tailieunhanh - Improved Outcomes in Colon and Rectal Surgery part 31

Improved Outcomes in Colon and Rectal Surgery part 31. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | improved outcomes in colon and rectal surgery differentiate fibrosis from tumor. If there is suspicion clinically of involvement we will treat with IORT. Sacrectomy is preserved for those who are fit for surgery with clear cortical destruction or marrow involvement by CT MRI below S1-2. Our initial experience with this approach is encouraging. 27 Postoperative chemotherapy is usually recommended in our institution but has been variably administered in the literature. OPERATIVE APPROACH The patient is placed in modified lithotomy position. Initial exploration is undertaken to carefully assess for extrapelvic metastatic disease. Careful attention is paid to the liver and the abdomen is assessed for carcinomatous implants. All adhesions are lysed and the ureters are identified. Ureteric catheters are typically used. The left colon is mobilized as is the splenic flexure and attention is focused on the IMA root. If it has not been taken it is mobilized. An assessment for resectablity is made and if the tumor is deemed resectable the IMA if not previously ligated is taken high. The neorectum is mobilized posteriorly initially laterally then anteriorly. The areas free from tumor involvement are most easily mobilized and are approached first. As much easy dissection should be done as can be done to identify landmarks initially. If anterior structures are clinically involved they are taken en bloc with the neorectum. It is much easier to take the bladder seminal vesicles and prostate en bloc with the neorectum than to try to separate them. If there is firm adherence to the posterior aspect of the bladder seminal vesicles or prostate they should be taken en bloc. If the lesion is quite low in the rectum and adherent to the prostate or vesicles alone the posterior portion of the prostate and or the seminal vesicles may be taken without the bladder but this is much more challenging technically than proceeding with en bloc cystoprostatectomy. In a female en bloc posterior .