Colorectal Surgery

Cancer on embryological planes, inflammation on a clock, and function always in the balance.

• Colorectal surgery treats the colon, rectum and anus: cancer resected along embryological planes, inflammatory bowel disease and diverticular disease with their perforations, and the perianal conditions that fill emergency lists.
• Its oncology has a beautiful core idea: the colon and rectum grew inside mesenteric envelopes, and cancer surgery removes the organ inside its intact envelope with the lymph nodes that drain it.
• Function shadows every decision: a cure that leaves a patient incontinent, or a stoma formed without counselling, is an incomplete operation. The specialty thinks about quality of survival, not just survival.
• The rhythm is MDT, theatre, ward: cancers staged and debated in a meeting, resected on planes, and then shepherded through the anastomotic days when leaks declare themselves.

Operative photo

• Altered bowel habit and rectal bleeding

  “Three months of looser stools and blood mixed with them in a 61-year-old: colonoscopy finds a rectal tumour at 8 cm.”

  • Blood mixed with stool, altered habit and age make a two-week-wait referral: fresh blood on the paper in a young patient is a different problem with a different pathway.
  • The colonoscopy answers what and where; staging answers how far: CT for distant disease, MRI for the rectum's local geography.
  • Rectal cancer's decisions hinge on millimetres: distance from the anal verge and from the mesorectal envelope's edge decide sphincter preservation and whether radiotherapy comes first.

  Live it as a case Low anterior resection with TME

• Large bowel obstruction

  “Four days of absolute constipation and distension in a 70-year-old; the CT shows an obstructing sigmoid mass and a caecum at 9 cm.”

  • Large bowel obstruction in this age group is cancer until proven otherwise; volvulus and diverticular strictures make up most of the rest.
  • The competent ileocaecal valve creates a closed loop: pressure builds between valve and tumour, and the caecum, widest and thinnest, perforates first. Caecal diameter and tenderness are the urgency.
  • The options fan by stability and stage: resection, a defunctioning stoma, or an endoscopic stent as a bridge to surgery or as palliation.

  Live it as a case Hartmann's procedureRight hemicolectomy

• Left iliac fossa pain and fever

  “A 58-year-old with three days of left iliac fossa pain, fever and localised guarding: CT shows sigmoid diverticulitis with a small pericolic abscess.”

  • Diverticulitis is graded before it is treated: uncomplicated inflammation, abscess, or free perforation, and the CT assigns the grade.
  • Uncomplicated disease settles with antibiotics or even without; abscesses over a few centimetres earn percutaneous drainage; generalised peritonitis earns a laparotomy.
  • Faeculent or purulent peritonitis is the emergency end: resuscitation, then usually a Hartmann's procedure, resection with an end colostomy, in a contaminated abdomen.

  Live it as a case Hartmann's procedure

• Perianal pain and swelling

  “48 hours of throbbing perianal pain, worse on sitting, with a hot fluctuant swelling beside the anal verge and a fever.”

  • A perianal abscess is pus in a closed space: antibiotics are an adjunct, drainage is the treatment, and diabetics and the immunosuppressed cannot wait.
  • The anatomy explains the disease: infection starts in the anal glands at the dentine line and tracks into the spaces around the sphincters; where it tracks names the abscess.
  • Half will declare a fistula, the persistent tract from gland to skin: the first operation drains and looks, but heroic fistula surgery in an acute field risks the sphincter.

  Live it as a case EUA and drainage of perianal sepsis

• Acute severe colitis

  “A known ulcerative colitis patient: ten bloody stools a day, HR 108, albumin falling, on day three of intravenous steroids.”

  • Truelove and Witts criteria name the severity: stool frequency, blood, fever, tachycardia, anaemia and inflammatory markers make 'severe' an objective word.
  • The steroid clock runs to day three: little improvement by then means rescue therapy or colectomy, decided jointly with gastroenterology, not another week of hoping.
  • The daily watch is for the colon dilating or perforating: abdominal films, examination and a rising heart rate are the early warnings, and steroids muffle the peritonitis.

  Live it as a case