lar =low anterior rescection, how they do it, gory details

pete43lost_at_sea said:

lar = low Anterior resection with total mesorectal excision
hi blake,

lar is what rectal cancer patients get here.

don't try this at home yourself. don't read further if squemish.

fyi this is fascinating reading, its almost what was done to me except point 9

Anterior resection with total mesorectal excision
R.J.C. STEELE, Professor of Surgical Oncology, University of Dundee

J.R.Coll.Surg.Edinb, 44, Feb 1999, 40-45

INTRODUCTION

The operation of anterior resection with total mesorectal excision (TME) has become the gold standard for the treatment of cancer of the rectum, except where the tumour is close to or involving the anal sphincter complex. The reason for this relates to the low incidence of local recurrence after this procedure, which has now been reported by several independent groups.1-3 Although controversy still exists around the role of TME in tumours of the upper rectum, it is now widely accepted for tumours of the middle and lower third.4

The procedure has two main drawbacks. Firstly, there is a high risk of anastomotic breakdown (in the region of 15%)5, and many surgeons use a defunctioning ileostomy to ameliorate the effects of this complication should it occur. Secondly, it can be associated with a high incidence of urgency and faecal leakage, and, on the basis of evidence from functional studies and randomised trials, it is becoming standard practice to fashion a short colopouch to improve functional results.6

Prior to surgery, patients should be fully investigated to exclude synchronous tumours and metastatic disease; bowel preparation, deep vein thrombosis (DVT) prophylaxis and perioperative antibiotics are also mandatory.4 Furthermore, it is very important to ensure that the patients are fully conversant with the implications both of the disease and the operation, and are prepared for stoma formation. It follows that they should be seen by a stomatherapist before operation and, where possible, by a colorectal cancer specialist nurse.4

Finally there is the question of adjuvant radiotherapy. The recent Stockholm II trial indicates that short course preoperative (25 Gy in 5 fraction sin the week before surgery) reduces local recurrence rates and improves survival when used with conventional surgery,7 but its role in conjunction with TME is far from clear. For this reason the MRC CR07 trial has been initiated, and, where any doubt exists, patients should be entered into this trial. It should be stressed, however, that this applies only to operable tumours. If a rectal tumour is fixed to the pelvis, then a long course of radiotherapy (e.g. 45 Gy in 20 fraction over four weeks) followed by a wait of about six weeks should be tried in an attempt to render the tumour operable.

1 Patient position

The patient is positioned in the extended Lloyd-Davis position. It is important that the legs are not angled too steeply, as this will restrict the operative field. A urinary catheter must be inserted but this can be done during the operation as a supra-pubic procedure. This is particularly preferable in males. A nasogastric tube is not used routinely.

2 Access

A long mid-line incision from the symphysis pubis to the xiphisternum is made. The skin is opened using cutting diathermy and the subcutaneous tissue using coagulation diathermy. In order to identify the midline in an obese patient, the subcutaneous tissue is split by the surgeon and the assistant using opposing finger traction. The linea alba and the fascia below the umbilicus is divided using coagulation diathermy and the peritoneum is opened close to the umbilicus using a knife to avoid burning underlying bowel. After a thorough laparotomy, looking particularly for liver metastases, intra-abdominal spread, lymphadenopathy and local spread, the small bowel is packed away into the right upper quadrant. This pack is held in place using a large blade of an "Omnitract" self-retaining retractor. Two further blades are then used to retract the left abdominal wall as far laterally as possible. With the surgeon on the left-hand side of the patient, the first assistant on the right-hand side and the second assistant between the legs, dissection can now begin.

just an excerpt, goto the link for full details

enjoy,

pete