Chapter 24. Operative Management of Rectal Tumors

Transanal Excision of Tumor

• Stage T1 tumors:
  • Mobile and < 4 cm in diameter.
  • Involving < 40% of the rectal wall circumference.
  • Located within 6 cm of the anal verge.
• Well or moderately differentiated histology only.
• Absence of vascular and lymphatic invasion.
• No evidence of nodal involvement on preoperative rectal ultrasound or MRI.

Low Anterior Resection (LAR) with Total Mesorectal Excision

• Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained within 2 cm of the anal sphincter in moderately or well-differentiated tumors or within 5 cm for poorly differentiated tumors.

Abdominoperineal Resection (APR) with Total Mesorectal Excision

• Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

Transanal Excision of Tumor

• Tumors stage greater than T1N0M0.
• Fixed tumors.
• Tumors > 4 cm in diameter or involving > 40% of the circumference of the rectal wall.
• Tumors located > 6 cm from the anal verge.
• Tumors with poorly differentiated histology or angiolymphatic invasion, or those that show evidence of nodal involvement on preoperative rectal ultrasound or MRI.

LAR with Total Mesorectal Excision

• Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

APR with Total Mesorectal Excision

• Malignant lesion of the lower rectum diagnosed by evaluation of a tissue biopsy specimen showing local invasion into the pelvic sidewall or pelvis that could benefit from neoadjuvant treatment to facilitate possible curative resection.

Transanal Excision of Tumor

• For posterior lesions, the patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups.
• For anterior lesions, the prone jackknife position is preferred.
• Sequential pneumatic compression devices should be applied.

LAR or APR with Total Mesorectal Excision

• The patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups.
• Sequential pneumatic compression devices should be applied.
• A Foley catheter and nasogastric or orogastric tube should be placed, especially if mobilization of the splenic flexure is contemplated.
• Consideration should also be given to the placement of a left ureteral stent if a difficult pelvic dissection is anticipated.

• Early ambulation is encouraged and diet is advanced as soon as tolerated.
• Patients requiring abdominal incision receive epidural analgesia and are transitioned to oral pain medications as soon as they can tolerate solids.
• Patients with ileostomies may require aggressive management of fluid status after the resumption of bowel function. We promote aggressive isotonic liquid consumption by ...