 SURGICAL MANAGEMENT

OF CA COLON
 Principles of surgical management


Surgery is the gold standard in the management of colonic malignancies.

Curative, palliative.

Helps in accurate staging of disease.

Guides adjuvant therapy.

Approach is based on site of lesion extent of lesion

Minimum 12-15 lymph nodes need to be removed.
​Surgeries

Right Hemicolectomy

Extended Right hemicolectomy

Left Hemicolectomy

Total Colectomy/Subtotal colectomy

Segmental colectomy
 Preparation for surgery

Requirement of Blood product transfusion: Depends on hemoglobin, age, physiological
status and extent of expected blood loss intraoperatively.

Bowel cleansing : agents like PEG. Should be started 1-2 days before surgery with
proper electrolyte and fluid monitoring.

Antibiotic prophylaxis : started 1 hour before incision and be limited to less than 24 hours.
Antibacterial spectrum – Aerobic and anaerobic bacteria.

Thromboembolic prophylaxis: Pharmacological – LMWH’s, calf muscle pump, atleast 2
hours prior to surgery.

Urinary catheterisation/ureteral stents

Nasogastric tube

Pre-operative marking of Ostomy site.

Pre-emptive pain mamagement – T6-T12.
 General Technical Principles

Objectives of colonic cancer surgery is to-

Perform a curative surgery by removing the cancerous segment of colon,
the mesentery with the primary feeding vessel and the lymphatics and
any organ with direct tumour involvement.

As the lymphatics run with the major arterial supply, the primary artery
supplying the segment of colon is to be resected and divided at the origin.

Ligation of the origin of the vessel ensures inclusion of the apical nodes
which is of prognostic importance.

The length of bowel and mesentry resected is dictated by tumour location
and distribution.

Radical resection of tumour should include a 5cm clearance at both
proximal and distal margins.

Tumour adherent or invading adjoining organs like kidney or small bowel
an en bloc resection should be done where feasable.

When synchronous cancers are present in the colon an extended
resection or even a total colectomy with ideally only 1 anastomosis should
be performed.

Occasionally, 2 separate resections eg a right hemicolectomy with a
LAR- with 2 anastomosis can be done to preserve colon length and
prevent avoid post colectomy diarrhoea.

Conditions like UC, FAP require total colectomy with a ileoanal pull
through procedure. If tumours are in proximal sigmoid – total
colectomy indicated.

A limited wedge resection may be considered for an unfit patient for
palliative resetion in those with widespread tumour. Prevents
obstruction and bleeding from primary tumour.
 Intraoperative Surgical Techniques

Positioning: All left sided colonic masses- modified lithotomy position. Lap
procedures require operating table to be tilted and moved to steep
Trendelenberg position.


Incision: Open procedures – Midline laparotomy incision.
Proctocolectomy – infraumbilical inciscion.Tranverse colon – subcostal
incision. For lap approach a first camera trocar is placed in Veress needle
or in open Hasson technique.

Other ports should be placed along a circle with target in the centre.

Exploration : Once the colonic cavity is entered,
abdomen is explored systematically to
determine resectability of tumor.

Special attention to distant metastasis in the
liver, peritoneal carcinomatosis or additional
synchronous lesions through large intestine.

Other organs checked, gall bladder, female
reproductive organs.

Colon Resection: Surgical technique has been
standardised for 3 segments – right colon, left
colon, rectosigmoid.

Depending on extent, the above techniques are
combined.

Maximal resection is a total
colectomy/proctocolectomy.

Mobilization of colon starts on right side, using Richardson/Balfour or
Bookwater retractors.

Small bowel is eviscerated from the abdomen and moved to the left.

The abdominal wall is retracted to the right side while exerting
countertraction on the caecum and asceding colon.

Small incision is made at the exposed white line of Toldt to enter the
retroperitoneum.

Elevating the ascending colon from the retroperitoneum.

The peritoneum is divided along the lateral gutter from the termila
ileum to the hepatic flexure


On the right side, the ureter is at low risk, but to
avoid damage to third part of duodenum.

The mobilization is facilitated by firm traction on the
colon and surgeons left hand is inserted into the
retroperitoneum as a guide to divide along the
peritoneal refelction.

Retrograde dissection of the hepatic flexure is done.

Lesser sac is then opened and the greater omentum
is dissected inferior to the gastroepiloic vessels.

Dissection of the gastrocolic ligament is carried from
left to right.

Connective tissue between antrum, duodenum,
transverse colon and hepatic flexure are divided.

Once mobilization is complete around hepatic flexure,
right colon, transverse colon are attached to only their
vascular supply and are ready for resection.

This is standard for any right hemicolectomy, or
extended transverse colectomy.
 For mobilising left side

Retractor is shifted to left side. Traction placed on the left portion of colon.

Dissection initiated at the level of sigmoid at white line of Toldt and
retroperitoneum entered.

Retroperitoneal structures are bluntly reflected off. Left ureter is exposed
and moved from field.

Gentle traction to be maintained while dissecting around descending colon
and sigmoid to pull down splenic flexure.

With gentle traction by placing hand in retroperitoneum, the spleen can be
dissected off splenic flexure.

Colon has to be dissected from terminal ileum.

Avascular window is made around the feeding
vessels of choice and dissection is done.

Care to be taken to ureters and hypogastric nerve
plexus.

It is preferred to ligate the vessels as proximally as
possible.

Vascular dissection continued along colonic
mesentry.

For FAP, UC, also a TME into pelvis is
warranted
 Right hemicolectomy

A right hemicolectomy is usually performed for cancer of the cecum and ascending

colon, and for some hepatic flexure.

In a classic right hemicolectomy, the ileocolic, right colic, and right branch of the
middle colic vessels are divided and removed withthe contiguous mesentery.

An ileocolicanastomosis is typicallyperformed.

Care must be taken to identify the right ureter, the ovarian or testicular vessels,
and the duodenum.

If the omentum is attached to the tumor, it should be removed en bloc withthe
specimen.
 Extended right hemicolectomy

An extended right hemicolectomywith ananastomosisbetween the ileum
and the distal transverse colon is typically performed for cancer of
the hepatic flexure and proximal transverse colon.

In the extended right hemicolectomy, the ileocolic, right colic, and middle
colic vesselswith their contiguous mesentery are divided and removed.

The inferior mesenteric vein may bedivided and included in the specimen.

Care must be taken to protect the duodenum, pancreas, and spleen.

Cancer of the transverse colon and splenic flexure can be resected
witha modificationof this procedure that includes resecting the
colon to the level of the proximal descending colon.

In this procedure, the ascending branch of the left colic artery is
preserved, providing excellent blood supply to the distal
anastomosis.
 Transverse Colectomy

A transverse colectomy maybe undertaken for mid transverse colon cancers aslong as
satisfactory resection margins and an adequatelymphadenectomy can be

obtained.

The transverse colon is resected along with the middle colic vesselsand its mesentery.

At times, the inferior mesenteric vein is also divided and included in the resected specimen.


Both the hepatic and splenic flexures may needto be mobilized in order to achieve a
tension-free anastomosis.

When mobilizingthe splenic flexure, caremustbetaken not to apply much tractionto the
omentum or colon, as this will invariably result in splenic capsule tears.
 Left hemicolectomy

A left hemicolectomyis appropriate for tumors in the distal transverse or

descending colon and for selected patients with proximal sigmoid colon
cancer. The

left branch of the middle colic vessels, the inferior mesenteric vein, and the left
colic

vesselsalong with their mesenteries are included with the specimen. In some
cases,

a segmental colectomy may beperformed aslong asadequate resection margins

and lymphadenectomy are achieved (Rouffet et al.)
 Sigmoid Colectomy



For sigmoid colon cancers, segmental or sigmoid colectomyis appropriate. The

inferior mesenteric artery is divided at its origin, and dissectionproceeds just under

the superior rectal vesselstoward the pelvis until adequate margins are obtained.


As with right-sided tumors,care mustbetaken while mobilizingthe sigmoid and

descending colon to identify the left ureter and the left ovarianor testicular
vessels.
 Subtotal and Total colectomy

Subtotal and total colectomy

A subtotal or a total abdominal colectomyis indicated if there are synchronous

neoplasms onthe right and left sides of the colon. Occasionally these
procedures are

performed in patients presenting with obstructing-left sided tumors.For patients

with hereditarynonpolyposis colorectal cancer (HNPCC) who presentwith a colon

cancer, total abdominal colectomyis the procedureof choice. It is also used in

selected patients with Familial Adenomatous Polyposis (FAP) and MUTYH

associated polyposis.
 Reconstruction or diversion

Pre-requisites: Age os patient, health/nutritional status,
performance status.

Well vascularised tissues, with no tension.

Total colectomy- ileoanal anastomosis with j pouch.

Hartmann’s procedure.

Placement of drains is usually warranted when a pelvuc
dissection and anastomosis have been performed.
 Special circumstances in
Emergency

TUMOUR OBSTRUCTION:

Caecal diameter >12cm

Large bowel >8 cm

Small bowel >4cm

Approaches include:

-Subtotal colectomy

- On table lavage with segmental colectomy, with
primary anastomosis

- perfoming a 2/3 step staged procedure. Eg:
Hartmann’s procedure.

Newer approach : SEMS in obstructive lesions.
 Tumour related perforation

Can lead to diffuse fecal peritonitis.

Significant morbidity, mortality.

Also tumour spillage.

Surgical intervention is must, must be of
oncologically correct fashion.
 Massive colonic bleeding

In cases of severe bleeding surgical
management is warranted.
 Management of Advanced disease

Locally advanced disease :

- 15% of colonic tumours adhere to adjacent organs

- resections can be curative if en bloc resections
can be done.

- Margins should be negative to ensure curative
resection
 Operable Metastasis

20% patients have stage 4 disease at
presentation.

Metastasis to liver and lung.

In case of a potentially resectable secondary,
the primary tumour should be resected in an
oncological fashion
 Inoperable Disseminated Disease

In unresectable disease, treatment goal is palliation and
prevent complications.

Limited segmental wedge resection.

Tumours of caecum and sigmoid – lap or lap assisted
resection as they can be mobilised.

Palliation can be done by creating an internal bypass or
proximal diversion.
 Complications of Surgery

Early complications: within first 30 days

- Injury to anatomic structures, like ureters, duodenum, hypogastric
plexus, spleen.

Bleeding, occur after first few days of resection due to anastomotic
leak or non specific infections at anastomosis.

Lung complications like pneumonia, atelectasis, poor respiratory
efforts by patient

Cardiac events like arrythmia, MI, etc

Post operative ileus.

Peritonitis, fever.

Late complications : post 30days

Stoma herniation, prolapse

Enterocutaneous fistulae

Anastomotic leak

Abdominal wall hernia

Wound site tumour
Stage wise management of ca colon

Stage 0. Surgery is often the only treatment needed for stage 0 colon cancer.

Stage 1. Surgery alone is recommended for stage 1 colon cancer. The technique
used may vary based on the location and size of the tumor.

Stage 2. Surgery is recommended to remove the cancerous section of the colon and
nearby lymph nodes. Chemotherapy may be recommended in certain circumstances,
such as if the cancer is considered high-grade or if there are high risk features.

Stage 3. Treatment includes surgery to remove the tumor and lymph nodes followed
by chemotherapy. In some instances, radiation therapy may also be recommended.

Stage 4. Treatment may include surgery, chemotherapy, and possibly radiation
therapy. In some instances, targeted therapy is also prescribed.
Management of
Ca Rectum
 Goals of surgery

The general principles of a surgical approach remain the
removal of all gross and microscopic disease with negative
proximal, distal, and circumferential margins.


Preserve intestinal continuity and the sphincter mechanism
whenever possible while still maximizing tumor control
 Surgical Options

LOCAL EXCISIONAL PROCEDURES


RADICAL PROCEDURES ( APR/LAR)
 Considerations
T1 lesions – Local Excisional Procedures

T3/T4 lesions – Radical Resection preferred.

T2 lesions- Controversial

- Most prefer APR/LAR

- Some Local excisional procedured with NACT/ ACT/RT
- Local excision recurrence – Salvage APR
 Criteria for Tumours Resectable by
Local Methods

T1NO or T2NO lesions

<4cm in diameter

<40% circumference of lumen

<10cm from dentate line

Well to moderately differentiated histology.

No evidence of lymphatic or vascular invasion on biopsy

Patients with extensive metastatic disease/ poor prognosis who require local control

Adjuvant treatment for patients with lymphatic invasion, T1 with poor prognosis features,
T2 lesions.
 Local Excision Procedures

Transanal Excision – for tumours less than 3 cm from dentate line but not invading
the sphincters


Transcoccygeal Excision – Tumours 5 cm from dentate line may need this approach
or a TEM


Transanal Endoscopic Microsurgery – Tumours 7-10cm from dentate line require
TEM, if greater – LAR.
 Margins
Proximal margin- atleast 5 cm, distal is controversial, most agree to 2cm.

CIRCUMFERENTIAL RADIAL MARGIN >> PROXIMAL/DISTAL MARGINS IN CA RECTUM.

Circumferentrial Radial Margin – (CRM)-

- Is an independent predictor of both local recurrence and survival.
- length of mesorectum to be excised is atleast 5cm.
 Operative Set Up
Positioning: For both LAR and APR require patients to be positioned in a Lloyd Davis
position with the legs carefully padded in stirrups, both arms tucked at the side, and with
the patient secured carefully to the operating table to minimize sliding while in steep
Trendelenburg position or extreme lateral tilt.

Instrumentation : For APR in low rectal tumors abutting the dentate line, or when ISR
with partial or complete resection is planned, a transanal setup including transanal
instrumentation with anorectal tray, anoscopes, a retractor (Cooper Surgical, Trumbull,
Connecticut), a headlight, and either absorbable sutures or a circular end-to-end
anastomosisstapler depending on how the coloanal anastomosis is completed.

Open LAR requires an adequate

set of abdominal and pelvic retractors, a headlight, and
a long instrument tray.
Low Anterior
Resection
 Surgical Procedure
Incision: Open LAR is performed through a vertical midline laparotomy incision

Procedure in brief: abdominal exploration to rule out peritoneal disease and liver
metastasis, vascular mobilization, mesenteric dissection, TME, rectal transection,
colon resection, and colorectal or coloanal reconstruction.
After completing abdominal exploration, the patient is positioned in Trendelenburg with
the right side down.
The small bowel is carefully retracted out of the pelvis and to the right.
A lateral-to-medial approach is used to mobilize the rectosigmoid colon.
Mobilization proceeds along the white line of Toldt to mobilize the left colon and sigmoid
colon.
The left gonadal vessels and ureter are identified as they cross the pelvic brim and travel
downward into the pelvis.
The peritoneum overlying the left common iliac artery is incised and this peritoneal
incision is extended further into the pelvis until reaching the avascular plane between the
rectosigmoid mesentery and retroperitoneum.
At this point, dissection should not proceed further and attention is returned to the
The lateral attachments of the proximal left colon are divided heading up toward
the splenic flexure, which is then mobilized.
This is followed by high ligation of the IMA, below the origin of the left colic
artery.
This part of the operation can also be performed using a medial-to-lateral
approach, first by scoring the peritoneum at the base of the sigmoid mesentery,
just above the sacral promontory, and extending this incision to the right and
toward the right posterolateral region of the pelvis, with high ligation of the IMA
near its origin.
Dissection then moves toward the lateral attachments of the left colon, which are
divided as they head up toward the splenic flexure.
Pelvic dissection of the rectum is then carried out anteriorly toward the
Anterior dissection is carried out with visualization of the seminal vesicles and prostate in men or
the posterior wall of the vagina in women.
Posteriorly, dissection is carried out along the plane between the Waldeyer fascia and the
mesorectal fascia, with care to preserve the integrity of the mesorectum according to the principles
of a TME.
In the case of a low or ultra LAR, posterior dissection between the mesorectal fascia and Waldeyer
fascia is extended down toward the levators.
Care should be taken to avoid injury to the pelvic autonomic nerves, specifically the superior
hypogastric nerves.
Following complete TME with mobilization of the rectum and mesorectum well below the level of
the tumor, the rectum is clamped below the tumor with a distal margin 2 cm .
The rectum is then transected, and either a stapled colorectal or handsewn anastomosis is
performed based on the level of rectal transection.
A diverting loop ileostomy is often performed depending on the height of the anastomosis and
ABDOMINO-
PERINEAL
RESECTIONS
APR can be performed either with simultaneous abdominal
and perineal dissections through a two-team approach or
with a sequential approach, in which the abdominal
dissection is performed first, followed by perineal resection.
Regardless of which method is used, many surgeons prefer
placing the patient in modified lithotomy position with
moderate Trendelenburg and the surgeon positioned on
the patient’s left for the abdominal portion
ABDOMINAL COMPONENT
Incision: Midline extending from the umbilicus to the pubic
symphysis.
The abdomen is initially explored for metastasis, and any suspicious
lesions may then be biopsied.
The patient is placed in a steep Trendelenburg position and rotated to
the right to allow the small bowel to fall into the right upper quadrant
with the aid of gravity.
Using a lateral approach, the sigmoid colon is grasped and mobilized medially by
dividing the lateral attachments anchoring it to the left pelvic wall. The avascular
plane along the line of Toldt is divided, mobilizing the left colon.
carefully separate the underlying gonadal vessels and ureter and protect them
The peritoneum is incised down to the cul-de-sac on the left side . It is crucial to
identify and protect the left ureter at this time because it may course in close
proximity to the root of the mesentery of the rectosigmoid, and can be easily
damaged or transected during dissection.
If preoperative ureteral stents have been placed, the ureter can often be easily and
frequently palpated to ensure it remains retracted to the left side of the pelvis and
out of the dissection plane.
The incision is made lateral to the inferiormesenteric and superior rectal vessels. It
is important to identify the right ureter, expose it carefully, and protect it from
accidental injury when dividing the peritoneal reflections. Identification of the
sacral
promontory is also a reproducible landmark that will allow entrance into the
avascular presacral plane and help the initial opening of the pelvic peritoneum.
With the proximal colon retracted anteriorly and laterally, the dissection begins
Dissection is done anteriorly, where the peritoneal reflection in the cul-de-
sac is incised behind the bladder in men or behind the uterus in women.
Dissection then proceeds in a plane anterior to Denonvilliers fascia until the
seminal vessels and prostate or rectovaginal septum is encountered
Lateral dissection must be performed cautiously as the autonomic nerve
plexus, middle rectal vessels, and ureters can easily be damaged as
dissection is carried down to the level of the levator musculature .
The rectum must be carefully separated from the parietal fascia overlying the
lateral pelvic wall structures.
Theautonomic nerve plexus can be seen coursing close to the rectum at the
level of the prostate or upper vagina.
Next, the blood supply to the rectosigmoid is divided
.We prefer to use an energy device, although a stapler with a vascular
load or clamps and suture ligation may also be used. Ideally, the
inferior mesenteric artery is ligated just distal to the origin of the left
colic artery .
Conversely, some prefer to divide the inferior mesenteric artery near
its point of origin at the aorta.
This will also help with gaining additional length for cases in which the
bowel needs to reach the anterior abdominal wall. Although this may
be safely accomplished, one must be aware that this leaves the
portion of the sigmoid that will be used as a colostomy dependent on
collateral flow from the marginal artery of Drummond.
High ligation of the inferior mesenteric artery also puts the preaortic sympathetic nerve
plexus at risk for damage, which results in retrograde ejaculation in the male. These nerve
fibers can be swept back onto the aorta to protect them. The point of proximal transection
must be planned to allow adequate oncologic margins while ensuring the rectal stump is
short enough to be tucked

into the pelvic cavity and allow closure of the overlying pelvic peritoneum. The redundant
sigmoid is retracted upward, and the proximal transection point is determined, which will
provide adequate blood flow and allow tension-free reach of the proximal bowel to the skin
surface for use as a permanent colostomy. The sigmoid is then transected at this point with
a GIA linear cutting stapler.
Following this, the peritoneal floor can be mobilized and closed, under the discretion of the
surgeon. If desired, toothed forceps are used to grasp the peritoneum and the margins are
bluntly freed with the surgeon’s hand. Although it is sometimes possible to close the pelvic
peritoneum in a straight line, a radial closure is more often needed to avoid tension on the
suture line. Anygap in the suture line risks capturing a loop of small intestine as an internal
During closure, the location of the ureters should be frequently assessed to avoid
inadvertent ligation. After pelvic closure, the table is leveled and the omentum is
positioned over the suture line.
Attention is then turned to the creation of the end colostomy. Ideally, the location
should be marked preop-eratively, within the left lower quadrant rectus muscle, in
consultation with an enterostomal therapist.
A 3-cm circular skin opening is created, and a two-fingerwide fascial incision is
made. The colon is grasped with a Babcock forcep and brought through the
opening, ensuring there is no undue tension or rotation of mesenteric blood flow.
The midline abdominal fascia and skin (or port sites) are closed in the usual fashion
and the incision is protected with sterile dressing prior to opening the staple line
and maturing the colostomy.
PERINEAL PORTION
The perineal resection may be performed either simultaneously with the
abdominal portion of the procedure as part of a two-team approach, or it may be
done sequentially following abdominal closure and colostomy creation.
Typically, the patient remains in the modified lithotomy position for this portion of
the operation. However, if done sequentially following abdominal closure, some
prefer to reposition the patient in the prone-jackknife position (Fig. 169.21).
The latter often provides better exposure for a cross-table assistant and
visualization of the anterior attachments, which are often the more difficult
portion of the procedure.The perineal dissection is begun by first identifying key
superficial landmarks: the perineal body, the coccyx, and the ischial tuberosities.
An elliptical incision is planned that extends from the perineal body to the coccyx
and laterally to the tuberosities (Fig. 169.22). It is important to remember the
location and size of the tumor when planning the initial incision to ensure the
Occasionally, en bloc resection of adjacent organs is required for locally
advanced tumors (Fig. 169.23). If extensive excision is anteriorly, and the
fascia of the gluteus maximus muscle posteriorly. Care must be taken in
the upper part of the ischiorectal fossa in identifying and suture ligating
the inferior rectal vessels including the pudendal artery and nerve as they
enter the external sphincter posterolaterally.
If inadvertently transected during dissection, these vessels may retract
only to cause bleeding at a later time.
The posterior dissection is continued by elevating the anal canal away
from the sacrum and dividing the areolar tissue between the rectal fascia
and presacral fascia, thus progressively elevating the rectum off the
presacral fascia. The curve of the rectum should be conceptualized as the
dissection proceeds and care should be taken not to dissect too closely to
the sacrum, to avoid the bleeding anticipated, preoperative consultation
The skin is incised at least 2 cm from the closed anal orifice and dissection is
carried through the subcutaneous tissue. The perianal skin and skin surrounding
the anal orifice may be grasped with several Allis clamps to aid with retraction as
the subcutaneous tissue is further divided with electrocautery.
Dissection continues posteriorly directly over the coccyx, and the anococcygeal
raphe is identified and sharply divided. Waldeyer fascia is then divided and the
presacral space is entered.
The superficial fascia laterally is divided, and the ischiorectal fossa is entered
bilaterally. Throughout lateral dissection, it is important to visualize the boundaries
of the ischiorectal fossa: those being the ischial tuberosity and obturator fascia
laterally, the fascia of the levator ani and sphincter muscles medially, the
transverse perinei superficialis and profunda muscles
Division of anococcygeal raphe. from presacral veins. The iliococcygeus muscle is
then palpated by placing an index finger into the presacral space and sweeping
laterally.
The surgeon may choose to apply curved clamps prior to transection of the
muscle to provide opportunity to control any bleeding vessels prior to them
retracting out of reach.
Dissection is continued anteriorly onto the pubococcygeal and puborectalis
muscles. This dissection may be facilitated by tension placed between the
ischiorectal fat laterally and rectum medially using malleable retractors.
After the levator ani muscles have been successfully transected, the anterior
dissection proceeds.
This is generally considered the most difficult portion of the perineal dissection,
particularly in male patients.The membranous urethra, prostate, and seminal
vesicles are all closely adhered to the anterior wall of rectum and anal
sphincters.
The perineal skin is retracted anteriorly while the anus and rectum are pulled
inferiorly and posteriorly to facilitate exposure.
The space between the rectum, and prostate is developed by dividing
the rectourethralis and the remaining anterior attachments are
progressively thinned. It is important to avoid dissecting too far
anteriorly because this may result in urethral injury.
Frequent palpation of the Foley catheter and prostate can assist the
surgeon in maintaining the proper plane of dissection. Alternatively, the
patient may be placed prone for this portion of the procedure to help in
identification of the proper dissection plane. In the female, the
dissection between the vagina and rectum is easier.
However, care should be taken to avoid inadvertent injury to the
posterior vaginal wall. It is also important to use gentle retraction and
support the rectum during the final stages of dissection as avulsion off
the urethra and prostate can result in injury and bleeding.
The sigmoid end of the specimen is clamped and delivered through the
posterior end of the perineal wound, and the final attachments of the
levator ani muscles are then transected.
The pelvic cavity is then irrigated and inspected for hemostasis. Bleeding
points are controlled with electrocautery and suture ligation. Persistent
venous oozing can generally be controlled by packing of the cavity with dry
sponges. After hemostasis is confirmed, one to two closed-suction drains
are generally placed in the presacral space. We prefer to close the wound
in multiple layers.
The levator ani muscles are approximated with 2-0 and 3-0 Vicryl sutures
(Fig. 169.30), and the subcutaneous tissue and skin are loosely
approximated with vertical mattress sutures .
 TOTAL MESORECTAL EXCISION
Why should it be done?

Old surgical methods still have a high chance of tumour recurrene as tumour cells can be
left behind in the pelvis.

TME removes the intact mesorectum which could contain the tumour cells and hence
prevent local recurrence if done skillfully.
Principles of TME