The patient was a 38 year old female with diagnosed carcinoma rectum. The growth was present 5 cm from the anal verge and approx 1 cm above the ano-rectal ring on per rectal evaluation. Patient completed neo-adjuvant Chemo-radiation of 50.4gy with Cepacitabine therapy. Due to the inferior extension of the growth, the patient was planned for an intersphincteric resection of the growth by a laparotomy and peri-anal approach.After a lower midline laparotomy, the inferior mesenteric vessels were identified and a high ligation of the same was done, as described by Heald, et. al. Care was taken the preserve the left colic branch with removal of all lymphatic tissue around the vessels. Dissection of the sigmoid colon and rectum was done along Toldts Fascia down to the pelvic floor. Care was taken to achieve a Total Meso-rectal Excision with complete removal of the peri-rectal fat. The Hypogastric plexus was also preserved.
After dissection of the rectum, the next step included the peri-anal mobilisation. Tagging sutures were placed from the dentate line to the external. Resection of the specimen was done trans-anally in the inter-sphincteric plane and specimen was delivered trans-anally. Reconstruction included a coloplasty and a colo-anal anastomosis. A loop ileostomy was performed to protect the anastomosis. Closure was done with a pelvic drain and an abdominal drain.
The interesting feature of this case is that even in certain low lying tumours of the rectum, the normal passageway can be preserved and a permanent colostomy can be avoided especially in younger patients. This is a new advancement in the field of oncology giving much better functional outcomes to selected patients.
Following are the photographs of the case.