.
Sphincter-sparing operations. The method avoids the need to create a channel for feces drainage. The operation is performed using the latest staplers.
Transanal excision. The method involves eliminating the pathology through the anus, but preserving the functions of the sphincter. The affected area, located in the lower part of the rectum, is removed with special instruments. The incision line is sutured with two stitches. The operation is suitable for excision of small tumors with non-aggressive development and in the absence of metastases in the lymph nodes.
Removing cracks. The method is more often used to cure hemorrhoids, chronic and acute cracking of the anal canal.
Bougienage. The method involves forced expansion of the rectum with its pathological narrowing.

How long it will take to perform one type of operation or another depends on the severity of the case and the degree of tissue damage. In the postoperative period, care and a special diet are required.

Complete removal

Removal of the rectum is called proctectomy. The procedure is complex and is used in extreme cases. Reasons for appointment:

oncology;
necrosis (death) of tissues;
rectal prolapse or prolapse of the intestine without the ability to set the organ back and with the ineffectiveness of conservative treatment methods.

Proctectomy is carried out to areas with tissues unaffected by pathology with the removal of adjacent lymph nodes. If the pathogenic process is very widespread, you should get rid of the anal sphincter. To eliminate complications after resection of the sphincter muscle, such as fecal incontinence, a stoma is formed to drain the intestinal contents into a special portable colostomy bag. At the same time, the fatty tissue is excised from the affected intestine, which reduces the risk of relapse.

There are two ways to completely remove the rectum, such as:

sphincter-preserving surgery of the anterior or transanal type;
abdominal anal resection of the rectum with excision of the anus and surrounding muscle structures, which requires the creation of a permanent colostomy.

Under favorable circumstances, the operation will last up to 3 hours. If a colostomy is performed, nutrition after rectal surgery should provide the body with the necessary substances without creating problems with bowel movements.

The rectal ampulla can be removed by laparoscopic resection. Treatment with this method is minimally invasive, but requires specific equipment and highly qualified medical staff. To perform laparoscopic resection, small incisions are made in the abdominal wall. If there are appropriate conditions for carrying out and the required equipment, laparoscopic surgery gives a positive outcome, it can reduce rehabilitation time, reduce the incidence of complications, and quickly improve the well-being of operated patients. Therefore, laparoscopic surgery is one of the most popular methods.

Before any operation for complete resection of the rectum, bowel preparation is necessary. To do this, laxatives are used and enemas are given to completely empty the intestines. This will eliminate the risk of complications during surgical treatment.

Repairing cracks

The procedure is necessary for the surgical removal of any type of fissures in the anal canal. Appointed in the absence positive result conservative treatment methods. The objectives of the method are to remove the formed scar, which prevents the proper healing of the open crack. To do this, a fresh incision is made, which reverses the process into the acute phase. The problem is then cured with medication.

The operation should be performed under local or general anesthesia. The technique is selected by the doctor according to the individual characteristics of the patient: the presence of hemorrhoids, individual tolerance to anesthesia, etc. The following are used for the operation:

The result does not depend on what instrument the doctor used to perform the operation. The procedure lasts on average 8 minutes. The time may vary depending on the type of anesthesia used. Longer operations are necessary in cases where the patient is diagnosed with hemorrhoids. In this case, resection of the anal fissure includes simultaneous removal of hemorrhoids. Special care promotes wound healing. Full recovery is possible in 3-6 weeks.

Bougienage

The method is both diagnostic and medical procedures carried out to eliminate pathologies in the lower part of the anal canal. Reasons for appointment:

tissue scarring;
congenital or acquired stenosis (narrowing of the intestinal lumen).

The purpose of the method is to force the expansion of the walls of a hollow organ. Special tools are used for this:

In some cases, the procedure is performed with a finger. The principle of the method is a gradual expansion of the lumen of the rectum due to a gradual increase in the diameter of the bougie. The procedure can be carried out in several stages, which are selected by the doctor individually for each patient, depending on the complexity of the pathology. Bougie expansion can be carried out on a daily basis or every other day. After the procedure, massage of the stricture area is required. With the gradual progress of the bougie, the risk of rupture of the intestinal wall is reduced.

The method is carried out without pain relief. But in severe cases of stenosis, it is possible to use anesthesia with nitrous oxide or through intravenous infusion of painkillers. The digital expansion method is used when the scars are sufficiently elastic and can be easily stretched. Before the procedure, the gloved finger is lubricated with lidase-based ointment. Then, slowly, with turning movements, it is introduced into the rectum and the lumen is gradually expanded.

The Hegar dilator is used for severe scarring. In addition to the course of stretching, physiotherapeutic procedures are prescribed. In the absence of positive dynamics, surgical intervention is performed.

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Removal of rectal cancer

Surgeries for rectal cancer are considered technically difficult. This is due to the fact that it is here that the inflamed mucous membrane comes into contact with feces, causing additional irritation. When removing, many factors are taken into account: the rate of development of the formation, the age of the patient, the depth of penetration of pathological cells, and more. Surgery takes place in parallel with drug therapy to avoid subsequent relapses.

For complicated forms of rectal cancer, surgery is performed, which can be performed in several ways, depending on the situation and financial capabilities of the patient.

Indications for surgery

Surgery is indicated in cases where the risk of complications poses a serious threat to the patient's life. Once the diagnosis is confirmed, chemotherapy is prescribed if necessary. Not just one area, but the entire abdominal cavity is taken under control, since the development of metastases on nearby organs is possible. When conservative treatment methods are powerless and the size of the tumor increases, intestinal obstruction occurs, which is life-threatening. Surgery for rectal cancer is indicated if complete excision of the tumor is impossible, but reduction in size is required to avoid complications.

Types of operations for rectal cancer

Operations to remove formations on the rectum are divided into two main groups: palliative and radical. In the first case, we are talking about less traumatic operations that are aimed at improving the quality of life and bear exclusively therapeutic effect. Radical can be described as complex manipulations aimed at resection of formations and affected areas, as well as removal of nearby mucosal tissues in order to avoid proliferation and the formation of new metastases. Operations related to the second type are complex in their implementation; the problem lies in the inaccessibility of the location of the formation, as well as the close cluster of arteries and nerve endings.

Anterior resection

This surgical procedure is performed only if the distance of the affected area to the anus is at least 6-10 cm. In addition to the formation of cancer cells, a purulent fistula may be the reason for the procedure. The doctor makes an incision in the lower abdomen and removes the plexus of the sigmoid colon and rectum, as well as any tissue that may be affected. The main advantage is that after removal, all vital functions are preserved, and subsequently the person will be able to defecate independently.

For rectal cancer, it is carried out by intervention through two incisions in the abdominal cavity to remove the affected areas of the organ. Return to contents

Abdominoperineal extirpation

To carry out the manipulation, the surgeon makes two incisions in the abdominal cavity and perineum. The main goal is resection of the affected area of the rectum, sections of the excretory canal and surrounding tissues. An endoscope is used as a handy tool, which passes through the anus, removing small tumors. If there is no need for it, then the manipulation is carried out with a scalpel. In practice, highly traumatic methods of intervention have become less and less common; in most cases, the functionality of the anal sphincter remains the same.

Abdominoanal resection

This type of operation is carried out in several stages; not in all cases they can be done simultaneously. An incision is made in the abdominal cavity, through which the sigmoid, rectum and descending colon are removed. At the second stage, the sigmoid colon is removed through the anus and carried into the small pelvis, and the rectum is removed. All functions are retained. A colostomy for rectal cancer can be temporary; after a few months, the operation is repeated until the desired result is achieved.

Proctectomy

The operation is simple and is performed when the malignant tumor is localized low in the rectum. The doctor removes the tumor along with the rectum, then the outlet of the large intestine is connected to the anus, therefore, the physiological function of natural bowel movements remains. Sometimes it will be necessary to remove a temporary stoma until it heals; after a few months it closes.

Local resection

This type of intervention belongs to microsurgery and is used in the initial developing stage. For this, special flexible tubes with a small chamber at the end are used; with their help, small formations can be removed. If we are talking about a malignant tumor, the doctor uses surgical instruments and inserts it through the anus by touch. This intervention is called transanal resection. Rectal fistulas are often removed using this method.

Total mesorectumectomy

One of the most common types of intervention, aimed at removing a section of the affected organ, part of the rectum, along with blood vessels and lymph nodes. The fat layer is also cleaned, which significantly reduces the risk of the spread of pathogenic cells. It is worth noting that healthy tissue is removed around the entire affected area.

Pelvic exenteration

Pelvic exenteration in men is prescribed in extreme cases in case of recurrence of a dangerous rectal mass or an identified tumor in the pelvic area. This involves removing the bladder, rectum, prostate gland and anus. The surgeon makes two holes to drain urine and feces. Before performing the intervention, the doctor discusses all the benefits and possible consequences operations. In women, this operation is performed with additional cleaning of all organs of the reproductive system.

Colostomy is performed to remove feces due to problems in the rectum, as a temporary or permanent intervention. Return to contents

What is a colostomy?

A colostomy is an opening made from the free part of the colon to remove waste products (stool). A colostomy can be temporary at the time of rehabilitation or permanent. In medicine, it comes in two types: loop and end. The choice of removal is determined by the doctor depending on many factors.

Contraindications to surgery

Surgical intervention is a vital necessity, so the most common contraindication is the unstable condition of the patient. After hospitalization, the main task of the medical staff is to prepare the patient as soon as possible, since cancer cells progress rapidly. Also, concomitant infectious diseases (infectious diseases) become the reason for refusal.

How to prepare?

Before the upcoming surgical intervention, the doctor conducts a full examination and collects the necessary tests:

Before surgery for rectal cancer, the patient undergoes tests and undergoes a series of hardware procedures.

clinical analysis of blood, urine, biochemical study to determine blood group;
research to identify infectious diseases: hepatitis, syphilis, HIV;
electrocardiogram;
chest x-ray;
Ultrasound of the abdominal and pelvic organs;
examination of all specialists;
malignant tissue sample.

Return to contents

Recovery after surgery

After surgical procedures, the patient is subject to long-term observation and a course of rehabilitation. From the operating room the patient is transferred to the intensive care unit. The first two days are the hardest, it is during this period that it is important to control work of cardio-vascular system, digestive tract and respiratory system. During your stay in the hospital, tubes are inserted to flush the rectal cavity with antiseptic solutions. After 3-4 days, the patient is allowed to eat soups, broths; in normal conditions, a transition to chewing food is allowed. To relieve stress from the abdominal muscles, a bandage is worn and placed on the legs compression stockings. Six months later, plastic surgery was allowed to correct deformed areas of the body.

After removal of the malignant tumor, it will take time to restore sexual activity; if sensitivity is impaired, you should contact a specialized specialist.

Chemotherapy and drug treatment for rectal cancer may be additionally carried out even after surgery due to the risk of relapse. Return to contents

Chemotherapy and drug treatment

Not always surgical removal guarantees a complete cessation of the development of the disease; rectal cancer may recur after surgery. After the surgical procedure, chemotherapy may be prescribed. Depending on the situation, exposure to rays and reception may also be used. hormonal drugs. This is done because it is not always possible to clear the tumor completely. Painkillers are administered as medications in the first days; during the recovery period at home, Imodium is taken 30 minutes before meals, which helps cope with the load on the digestive tract.

Lifestyle, diet

After an illness, your lifestyle changes dramatically. First of all, you need to get rid of bad habits that affect your overall health. Activity should increase gradually and be distributed throughout the body, including the abdominal muscles. Food during the recovery period is mainly liquid and puree, drink plenty of water (at least 2 liters). Over time, the functioning of the gastrointestinal tract will normalize, and the diet can be expanded.

The consequences of rectal cancer depend on the stage of the disease, the quality of the surgical technique performed and proper postoperative recovery. Return to contents

Consequences of cancer

The impact of intestinal cancer on life expectancy is varied; it depends on timely diagnosis, adequacy of therapy, patient age and the presence of metastases. The consequences are the most unpredictable, one of the most common is the lack of fastening of the intestines, this occurs when the sutures in the area where the operation was performed come apart or their tension weakens. Involuntary defecation is also common when sensory nerves are damaged during removal.

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Rescue measure: types of operations to remove the rectum and possible complications

The operation to completely remove the rectum is a difficult surgical procedure to perform. It is carried out in the most advanced cases of cancer, when it is impossible to restore the tissues and functions of this part of the intestine and when conservative therapy methods do not provide a therapeutic effect. Read on to find out when such an operation is indicated, how it is performed and what its possible complications are.

In what cases is resection indicated?

The most common indications for rectal removal are:

cancer in advanced cases;
tissue necrosis;
prolapse of the intestine, which cannot be reduced.

In close proximity to it there are genital organs, ureters, large arteries, and during the operation there is some risk of damage to them. It is larger for patients with significant excess weight and for those who have a naturally narrow pelvis.

In addition, due to the complexity of rectal resection, there is some likelihood that the tumor will grow again.

Diagnosis before resection

Malignant tumor is the main disease. which may lead to the need for rectal resection. Signs of cancer most often make themselves felt in the later stages, the symptoms are as follows:

disturbances in the regularity of bowel movements;
pain that is felt during defecation;
the presence of pus, mucus and blood in the stool;
tenesmus, or false and painful urge to defecate.

As the disease progresses, it becomes difficult to pass stool, constipation and serious bowel dysfunction occur. A blood test determines the presence of anemia, which is a low concentration of red blood cells.

Diagnostic procedures used to detect cancer:

examination by a proctologist;
anoscopy;
sigmoidoscopy;
ultrasonography.

Types of operations and methods of their implementation

The extent of resection depends on how much the tumor has spread; according to this, the following types of operations to remove the rectum are distinguished:

sphincter-preserving, which include transanal excision and two types of anterior resection;
abdominal-perineal extirpation, when the anal sphincter is removed and a colostomy is formed.

Anterior resection

Low anterior resection

Transanal excision

Abdominoperineal extirpation

Preparatory stage

You should also take all medications prescribed by your doctor strictly according to schedule. It can be:

beta blockers - reduce the risk of heart complications in patients with vascular atherosclerosis;
diuretics – reduce the risk of a heart attack that can occur due to excess fluid in the body;
Antihypertensive drugs help stabilize blood pressure during surgery.

It is prohibited to take medications that affect blood clotting before surgery. These are NSAIDs (in particular ibuprofen and aspirin), anticoagulants. Taking medications for diabetes must be discussed with your doctor.

Possible complications

The percentage of cases of adverse consequences of surgery to remove the rectum is about 10-15%. Possible complications include:

suppuration of the postoperative suture;
secondary growth of a cancerous tumor;
abdominal infection;
if the nerve responsible for the functioning of the bladder and sexual desire is damaged, problems with urination and sexual function may occur.

There is no other way to completely cure a rectal tumor other than surgery. Other methods, such as radiation and chemotherapy, never guarantee a 100% result and act more often as supportive measures and are used before and after removal of the rectum.

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Surgeries on the rectum: indications, types, indications, prognosis

The rectum is the final segment of the human digestive tract and performs a very important function: feces are accumulated and excreted here. The normal functioning of this organ is very important for a full, high-quality human life.

The main diseases of the rectum: hemorrhoids, rectal prolapse, anal fissure, proctitis, paraproctitis, ulcers, benign and malignant tumors.

The most significant and most complex operations on the rectum are operations with oncological diseases this organ.

Precisely because feces accumulate in the rectum, its mucosa has the longest contact with digestive waste compared to other parts of the intestine. This explains the fact that the largest percentage of all intestinal tumors are rectal tumors.

The radical treatment for rectal cancer is surgery. Sometimes surgical treatment is combined with radiation therapy, but if a rectal tumor is diagnosed, surgery is inevitable.

The rectum is located mostly in the small pelvis, deep, which makes it difficult to access. Through a conventional laparotomy incision, only tumors of the supramullary (upper) part of this organ can be removed.

Types of rectal resections

The nature and extent of the operation depends on the location of the tumor, or more precisely, the distance from the lower edge of the tumor to the anus, on the presence of metastases and on the severity of the patient’s condition.

If the tumor is located less than 5-6 cm from the anus, abdominal-perineal extirpation of the rectum is performed, that is, its complete removal along with the surrounding tissue, lymph nodes and sphincter. During this operation, a permanent colostomy is formed - the descending sigmoid colon is brought out and sutured to the skin in the left half of the abdomen. The unnatural anus is necessary for the removal of feces.

In the first half of the 20th century, when rectal cancer was detected, only its removal was performed.

Currently, the approach to radical treatment of tumors of this organ has been revised in favor of less mutilating operations. It has been found that complete removal of the rectum is not always necessary. When the tumor is localized in the upper or middle third, sphincter-preserving operations are performed - anterior resection and abdominal-anal amputation of the rectum.

The main types of rectal operations currently used:

Abdominoperineal extirpation.
Anterior rectal resection.
Abdominal-anal amputation with reduction of the sigmoid colon.

In cases where it is impossible to radically remove the tumor, a palliative operation is performed to eliminate the symptoms of intestinal obstruction - a colostomy is removed, and the tumor itself remains in the body. Such an operation only alleviates the patient’s condition and prolongs his life.

Anterior rectal resection

The operation is performed when the tumor is located in the upper part of the intestine, on the border with the sigmoid. This section is easily accessible through the abdominal approach. The intestinal segment along with the tumor is excised and removed, the descending segment of the sigmoid and the rectal stump are sutured manually or using a special apparatus. As a result, the sphincter and natural bowel movements are preserved.

Abdominoanal resection

This type of intervention is planned if the tumor is located in the middle part of the rectum, above 6-7 cm from the anus. It also consists of two stages:

First, the sigmoid, rectum, and descending colon are mobilized through a laparotomy incision for subsequent resection and reduction.
The rectal mucosa is separated through the anus, the sigmoid colon is lowered into the small pelvis, the rectum is removed, while the anus is preserved. The sigmoid colon is sutured around the circumference of the anal canal.

It is not always possible with this type of operation to perform all stages simultaneously. Sometimes a temporary colostomy is performed on the abdominal wall, and only after some time a second operation is performed to restore intestinal continuity.

Other treatments

If the tumor size is more than 5 cm and there is suspicion of metastasis to regional lymph nodes surgical treatment usually combined with preoperative radiation therapy.
Transanal tumor resection. It is carried out using an endoscope in cases of small tumor size (no more than 3 cm), its germination no further than the muscle layer and complete confidence in the absence of metastases.
Transanal resection of part of the rectum.
It is also possible to perform laparoscopic resection of the rectum, which significantly reduces the invasiveness of the operation.

Abdominoperineal extirpation

As already mentioned, this operation is applied as radical method treatment of tumors located in the lower third of the rectum. The operation is performed in two stages - abdominal and perineal.

At the abdominal stage, a lower laparotomy is performed, the sigmoid colon is cut off at a level above the upper pole of the tumor, the descending segment of the intestine is somewhat sutured to reduce the lumen and brought into the wound, sutured to the anterior abdominal wall - a colostomy is formed to remove feces. The rectum is mobilized (the arteries are ligated, the fixing ligaments are cut). The wound is sutured.
The perineal stage of the operation involves a circular incision of the tissue around the anus, excision of the tissue surrounding the intestine and removal of the rectum along with the descending segment of the sigmoid colon. The perineum at the anus is tightly sutured.

Contraindications for rectal surgery

Since surgery for malignant tumors is a life-saving operation, the only contraindication to it is the very serious condition of the patient. Quite often, such patients actually arrive at the hospital in serious condition (cancer cachexia, anemia), but preoperative preparation for some time makes it possible to prepare such patients.

Preparing for rectal surgery

Basic examinations that are prescribed before surgery:

Analyzes: general tests blood, urine, biochemical analysis blood, coagulogram, determination of blood group and Rh factor.
Study of markers of infectious diseases - viral hepatitis, syphilis, HIV.
Electrocardiogram.
X-ray of the chest organs.
Ultrasound examination of the abdominal organs.
Examination by a therapist.
For women - examination by a gynecologist.
To more accurately determine the extent of the tumor, an MRI of the pelvic organs may be prescribed.
A biopsy of the tumor is required to determine the extent of tissue removal (for less differentiated types of tumors, the boundaries of the tissue removed should be expanded).

A few days before surgery:

A slag-free diet (with minimal fiber content) is prescribed.
Drugs that cause blood thinning are discontinued.
Antibiotics are prescribed to kill pathogenic intestinal flora.
On the day before the operation, solid food is not allowed (you can only drink), and the intestines are cleansed. It can be done:
With the help of cleansing enemas performed after some time during the day.
Or taking strong laxatives (Fortrans, Lavacol).
8 hours before surgery, food and water are not allowed.

In cases where the patient is very weakened, surgery may be postponed until the general condition normalizes. Such patients undergo blood transfusion or its components (plasma, red blood cells), parenteral administration of amino acids, saline solutions, treatment of concomitant heart failure, metabolic therapy.

The rectal resection operation is performed under general anesthesia and lasts at least 3 hours.

Postoperative period

Immediately after the operation, the patient is placed in the intensive care unit, where the functions of the heart, breathing, and gastrointestinal tract will be carefully monitored for 1-2 days.

A tube is inserted into the rectum, through which the intestinal lumen is washed with antiseptics several times a day.

Within 2-3 days the patient receives parenteral nutrition, after a few days it is possible to take liquid food with a gradual transition to solid food over two weeks.

To prevent thrombophlebitis, special elastic stockings are put on the legs or elastic bandages are used.

Painkillers and antibiotics are prescribed.

Main complications after rectal surgery

Bleeding.
Damage to neighboring organs.
Inflammatory suppurative complications.
Urinary retention.
Dehiscence of anastomotic sutures.
Postoperative hernias.
Thromboembolic complications.

Life with a colostomy

If a complete extirpation of the rectum with the formation of a permanent colostomy (unnatural anus) is to be performed, the patient should be warned about this in advance. This fact usually shocks the patient, sometimes to the point of categorically refusing the operation.

Very necessary detailed explanations to the patient and relatives that a full life with a colostomy is quite possible. There are modern colostomy bags that are attached to the skin using special plates, are invisible under clothing, and do not allow odors to pass through. Special products for stoma care are also available.

When discharged from the hospital, ostomy patients are trained in stoma care, control of discharge, and a colostomy bag of the appropriate type and size is selected for them. In the future, such patients have the right to free colostomy bags and plates.

Diet after rectal surgery

For the first 4-6 weeks after rectal surgery, the consumption of coarse fiber is limited. At the same time, the problem of preventing constipation becomes urgent. It is allowed to eat boiled meat and fish, steamed cutlets, stale wheat bread, soups with weak broth, porridges, vegetable purees, stewed vegetables, casseroles, dairy products, taking into account milk tolerance, pasta dishes, eggs, fruit purees, jelly. Drinks - tea, herbal decoctions, still mineral water.

The volume of liquid is at least 1500 ml per day.

Gradually, the diet can be expanded.

The problem of preventing constipation is urgent, so you can eat bread made from wholemeal flour, fresh vegetables and fruits, saturated meat broths, dried fruits, sweets in small quantities.

Colostomy patients typically experience discomfort when excessive gas is passed, so they should be aware of foods that may cause increased gas formation: milk, brown bread, beans, peas, nuts, carbonated drinks, beer, baked goods, fresh cucumbers, radishes, cabbage, onions and some other products.

The reaction to a particular product can be purely individual, so such patients are recommended to keep a food diary.

Laparotomy (open classic approach)

The classic method of rectal resection or removal for cancer involves opening the abdomen with an incision. This gives the surgeon a better overall picture of the abdomen and pelvis, which facilitates reliable removal of the rectal tumor. The ability to study tissue changes near the tumor during surgery improves safety and ensures complete removal of the tumor within healthy tissue. This is especially important in the case of large tumors or when they have invaded neighboring organs. After tumor removal, intraoperative intracavitary chemotherapy with hyperthermia is possible to reduce the possibility of rectal cancer recurrence.

Which surgical methods are they applied?

The choice of surgery in patients with rectal cancer depends largely on the location of the tumor. Before surgery, it is necessary to determine whether it is possible to preserve the sphincter muscles (anus) and, thereby, maintain fecal continence. This decision is based on the tumor's proximity to the anus and pelvic floor. If there is insufficient supply of healthy tissue between the tumor and these structures (proximity or involvement in the tumor process), the rectum must be completely removed. This means that a permanent stoma is required. However, even with an ostomy, patients can achieve a high quality of life.

Anterior rectal resection (removal of the rectum while preserving the anus)

Anterior rectal resection is performed when the tumor is located above 12 cm from the edge of the anus and includes removal of part of the sigmoid colon along with the part of the rectum containing the tumor. After this procedure, the remaining part of the rectum is sufficient to form an anastomosis (connection between the overlying intestine and the rectum) and good fecal continence function. During this operation, it is possible to preserve the nerves in the pelvis, which are necessary for normal control of urination and sexual function.

Low anterior rectal resection (removal of the rectum while preserving the anus).

Oncoproctology and chemotherapy room.

If the tumor is located 6 to 12 cm from the anus, a low anterior resection of the rectum is performed, which includes removal of part of the sigmoid colon and the entire rectum, except the anus. After this stage of the operation, to replace the lost reservoir functions of the rectum, a “reservoir” is formed from the overlying (reduced intestine), then an anastomosis is formed using a special stitching device (intestine to intestine is sewn together). Intestinal anastomoses with low anterior resection are located in close proximity to the anus and heal slowly, especially in patients who have undergone prior radiation. In order to prevent feces from entering the anastomotic area, the operation ends with the formation of a temporary stoma (excretion of the intestine onto the anterior abdominal wall) from the overlying colon or small intestine. After 2-3 months (after the anastomosis has healed), a repeat reconstructive operation ("closing" the stoma) is possible in order to restore normal bowel movements.

Abdominal-anal resection of the rectum (removal of the rectum with complete or partial preservation of the anus)

Oncoproctology and chemotherapy room.

If the tumor is located 4 to 6 cm from the anus (very close location, but without involving it), an abdominal-anal resection of the rectum is performed, which includes removal of part of the sigmoid and the entire rectum containing the tumor, sometimes with part of the anus . After this procedure, to replace the lost reservoir functions of the rectum, a “reservoir” is formed from the overlying (reduced intestine), then an anastomosis is formed using a hand suture (the intestine is sutured to anus). Considering the location of the anastomosis in the anus and its slow healing, especially in patients who have undergone preliminary irradiation, the operation ends with the formation of a temporary stoma (removal of the intestine to the anterior abdominal wall) from the overlying large or small intestine. After 2-3 months (after the anastomosis has healed), a repeat reconstructive operation ("closing" the stoma) is possible in order to restore normal bowel movements.

Abdominoperineal extirpation of the rectum (removal of the rectum with complete removal of the anus)

Oncoproctology and chemotherapy room.

If the rectal tumor is located near the anus or is involved (invaded), abdominoperineal extirpation of the rectum is performed, which includes removal of part of the sigmoid and the entire rectum and anus, and part of the pelvic floor muscles. After complete removal of the tumor, the pelvic defect is closed (sutured), and the colon is brought to the anterior abdominal wall in the left lower abdomen in the form of an end (permanent) stoma. Given the complete removal of the sphincter, the overlying intestine is not brought down into the pelvic cavity and an anastomosis is formed. For a patient who has never experienced an artificial bowel outlet (ostomy) before, living with an ostomy may seem unimaginable at first. Complete removal of the tumor is of paramount importance for the prognosis of treatment and there can be no compromise here. After surgery, patients receive detailed instructions on stoma care and on organizing their normal daily activities. This includes sports and recreational activities, including swimming, as well as intimate relationships with your spouse or partner. The experience shared by numerous patients and the results of large studies shows that patients achieve a high quality of life despite having an ostomy.

Hartmann's operation

Oncoproctology and chemotherapy room.

When big size rectal tumors, invasion into neighboring organs, presence of severe intestinal obstruction, severe somatic status of the patient, a Hartmann operation is performed, which includes removal of part of the sigmoid colon and the entire rectum containing the tumor, sometimes with neighboring organs. During this operation, an anastomosis is not formed (intestine is not sutured to intestine); an end stoma is formed in the left lower part of the abdomen. Considering the fact that the anus is preserved during the operation, in the long term (after 6 months) it is possible to perform a reconstructive operation to eliminate the end stoma with the formation of an anastomosis. However, you need to understand that this operation, given its repeated nature, is quite difficult both for the surgeon (adhesions in the abdominal cavity and pelvis) and for the patient (large blood loss, duration of the operation, poor function of holding feces).