Compared with radical resection of rectal tumors, local resection of rectal tumors has the advantages of small surgical trauma, low risk, fast postoperative recovery and short hospital stay, in particular, it is necessary to avoid artificial anus dysfunction and obstacles caused by radical surgery and postoperative voiding function and sexual function.
There are many surgical methods and methods for local excision of rectal tumors, such as transanal approach, transsacral approach, transsphincter approach, and transanal endoscopic approach. They overlap and differ in surgical indications.Due to the different surgical approaches and methods, postoperative complications also vary. Therefore, familiarity with these surgical methods, and on the premise of strictly grasping the surgical indications, correct selection of surgical methods can significantly improve surgical efficacy and reduce surgical complications.
At present, there are various approaches and methods for local excision of early rectal tumors. The following is a brief introduction to various surgical methods for local excision of rectal tumors.
1. Transanal local excision of rectal tumor
This is one of the most ancient and common surgical methods. Its advantages are direct surgical approach, simple operation, no surgical incision on the body surface after operation, and less trauma and surgical risk.
But its disadvantages are:
(1) Due to the position of the patient during the operation, most doctors can only perform surgery in a sitting position, and the surgeon's line of sight and the lesion are in the horizontal position instead of the traditional overlooking surgery that conforms to the surgeon's habits.
(2) The degree of freedom of operation of surgical instruments in the rectum and anal canal is limited, and can only be performed within 45 degrees at most, and many fine operations cannot be performed.
(3) It is difficult to expose the surgical field and the operating space is narrow, so the accuracy of the operation is greatly affected.
(4) The technical difficulties and shortcomings will become more and more obvious as the distance between the tumor and the anal verge increases.
(5) Surgical specimens might be broken or cannot be evaluated during pathological examination. As a result, it is difficult to provide meaningful guidance for postoperative treatment of patients.
All of these may ultimately bring some disadvantages and uncertainties to the future surgical efficacy. Surgical indications for transanal resection are therefore usually limited to:
The lesion is located within 4-5cm from the anal verge.
The diameter of the lesion is not greater than 2cm.
If it is a malignant tumor, it must be Tis-T1N0. The more common complications after this operation are postoperative wound bleeding and urinary retention. Accurate mastery of suturing techniques and preoperative prophylactic placement of urinary catheters can prevent the occurrence of these complications.
2. Local resection of rectal tumor through the sacrococcygeal region
Transsacral rectal tumor resection is also known as Kraske's operation; the procedure was pioneered by German surgeon Kraske in 1885.
The surgical steps are briefly described as follows:
The patient was placed in a prone position, and a straight incision was made from the sacrococcygeal joint to the anus. After the coccyx was removed, the pelvic floor muscles were separated to expose the posterior rectal wall, and the posterior rectal wall was incised at the upper edge of the puborectalis to expose the tumor in the rectal cavity. After resection of the tumor, wounds such as the rectum were repaired and sutured. Compared with transanal local resection of rectal tumors, Kraske's surgical field is slightly improved, and the operation is also in line with the surgeon's habits, but its disadvantages are as follows:
(1) The requirements for the location of the lesion are stricter. The lesion on the anterior wall of the rectum is the best indication. For tumors located on the posterior wall of the rectum or less than 4 cm or more than 7 cm from the anal verge, due to unclear location of the lesion or poor exposure of the surgical field It will make the operation very difficult.
(2) Long-term sacrococcygeal pain is often associated with coccyxectomy, especially when sitting.
(3) The incidence of postoperative wound infection and rectocutaneous fistula is relatively high. A Japanese author reported that the incidence of rectal skin fistula was as high as 20%. The occurrence of the latter will cause greater psychological and physical intrusion to the patient, and the treatment and treatment of this complication are also relatively complicated. In severe cases, a temporary enterostomy is required. This treatment is difficult for patients to understand and accept. Therefore, at present, very few people in the field of colorectal surgery in China use this kind of operation to treat rectal tumors.
3. Local resection of rectal tumor through the anal sphincter
This operation is also known as the Mason operation. Introduced by British surgeon Mason in 1970.
The surgical steps are briefly described as follows; the patient is placed in the prone position. Make a straight incision from the sacrococcygeal joint to the anal edge, cut the skin and subcutaneous tissue, and decide whether to remove the coccyx according to the location of the tumor (when the lower edge of the tumor is greater than 6-7cm from the anal edge, the coccyx needs to be removed). After removing the coccyx, cut off the external anal sphincter For the superficial group and the subcutaneous ring, cut the mesorectum, cut off the puborectalis muscle, expose the posterior wall of the rectum, incise the posterior wall of the rectum from the anal edge to the proximal side, and open and expose the rectum. After resection of the lesion, the rectum and external sphincters of each group were repaired and sutured.
Compared with the previous two operations, the biggest advantage of this operation is that the exposure of the operation field has been greatly improved, and the surgeon can perform various fine operations in a spacious operation field, and the operation quality and curative effect have been greatly improved. Moreover, due to its special surgical approach and surgical method, its surgical indications are broader. All rectal tumors within 8cm from the anal verge, such as rectal adenomas, including carpet-like villous adenomas, early cancers of adenomas, early rectal cancers, rectal carcinoids, and rectal stromal tumors (malignant tumors should be classified within Tis-T1N0 stage) Rectovaginal fistula and rectourethral fistula can be treated with this surgical method.
4. Transanal endoscopic microsurgery TEM
In the 1980s, German surgeon Gerhard Buess and Wolf Company jointly invented and developed a set of transanal endoscopic microsurgery system, namely TEM. This is a new surgery that combines modern laparoscopy, endoscopy and minimally invasive techniques. The main components of the system are;
1 Special rectoscope, two lengths of 12cm and 20cm are available for different conditions.
2 double ball joint movable arm device to fix the rectoscope.
3 The endoscopic system can display the magnified surgical field of view on the image monitor in real time.
4 Inflation and flushing suction system, the former can keep the air pressure in the intestinal cavity constant, and the latter keeps the operating field clear and clean.
5 Special instruments include needle-shaped electric scalpels with different curvatures for intracavitary surgery, aspirators, and needle holders that can automatically return suture needles, etc.
These well-made surgical instruments provide a reliable guarantee for precise operation. Compared with traditional local resection of rectal tumors, TEM has excellent surgical field exposure and a large enough operating space. Excellent surgical conditions and surgical instruments have significantly improved the quality of local resection of tumors, and enabled patients to recover during surgery. Compared with traditional surgery, it has obvious advantages in terms of bleeding, rapid postoperative recovery and shortened hospitalization days.
Due to its special design concept and the excellent performance of the instrument, TEM covers almost all the diseases that can be operated by Mason's operation, and expands the surgical site from the original 8cm from the anal verge to the colorectum within 20cm from the anal verge. Based on the above advantages, TEM has become the first choice for local resection of rectal tumors at home and abroad, and is recommended by NCCN as the first choice for resection of early rectal cancer. The more common complications of TEM surgery include postoperative bleeding and pelvic infection. The former is related to unskilled suturing techniques during the operation, and the latter is related to improper protection techniques and treatment measures when the rectum is cut through during the operation. However, with the continuous proficiency and accumulation of surgical techniques and experience, these complications will become less and less common.
The article is traslated from Qiu Zhonghui '直肠肿瘤局部切除的几种手术方式'.
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