Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Winter, 2006 issue of the Journal.

Search for the Critical Difference in Surgical Technology for Colorectal Cancer Resection

Paul H. Sugarbaker, MD, FACS, FRCS
Washington Cancer Institute, Washington, DC, USA

Corresponding author:
Paul H. Sugarbaker, MD, FACS, FRCS
Washington Hospital Center
106 Irving St., NW, Suite 3900
Washington, DC 20010, USA
Tel #: (202) 877-3908
Fax #: (202) 877-8602
E-mail: Paul.Sugarbaker@medstar.net

ABSTRACT
Objectives: The technology utilized for resection of colon and rectal cancer varies greatly between caregivers. A discipline for optimizing resection so that there is minimal local regional recurrence and a maximum long-term survival is presented.

Methods: Our hypothesis is that complete clearance of the lateral margins and the lymph node groups combined with complete containment of the specimen to be resected by maintaining intact normal tissue surrounding the disease process is necessary to eliminate microscopic residual disease.

Results: Optimal colorectal cancer resection can be performed with almost no blood loss and a minimum of morbidity and mortality. The skill of the cancer surgeon is the major determinant of the overall results of treatment. Wide exposure, meticulous hemostasis, and generous peritonectomy integrated into a centripetal approach are required.

Conclusions: The local recurrence rate of colon and rectal cancer can be brought down to near 0%. Optimal resection combined with a multimodality program in management should result in a maximum survival of colon and rectal cancer patients.

SHORT SUMMARY
The surgical technology involved in the resection of colorectal cancer is a determinant of prognosis. Complete clearance of the primary cancer combined with containment of microscopic disease are requirements of maximal survival.

INTRODUCTION
Goligher and colleagues writing from their clinical and laboratory observations, suggested that cancer surgery is a mechanism for dissemination of gastrointestinal malignancy. They regarded local progression as iatrogenic recurrence.¹ Another outspoken clinician who suggested that a contained colorectal cancer can be converted to a disseminated malignancy as a result of cancer resection was Turnbull.² He advocated the no-touch isolation technique for the resection of colon and rectal malignancy. Recently, data has emerged strongly suggesting that the surgeon’s role in the cure versus intraoperative dissemination of gastrointestinal cancer is more crucial than has been accepted in the past. Hermanek and colleagues showed that the local recurrence rate for rectal varied from 5% to 55% when the data was analyzed on a surgeon by surgeon basis.³ This translated into an approximate 40% difference in 5-year survival. Porter and colleagues suggested that well-trained and experienced surgeons could expect a 67% long-term survival.⁴ A surgeon without special training who occasionally performs rectal cancer excisions had only half as many long-term survivors. Other factors that would explain these marked differences in survival such as stage of the disease, grade of the malignancy, socioeconomic status, emergency versus elective presentation, and other factors were not able to statistically explain these large differences in outcome. The reader is left to conclude that for some surgeons’ skill in resection of the malignant process could result in cure; for other surgeons the same patient will develop recurrence as a result of local and regional disease, and cancer death.

In this manuscript we assume that the crucial difference between adequate and inadequate cancer surgery is the absence versus presence of microscopic residual disease following cancer resection. Complete clearance and perfect containment of the malignancy will minimize local regional recurrence and maximize long-term survival. Selected use of peritonectomy and perioperative intraperitoneal chemotherapy offers the best options to patients with small volume of peritoneal seeding.

PATIENT PRESENTATION
A 48-year-old male weighing 250 lbs. and 6 feet 2 inches in height noted rectal bleeding. After a delay in diagnosis of approximately 6 months a colonoscopy was performed which revealed a near-circumferential cancerous mass palpable by rectal examination. Endoscopic ultrasound suggested invasion into the perirectal fat. The patient received perioperative chemotherapy and radiation therapy. He was taken approximately 4 weeks following radiation therapy to the operating room. Upon exploration there was no disease dissemination in the liver or on peritoneal surfaces. The cancer was visible through the peritoneum in the cul-de-sac of Douglas. The peritoneum over the cancer was distorted and hemorrhagic. By gentle palpation the mass was fixed within the tissues of the pelvis, especially the base of the bladder.

DISCUSSION
This approach to colon or rectal cancer excision has evoked in response to the hypothesis that microscopic residual disease is a prominent cause of surgical treatment failure.⁶ In order to eliminate residual disease the surgery should maximize the clearance of the malignancy and maximize the containment of any free cancer cells. Maximal clearance with rectal or colon cancer surgery comes from maintenance of the mesorectal envelope as advocated by Quirke and colleagues and Heald and colleagues.^7,8 This is to prevent the disruption of the cancer specimen and the fallout of cancer cells into the operative site that may result. If the mesorectal envelope is traumatized then cancer cells from lymph nodes within the mesorectum or from satellite tumor deposits within lymphatic channels also contained within the mesorectum may be traumatically disseminated.

Another crucial aspect of adequate clearance involves adequate lymphadenectomy. All of the lymph nodes should be maintained within the specimen without trauma. The inferior mesenteric artery and vein are ligated at their origin on the aorta and near the origin on the splenic vein respectively. The major lymphatic channels follow the arterial blood supply. A conglomerate ligation of tissues on the specimen side of the inferior mesenteric artery will minimize lymphatic leakage of cancerous cells from the specimen. Arguments advocating reduced lymph node dissection cannot be rationally defended. The lymph node dissection that always results in an absence of recurrence within lymphatic channels or lymph nodes is the only one that should be recommended. The complete lymphatic dissection has never been associated with an increased morbidity or mortality. Excuses for a reduced lymphadenectomy cannot be supported.

Not only perfect clearance but also perfect containment of the cancer must be maintained during the cancer resection. Conversion of a contained malignant process to a disseminated one is, unfortunately, a common occurrence with inadequate surgical technology.⁹ Centripetal surgery through a wide peritonectomy is required to provide maximal containment. Approaching the malignancy from a retroperitoneal rather than from an intraperitoneal approach assures that the cancerous process will be lifted off of its nearby structures without disrupting the soft tissues surrounding the primary cancer and causing cancer dissemination.¹⁰

The approach used for an optimal colorectal cancer resection is referred to as “centripetal surgery.” There are several essential technical requirements of centripetal surgery. Wide exposure using self-retaining retractors will allow the surgeon to work in a circular fashion going around and around the malignant process. If handheld retractors are used a cumbersome repositioning of these retractors and unnecessarily slow and laborious dissection results. Electroevaporative surgery (pure-cut, high voltage, ball-tip) is necessary in performing the peritonectomy or unnecessarily large amounts of blood loss will occur. As the peritoneum is stripped away from the abdominal wall and from retroperitoneal and pelvic structures, all small bleeding points are closed off by the high voltage pure-cut electrosurgery.¹⁰ These two surgical technologies along with a thorough knowledge of the anatomy allow the surgeon to move from the most peripheral part of the cancer operation to the malignancy itself. The cancerous process is usually the last anatomic structure to be approached. The surgeon must discipline himself to proceed only when the site for further dissection is optimal. Three criteria must be met in order for the surgery to proceed at a particular anatomic site: 1) There must be no bleeding. 2) There must be no danger of damage to vital structures. 3) The desired margin of excision on the malignancy is obtained. If any of these 3 criteria are not met, rotation to another anatomic site for further dissection should occur. The motto is “Do what is easy first.”

Resection of the greater omentum is thought to be an essential part of all gastrointestinal cancer operations. The experimental literature would strongly suggest that a first site for cancer cell containment is in the greater omentum itself. It is possible that many thousands, perhaps even millions of cancer cells may be contained within a normal appearing omentum. Although the greater omentum can engulf these tumor cells it is not able to destroy them. The containment within the structure is only temporary and therefore its removal is advisable. Performing the greater omentectomy in this particular patient greatly facilitated exposure and released the splenic flexure from its retroperitoneal attachments.

The electroevaporative surgery has several important functions in oncologic surgery. Electroevaporative surgery is performed with a ball-tip using the electrosurgical generator on pure-cut at high voltage. The tissues are not transected but rather are electroevaporated thereby creating a lenticular defect as the dissection proceeds. This eliminates all bleeding from small vessels. Even vessels up to 1 mm in diameter can be heat sealed so that active bleeding is prevented. Electroevaporative surgery keeps the field absolutely clear of blood so that the translucent nature of the tissues is preserved. Once the tissues become stained by blood the rapid and accurate centripetal dissection is no longer possible. The electroevaporative surgery is critical where there are narrow margins of excision. If the cancer penetrates up to but not beyond the margin of dissection it can be contained using this electroevaporative approach. It creates a margin of heat necrosis on the patient side of the dissection. Also, heat necrosis of tissues within the specimen will minimize the opportunity for escape of viable cancer cells.

Frequent irrigation of the entire operative field is mandatory with the use of electroevaporative surgery. The irrigation tends to preserve the transparent nature of the tissues so that errors in dissection causing trauma to vital structures does not occur. This frequent irrigation should always be combined with electroevaporative surgery in order to minimize heat buildup that may lead to focal necrosis of tubular structures. Also, frequent irrigation every 7 to 10 minutes can remove cancer cells that have entered the field of dissection prior to their being fixed within coagulated fibrin.9 Frequent irrigation is an important part of every gastrointestinal cancer resection.

SPECIAL TREATMENTS FOR PATIENTS WITH PERITONEAL SEEDING
Unfortunately, some patients will come to the operating theater with peritoneal dissemination of cancer. Even the most radical surgery with extensive peritonectomy will not eradicate microscopic residual disease in these patients. Included in this group are patients with biopsy proven peritoneal implants or omental nodules, ovarian involvement, perforated cancer, cancer with adjacent organ invasion, cancers resected piecemeal or with disruption of the specimen and cancers associated with positive peritoneal cytology (Table 1). These patients are recommended for concomitant treatment of the primary malignancy by large bowel resection and treatment of carcinomatosis by peritonectomy and perioperative intraperitoneal chemotherapy.

Very little information is available regarding the success of treatments of primary colorectal cancer with peritoneal seeding. Pestio observed a statistically significant improvement in survival when concomitant resection of the primary cancer, peritonectomy of the implants, and perioperative intraperitoneal chemotherapy were utilized. No randomized and controlled data regarding multimodality treatment versus simple resection is available.

However, some data is available from phase II studies of patients with documented peritoneal seeding. In these studies, patients were treated intraoperatively with heated mitomycin C chemotherapy using a technique for manual distribution of the chemotherapy solution (Figure 20). This technique allows for the uniform distribution of both heat and cytotoxic effects throughout the extensive abdominal and pelvic surfaces. Also, vigorous debridement of peritoneal surfaces using gauze causes adherent cancer cells to be dispersed into the chemotherapy solution. Not only peritoneal seeding, but also cancerous fallout at a resection site should be eliminated using this technology. The standardized orders for heated intraoperative intraperitoneal mitomycin C are shown in Table 1.

The apparatus utilized allows 3 or 4 liters of chemotherapy solution to fill the abdominal and pelvic space. The apparatus is shown in Figure 20. The apparatus, which provides heated perfusion to the solution within the abdomen and pelvis, is shown in Figure 21.

In the early postoperative period, the tubes and drains that were used for intraperitoneal chemotherapy are left within the abdomen and pelvis. A purse string suture is used at the skin in order to prevent leakage of intraperitoneal fluid. Patients receive early postoperative intraperitoneal 5-fluorouracil using the standardized orders shown in Table 3. If the patients have received prior systemic 5-fluorouracil, they are treated with intraperitoneal paclitaxel.

RESULTS OF TREATMENT
The results of this multimodality approach to carcinomatosis have been reported. Two quantitative prognostic indicators are important in determining the outcome. The Peritoneal Cancer Index was used to score the volume of carcinomatosis at the time of abdominal exploration. The Peritoneal Cancer Index is an assessment of both implant size by means of a lesion size score, and the distribution of peritoneal implants in 13 abdominopelvic regions. The lesion size score quantitated the diameter of the largest peritoneal implant in a particular abdominopelvic region. Lesion size 0 indicated no implants. Lesion size 1 indicated tumor nodules less than 0.5 cm in diameter. Lesion size 2 indicated tumor nodules 0.5 to 5.0 cm in diameter. Lesion size 3 indicated tumor nodules greater than 5.0 cm in greatest diameter or a layering of malignancy within any part of the abdominopelvic region. Summation of the lesion size scores in the 13 abdominopelvic regions constituted the Peritoneal Cancer Index. Two horizontal and 2 vertical planes defined abdominopelvic regions

0 through 9. The horizontal lines were defined by the lowest aspect of the rib cage right and left and by the crest of the ilium right and left. The two vertical planes divided the abdomen and pelvis into 3 equal parts. Abdominopelvic regions 9 and 10 were defined by upper and lower jejunum and abdominopelvic regions 11 and 12 by upper and lower ilium. The maximum score by this quantitative assessment of abdominal and pelvic tumor was 39 (13 x 3). Figure 22 illustrates the quantitation of peritoneal implants.

The survival of approximately 100 colon cancer patients by the Peritoneal Cancer Index is shown in Figure 23. Clearly, the outcome using this treatment strategy improves in patients who have a lower volume of carcinomatosis. Current recommendations are that all patients with a PCI of less than 10 should have this multimodality approach. Only especially fit and young patients would profit from the aggressive approach when a hire peritoneal cancer index score is recorded.

The second quantitative prognostic indicator is the completeness of cytoreduction score. In this system, patients with no tumor nodules remaining at the completion of cytoreduction or only a few nodules less than 2.5 mm in diameter remaining are scored as a complete cytoreduction. Patients with tumor nodules greater than 2.5 mm in diameter are scored an incomplete cytoreduction. As shown in Figure 24 the complete removal of carcinomatosis is mandatory for a long term survival in this group of patients.

The morbidity and mortality of this approach has been acceptable.4 When peritonectomy was combined with heated intraoperative and early postoperative chemotherapy, the combined grade 3 and 4 morbidity was 27%. Complications observed included pancreatitis (6%), fistula (4.5%), postoperative bleeding (4.5%) and hematologic toxicity (4%). Except for the hematologic toxicity, the incidence of these complications was related to the extent of cytoreduction.The treatment related mortality was 1.5%.

SUMMARY
Although colorectal cancer surgery has been of great benefit to patients, imperfect surgical technique has resulted in the unnecessary deaths of countless patients. Although the surgeon successfully extirpates the primary tumor, too often perfect clearance and perfect containment has not been the goal. Microscopic residual disease within the abdomen and pelvis not appreciated by the surgeon has resulted in persistent cancer cells within the abdomen and pelvis and may be responsible for 30 to 50% of the patients who die with this disease. Surgical techniques using centripetal surgery minimize the microscopic residual disease along with adequate lymphadenectomy and generous lateral margins of excision can greatly improve the outcome of these patients.

Not only should the surgical event for primary colon and rectal cancer be optimized, but also the successful treatment of limited peritoneal carcinomatosis should be pursued. A specific group of patients that are at high risk for persistent microscopic residual disease are those with a perforated malignancy, positive peritoneal cytology, ovary involvement, tumor spill during surgery and adjacent organ involvement. Data gathered from patients with demonstrated peritoneal seeding suggests that long term survival should be possible in a substantial proportion of these patients. Heated intraoperative intraperitoneal mitomycin C chemotherapy and early postoperative intraperitoneal 5-fluorouracil chemotherapy have been used with good results and acceptable morbidity and mortality. In combination with proper techniques and knowledgeable patient selection, intraperitoneal chemotherapy can participate in an optimization of the surgical treatment of patients with large bowel cancer.

Table 1: Patients with colorectal cancer at high risk for peritoneal recurrence.

• Limited peritoneal implants or omental nodules
• Ovarian involvement by cancer
• Perforated cancer
• Cancer with adjacent organ invasion (T4)
• Cancer resected piecemeal or with disruption of the specimen
• Positive peritoneal cytology
• Patients with abdominopelvic recurrence

Table 2: Physicians orders for heated intraoperative intraperitoneal chemotherapy using mitomycin C.

1. For pseudomyxoma peritonei and adenocarcinoma from appendiceal, colonic, and rectal cancer: Add mitomycin C _________ mg to 2 liters of 1.5% dextrose peritoneal dialysis solution.
2. Dose of mitomycin C for males 12.5 mg/m2; dose of mitomycin C for females 10 mg/m2.
3. Use 33% dose reduction for heavy prior chemotherapy, marginal renal function, age greater than 60, extensive intraoperative trauma to small bowel surfaces, or prior radiotherapy.
4. Send 1 liter of 1.5% dextrose peritoneal dialysis solution to test the perfusion circuit.
5. Send 1 liter of 1.5% dextrose peritoneal dialysis solution for immediate postoperative lavage.
6. Send the above to operating room _______ at _______ o'clock.

Table 3: Physicians orders for early postoperative intraperitoneal chemotherapy with 5-fluorouracil on postoperative days 1-5.

1. 5-FU ______ mg (600 mg/m2, maximum dose 1200 mg), and 50 meq sodium bicarbonate in _______ cc 1.5% dextrose peritoneal dialysis solution via IP catheter on _____________ - _____________. Last dose ________________. Dwell for 23 hours and drain for 1 hour prior to next instillation.
2. Use 1 liter of 1.5% dextrose peritoneal dialysis solution for body surface 1 – 2 m2, 1.5 liters for body surface > 2.0 m2.
3. Continue to drain abdominal cavity after last dose until Tenckhoff catheter is removed.
4. During initial 6 hours after all chemotherapy infusion, patient’s bed should be kept flat. The patient should be on the right side during infusion. Turn at ? hour post-infusion onto the left side and continue to change sides at ? hour intervals for 6 hours.

Figure 1. Patient position and incision. The patient is placed in a modified lithotomy position with the legs extended in St. Mark’s leg holders (ANSCO, Eire, PA). After routine prep of the abdomen and perineum the abdominal cavity is opened through an incision that extends from xiphoid to pubis. This midline abdominal incision is carefully directed through the linea alba and is standard for all gastrointestinal cancer operations. The epigastric fat pad and preperitoneal fat above the bladder are resected in order to improve exposure.

Figure 2. (above left) Exposure. A Thompson self-retaining retractor (Thompson Surgical Instruments, Traverse City, MI) is positioned to widely expose the entire abdomen and pelvis. The accessories required for this surgical technology are attached to the Thompson retractor. Care is taken to secure the smoke evacuator, electrosurgical cable, and liquid suction apparatus to the periphery of the self-retaining retractor so that it does not interfere with the retraction system. After opening the skin with a knife and the subcutaneous tissue and fascia with blade-tip electrosurgery all subsequent dissection is performed with ball-tip electrosurgical handpiece (Valleylab, Boulder, CO). The electrosurgical generator is used on high voltage purecut to dissect or on high voltage pure-coagulation for hemostasis (ConMed Corp., Utica, NY). Using ball-tip electrosurgery creates a large amount of smoke as a result of carbonization of the electroevaporated tissues. In order to maintain visualization of the operative field and to preserve a smoke-free atmosphere in the operating theater a smoke evacuation unit is utilized (Stackhouse Inc., El Segunda, CA). The vacuum tip is maintained 2 to 3 inches from the field of dissection whenever electrosurgery is in use. This dissection technique is referred to as electroevaporative surgery. Figure 3. (above right) Complete greater omentectomy. The initial procedure in all gastrointestinal cancer operations is the greater omentectomy. Unless there is a crucial role for the omentum, for example an omental pedicle flap to the pelvis, it is always resected. In this patient the entire greater omentum was removed sparing the gastroepiploic arcade on the greater curvature of the stomach. Clearing the greater omentum reduces the risk for subsequent peritoneal carcinomatosis and frees up the hepatic and splenic flexure. In this patient with a left colon cancer, takedown of the splenic flexure was necessary in order to lengthen the descending colon for the subsequent colorectal anastomosis. Complete removal of the omentum greatly facilitated the release of the splenic flexure.

Figure 4. (above left) Peritonectomy of the left paracolic sulcus. Centripetal surgery begins through an elevation of the descending colon. This is initiated by dividing the peritoneum lateral to the left colonic mesentery in the left paracolic sulcus. This peritoneal incision is continued superiorly to the lower border of the pancreas. Figure 5. (above right) Release of the mesentery of the left colon from the retroperitoneum. By placing moderate traction on the left colon especially at the splenic flexure, the base of the mesocolon is divided from lateral to medial so that the entire descending colon and splenic flexure are released from the retroperitoneal structures. The structures on the inferior aspect of this dissection include the perirenal fascia, the left ureter, left gonadal vessels, and lower aspect of the pancreas. Throughout this dissection the malignancy is handled with greatest care in order to minimize the opportunity for traumatic dissemination of cancer cells.

Figure 6. (above left) Schematic diagram of the pelvic peritonectomy. The lines of incision of the peritoneum laterally are the right and left paracolic sulcus, superiorly the root of the mesentery and ligament of Treitz, and inferiorly the lower aspect of the abdominal incision. Within this area, including the peritoneum covering the bladder and the cul-de-sac of Douglas, the peritoneum is stripped away using electroevaporative surgery. Figure 7. (above right) Peritonectomy of the right paracolic sulcus. Similar to the left the peritoneum in the right paracolic sulcus is divided along its lateral aspect. Traction on the specimen moves the tissues from lateral to medial. The peritoneal incision is extended medially along the base of the small bowel mesentery until the ligament of Treitz is encountered and obliterated by the dissection. Inferiorly, this incision is connected with the lower aspect of the abdominal incision. An appendectomy is performed to facilitate elevation of the cecum and terminal ileum. The advantages of this generous lower abdominal and pelvic peritonectomy are many. It approaches the inferior mesenteric vein and inferior mesenteric artery from a retroperitoneal position so that they can be ligated and then divided in their most proximal position without disruption of lymphatic channels within the specimen. Also, the right and left ureters are clearly visualized from the abdomen and are then traced down into the pelvis with a reduced likelihood for damage. In a male the right and left the gonadal vessels are spared as their peritoneal covering is moved from lateral to medial to advance the centripetal approach to resection. In a female, the ovarian vessels are ligated at the lower level of the kidneys in preparation for a total hysterectomy and oophorectomy.With the peritoneum surrounding the cancer intact there is minimal disruption of the normal tissues that contain the malignant process. Approaching the pelvis from a retroperitoneal perspective sets up the preservation of the mesorectal envelope so that errors in dissecting deep to the cancer should not occur. This approach to cancer surgery whereby one begins the operation at a most distal anatomic site and progressively removes the cancer by working around and around the mass is called “centripetal surgery.”

Figure 8. Inferior aspect of the complete peritonectomy. A Babcock clamp is used to secure the urachus so that strong upward traction can be placed on the bladder. The electroevaporative surgery is used to separate the visceral peritoneum of the bladder from this structure. This continues inferiorly beneath the cul-de-sac of Douglas. The seminal vesicles are clearly exposed on the right and left. This dissection connects to the peritonectomy of the right and left paracolic sulcus. Figure 9. Y-to-V conversion of the left colic and sigmoidal arteries. In order to preserve not only the marginal vessels but also the intermediate blood supply of the descending colon, one ligates the sigmoidal and left colic vessels just proximal to their division into the arcade. This preserves the intermediate blood supply and also allows for a maximal lengthening of the descending colon.

Figure 10. Schematic diagram of the Y-to-V conversion. Figure 11. Ligation of the inferior mesenteric artery and inferior mesenteric vein. With the peritonectomies complete there is great mobility of the descending and sigmoid colon. Morsilization of the fat between thumb and index finger at the base of the inferior mesenteric artery is performed to skeletonize this large vessel. The inferior mesenteric artery is ligated in continuity to cause a relative avascularity to the entire specimen. Arterial ligation should always be performed prior to venous ligation in order to prevent venous stasis within the specimen. After ligation and then suture ligation of the inferior mesenteric artery the inferior mesenteric vein is ligated, suture ligated, and divided. The inferior mesenteric artery and inferior mesenteric vein are surrounded by a silk suture. The first portion of the jejunum at the ligament of Treitz is protruding between the surgeon’s ring and middle fingers. The only major vessels to be ligated in this operation are the inferior mesenteric artery and vein. The technique used to secure the inferior mesenteric artery on the aorta is very different from the technique used for ligation on the patient side of the dissection. To secure the vessel on the aorta it is skeletonized, ligated and then suture ligated. The transected lymphatics from the retroperitoneum leak into the operative field. In contrast, on the specimen side of the arterial transection all nearby soft tissues are included as a conglomerate ligation. This minimizes lymphatic leakage from the cancer specimen into the operative field.

Figure 12. Division of the colon at the junction of sigmoid and descending colon. A linear stapler/cutter (Ethicon Inc., Cincinnati, OH) is used to divide the colon. The marginal vessel is divided directly perpendicular to this division of the bowel in order to maximize the blood supply to the distal descending colon. Figure 13. Pelvic exposure using a second tier of self-retaining retractors. In order to maximize exposure of the pelvis and to minimize possible dissemination of cancer cells up into the abdomen, a second tier of self-retaining retractors is used. The original retraction system to separate the edges of the abdominal incision is maintained. After separation of the sigmoid and descending colon all large and small bowel can be placed beneath a sterile towel and secured in the upper abdomen with wide, deep retractors. Not only does this exposure minimize the likelihood of cancer dissemination but it also minimizes the likelihood of damage to ureters, hypogastric nerves and pelvic veins.

Figure 14. Centripetal pelvic dissection. At this point the surgeon moves in a circular fashion around and around the rectum. The dissection continues to be performed with the electroevaporative technique. The mesorectal envelope is maintained intact and blunt dissection is not permitted. The peritoneum that covers the cul-de-sac of Douglas remains intact. Seldom is it necessary to ligate the middle hemorrhoidal vessels or the extension of the superior hemorrhoidal vessels. Rather, electrocoagulation is used to maintain hemostasis. Usually, an extender of approximately 15 cm is placed on the electrosurgical handpiece in order to maintain exposure and light in the pelvis. Otherwise the surgeon’s hand is continuously in the line of vision for the resection. A roticulator stapler (US Surgical, Norwalk, CT) is placed across the rectum approximately 4 inches below the palpable lower edge of the malignancy. Copious irrigation of the rectum with saline occurs prior to stapling off the rectal stump. Figure 15. Completed centripetal dissection of the pelvis. The St. Mark’s retractor (Thompson Surgical Instruments, Traverse City, MI) elevates the bladder and seminal vesicles. The levator muscles are seen in the depths of the pelvis. The rectal stump closed off by the stapler appears fully viable and has not been unnecessarily traumatized.

Figure 16. Colorectal anastomosis using a circular stapler. Figure 17. The rectal cancer specimen opened through its posterior aspect. The irradiated cancerous ulcer persists. The lowest edge of the rectal cancer is approximately 4 inches from the distal margin of dissection.

Figure 18. The superior aspect of the specimen. The peritoneum has been maintained intact over the cul-de-sac of Douglas. This peritoneum has functioned as a biological dressing to prevent spillage of cancer cells from the specimen. Histopathologic examination showed cancer penetration into the perirectal fat (T3) with 2 of 14 lymph nodes involved by cancer. Figure 19. Abdominal closure. The abdomen was closed with a running no. 1 nonabsorbable monofilament suture (Ethicon Inc., Cincinnati, OH). The skin was closed with clips. A single closed-suction drain is left behind in the pelvis for approximately 3 days to remove excess serous fluid.

Figure 20 & Figure 21

Figure 22 & Figure 23

Figure 24

REFERENCES

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7. Quirke P, Durdey P, Dixon MF, et al. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Lancet. 1986; 2: 996-9.

8. Heald RJ, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986; 1: 1479-82.

9. Sugarbaker PH. Successful management of micro scopic residual disease in large bowel cancer. Cancer Chemother Pharmacol. 1999; 43(suppl): S15-S25.

10. Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995; 221: 29-42.

11. Sugarbaker PH. Management of peritoneal surface malignancy: The surgeon’s role. Langenbeck’s Arch Surg. 1999; 384: 576-87.

12. Sugarbaker PH. Management of peritoneal surface malignancy using intraperitoneal chemotherapy and cytoreductive surgery. A Manual for Physicians and Nurses, 3rd ed. Grand Rapids: The Ludann Company; 1998.

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14. Stephens AD, Alderman R, Chang D, et al.Morbidity and mortality of 200 treatments with cytoreductive surgery and hyperthermic intraoperative chemotherapy using the Coliseum technique. Ann Surg Oncol. 1999; 6: 790-6.

Legends for Illustrations