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New surgical techniques
There has been a significant transition
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in the past 15 years from open | ||||
surgery to minimally invasive techniques | ||||
in many specialised centres, |
with most resections performed using a minimally invasive technique. |
Figure 2.
Rectal cancer.
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Open surgery may still be indicated, |
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depending upon patient-related factors, locally available surgical specialisation and experience.
ROBOTIC SURGERY Robotic surgery( see figure 6) offers the promise of enhanced visualisation, less dependence on surgical assistants, wristed and more flexible instruments and the potential reduction of fatigue for the surgical team.
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Emmanuelm / CC BY-SA 3.0 / bit. ly / 3M8ejQK |
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These are commonly cited as advantages | ||||
for technically challenging situations | ||||
such as in morbid obesity. | ||||
However, there are minimal data | ||||
showing its superiority or equivalence | ||||
to laparoscopic or open surgery | ||||
. Furthermore, robotic training | ||||
in Australia is limited for trainees, | ||||
and most surgeons with extensive | ||||
training have gained this in international | ||||
centres. Most public hospitals | ||||
in Australia have limited or no access | ||||
to robotics. While there are many | ||||
potential benefits, research is still | ||||
required in this area. |
TRANSANAL TOTAL MESORECTAL EXCISION Transanal total mesorectal excision was described more than a decade ago. Using the same platform as for transanal minimally invasive surgery, |
Figure 3. Colorectal cancer, gross appearance of an opened colectomy specimen. |
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the entire rectum and mesorectum |
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can be excised. Initially there was |
with subsequent potential benefits to |
and subsequent bowel function. A |
option. Other patients who may be pre- |
Specific operations such as deep |
great enthusiasm as this provided |
postoperative pain, recovery and cos- |
minimum gross distal margin of 1cm |
dicted to have poor bowel function |
pelvic resection, particularly after |
an option to overcome the technical |
mesis. Early data are promising; how- |
is considered acceptable. A num- |
( poor preoperative bowel function, |
preoperative radiation therapy, |
challenge of the bulky rectum in the |
ever, more research is required. |
ber of different reconstructive tech- |
elderly, frail), may opt to have a perma- |
requires discussion of further risks, |
narrow male pelvis. However, con- |
New laparoscopic and robotic |
niques, such as a colonic pouch, have |
nent stoma upon discussion. |
including the risk of pelvic floor dys- |
cerns regarding oncological safety |
instruments have also led to the pos- |
been attempted to try and improve |
function, sexual dysfunction and |
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have led to a moratorium in Norway |
sibility of the entire operation being |
function. Although these do show |
WHO NEEDS A STOMA? |
anorgasmia in women and men, and |
on the technique as well as an inter- |
carried out through the vagina or rec- |
improved function in the short term, |
While every effort is made to avoid |
failure of tumescence and ejacula- |
national rethink on its utility. Con- |
tum without any skin incisions. How- |
long-term data suggest that all meth- |
a stoma( see figure 7), there are sit- |
tion in men. |
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sequently, few surgeons in Australia regularly use this technique.
NATURAL ORIFICE SURGERY AND EXTRACTION Minimally invasive colorectal surgery still requires a 3-5cm( sometimes larger) incision to remove the specimen. Removal of the specimen through the vagina or rectum allows for a completely minimally invasive technique,
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ever, there are no data regarding the oncological safety and these techniques are confined to clinical trials.
Surgical treatment of low rectal cancer
Carcinomas of the low rectum( within
6cm of the anal verge) pose special challenges. These include preservation of the anal sphincters, achieving an acceptable oncological margin
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ods of reconstruction are similar in their bowel function.
Despite these techniques, there are patients where a reconstructive approach is not possible. This is usually because the tumour involves anal sphincters or is so close to the sphincters that an acceptable margin cannot be obtained. In these cases, an abdominoperineal resection with a permanent colostomy is the only safe oncological
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uations where they may be required( see box 3).
INFORMED CONSENT AND RISK OF COMPLICATIONS AT COLORECTAL RESECTION
INFORM patients and their families
regarding the risk of colorectal resection.
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RECOVERY AFTER SURGERY
THIS varies widely and will depend
on the extent of the surgery, whether the surgery was open or minimally invasive, the underlying patient physiology and patient psychosocial factors. With increasing working from home arrangements, patients may go back to light duties PAGE 40
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