Abstract

---

To-day’s oncological rules suggest standardized procedures for colo-rectal neoplasms, preferring radical hemicolectomies to more limited segmental resection Usually this policy agrees with the general surgical principles.

Introduction

---

Recently many researches have been made to study the real incidence of colo-rectal cancer and the results of its treatment (1). Considering this last aspect of the problem, we find many different surgical techniques employed, not clearly standardized and accurately reported. Our aim of is to propose a simple classification of the different surgical procedures generally used in the treatment of colo-rectal tumours, following the fundamental oncologic principles, and so also facilitating prospective and retrospective reviews.

Methods

---

We have divided the main surgical techniques of colo rectal surgery in two different categories:                ;                &nb sp;              
1. Procedures performed with oncological indication (Table 1);
2. Procedures performed with not oncologic indications, but for various disease (inflammatory, vascular, traumatic, closure of colostomy etc.) (Table 2).
It is evident that in absence of oncological indication, respect of the main vascular supply, of function of the anal sphincter, preservation of ileo-cecal valve, unnecessary too large resection, limited retroperitoneal dissection , are the main targets for the surgeon. On the contrary, oncological rules oblige to obtain sure resection margins, to perform radical lymphadenectomy, regional dissection, primary venous or arterial devascularization, and possibly to follow the “no touch” technique.
Table 1 Main surgical procedures of colo-rectal resection with oncological indications.
1. Right hemicolectomy (eventually extended to the transverse colon)
2. Left hemicolectomy
3. Total coletomy
4. Anterior resection of the recto-sigmoid
5. Abdomino-perineal resection
Table 2 Other main procedures without oncological indications.
Segmental resection of:
a. Caecum
b. Right flexure
c. Transverse colon
d. Left flexure
e. Sigmoidectomy
f. Sigmoido-protectomy

Discussion

---

Many factors play in favour of radical hemicolectomies in case of oncological indication.
At first, it is essential to considerer that lymphatic drainage,which parallels the arterial branches supplying the colon and rectum, must guide the extension of resection (2). Consequently the surgical dissection extended to the level of the origin of the primary feeding vessels is formerly advised to ensure inclusion of apical nodes, whose secondary involvement conveys prognostic significance(3). Besides, a tumour can be located in border zones, between two contiguous vascular pedicles; it is evident that corresponding both contiguous lymphatic chains must be resected , to encompass possible bidirectional spread. Extended lymphadenectomy can be justified also by the possibility, present in 4-8% of the cases, of lymphatic skipped metastasis(4).
Considering the vascular supply of the left colon, it must be observed that at the level of the splenic flexure, in 48% of the cases, the marginal artery can be incompletely developed, resulting in a potential “watershed area”, with resection margins possibly ischemic and not suitable for a sure anastomosis(5).
From a technical point of view, we must also considerer that an adequate mobilization of the colonic segments is necessary before every anastomosis; this is facilitated by the technique of radical hemicolectomies.
These last procedures permit a wide exposition of the retroperitoneum, with the possibility of “en bloc” resection of other structures ( Gerota capsule, perirenal fat, gonadal vessels, etc.), as well as, inside the peritoneal cavity, excisions enlarged to greater omentum, gastro-colic ligament, parietal peritoneum.
For tumours of the transverse colon, an extended transverse colectomy enclosing the greater omentum, the right and left superior vascular pedicles with the corresponding lymphatic chains, is necessarily followed by an anastomosis between the ascending and the descending colon. It is clear that a right hemicolectomy extended to the entire transverse colon is technically easier and oncologically preferable (6).
While all these reasons advise against segmental resections, in particular conditions other equivalent solutions can be admitted: sigmoidectomy in case of a long sigmoid and neoplasms located in its middle part (7),and similarly resection of the left flexure,both performed with radical lymphadenectomy and division of the vascular pedicles at their origin. With good reasons these two last procedures, if correctly performed, have been called respectively “upper” and ”lower” left hemicolectomy, because of their correspondence with the classical hemicolectomy (8).

Conclusion(s)

---

To-day in the treatment of colo-rectal cancers, general oncological rules induce to prefer radical hemicolectomies to more limited segmental resections,which, nevertheless, in particular cases (sigmoidectomy, or resection of the left flexure), must be performed correctly, with radical lymphadenectomy and vascular pedicle dissection, and not as an inadequate or hurried operation. At this regard  we must always remember that surgery still remains the primary therapeutic resource, well supported by modern of pre- and post-operative care measures.(9,10).

Reference(s)

---

1. Ponz de Leon M., Pezzi A., Benatti P. et al. Survival, surgical management and perioperative mortality for colo- rectal cancer in the 21-year experience of a specialized registry. Int.J.Colorectal Dis. 2009; 24:777-788.
2. Yada H., Sawai K., Taniguchi H. et al. Analysis of vascular anatomy and lymph node metastasis warrants radical segmental bowel resection for colon cancer. World J.Surg 1997;21:109-115.
3. Malassague B., Valleur P., Serra J. et al. Relationship of apical lymph node involvement to survival in resected carcinoma. Dis. Colon Rectum 1993; 36:645-653 (PMID 8394236).
4. Stojadinovic A., Allen P.J., Pratic M. et al. Colon sentinel lymph node mapping :practical surgical application. J.Am.Coll. Surg. 2005; 201:297-313 (PM 16038828).
5. Meyers M.A. Griffith’s point : critical anastomosis at the splenic flexure . A significance in ischemia of the colon.Am.J.Roentgenol.1976;126:77-94.
6. Le P.,Mehtari L., Billey C. Les tumeurs du colon transverse. J.Chir. 2006 ;143 :285-293.
7. Gallot D. Colectomie du sommet de l’anse sigmoide pour cancer, par voie ouvert. J.Chir. 2005 ;142 :30-34.
8. Ruo L., Guillem J.G. Cancer of the colon. In: Bland K.I., Daly J.M.,Karakousis C.P., editors:Surgical Oncology:contemporary principles and practice. McGraw-Hill Co.New York,2001
9. Nelson H., Petrelli N., Carlin A. et al. Guidelines for colon and rectal cancer surgery. J.Nat.Cancer Inst. 2001;93:583-596.
10. Lasser P., Elias D. Generalites sur la chirurgie d’exerese des cancers coliques. Problemes techniques generaux et strategie therapeutiques. EMC(Elsevier Masson SAS,Paris) Traite de Techniques chirurgicales-Appareil Digestif 40-555(1996).

Source(s) of Funding

---

none

Competing Interests

---

none

Disclaimer

---

This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.