Open Surgical Management of Rectal Cancer

Abstract

Total mesorectal Excision (TME) is now considered the gold standard surgical treatment for rectal cancer with fewer local recurrences and better overall survival (Heald et al., Arch Surg 133:894–899, 1998; Kapiteijn et al., N Engl J Med 345:638–646, 2001). Major resectional surgery is technically challenging due to relative inaccessibility within the confines of the bony pelvis, risk of anastomotic leakage and significant risks of local recurrence. Adequate preoperative clinical, endoscopic and radiological assessment is crucial and optimal management is facilitated by discussion at a Multidisciplinary Team meeting. The principles of TME surgery are based on knowledge of the anatomical structures and their relationship within the pelvis, appropriate three-dimensional dynamic traction providing optimal views so that precise sharp diathermy dissection can be performed in the “Holy Plane” (Heald, J R Soc Med 81:503–508, 1988). The surgical approach is specimen oriented with clear circumferential and longitudinal margins and an intact mesorectal fascial package. Overall sphincter preserving surgery for rectal cancer is feasible in 80–90 % of operable patients. In the remainder an Abdomino perineal excision (APE) is required where the sphincters or levators are involved or where sphincter function is poor. A good quality preoperative MRI scan helps plan the appropriate operation in order to obtain clear margins and avoid ‘waisting’ or disruption of the specimen (Brown et al., Br J Surg 90:355–364, 2003). This might entail an Intersphincteric APE or an Extra Levator APE (ELAPE). An ELAPE may need reconstruction with either a mesh or a flap (Holm et al., Br J Surg 94:232–238, 2007).