Colorectal Surgery

Shared operative foundations taught once, the room they happen in, the instruments on the tray, and the anaesthetic that makes it possible.

• Embryological planes & mesenteric envelopes

  The idea that made colorectal cancer surgery an oncologic discipline: the gut grew inside mesenteric envelopes, and dissecting the bloodless plane around an intact envelope removes the cancer with its lymphatic field. Total mesorectal excision is this idea applied to the rectum; every colonic resection is the same idea at a different address.

  1. 01The embryology. The gut and its mesentery rotated and fused against the retroperitoneum, leaving fusion planes: potential spaces where two once-free surfaces lie together, openable without cutting a vessel.
  2. 02The holy plane. Around the mesorectum lies such a plane: dissect it faithfully and the rectum lifts out inside a shiny intact package containing every node that drains it. Breach it and tumour cells are left behind.
  3. 03Why it is oncology. Local recurrence rates fell dramatically when TME standardised the plane: the pathologist grading the specimen's surface is grading the surgery itself.
  4. 04The pedicle logic. Each colonic segment hangs on a named artery (ileocolic, inferior mesenteric): taking the vessel at its origin harvests the lymphatic chain that follows it, which is why resections are defined by pedicles rather than by centimetres of bowel.
  5. 05Everywhere else. The same fusion-plane logic mobilises the right colon, the spleen's attachments and the duodenum: surgical anatomy is mostly the memory of embryology.

  Used byRight hemicolectomyLow anterior resection with TMEHartmann's procedure

• Stomas: formation, function, life

  Half the specialty's operations create, protect or reverse a stoma: what they are for, how they differ, and what living with one asks of a patient.

  1. 01The taxonomy. End colostomy (Hartmann's, permanent after some rectal cancers), loop ileostomy (defunctioning, temporary), end ileostomy (after colectomy): the name encodes the bowel used and the intent.
  2. 02Why defunction. A loop stoma upstream of a fresh join diverts the stream: it does not stop a leak, it changes what a leak means, from peritonitis to a contained, survivable problem.
  3. 03Siting. Marked pre-operatively, away from creases, bones and belts, where the patient can see it: a badly sited stoma is a daily complication that lasts years.
  4. 04Physiology. Ileostomies run liquid and salty: high-output stomas dehydrate patients and strand their kidneys, and the fix is measurement, restriction of hypotonic fluids and pharmacology, not just more water.
  5. 05The reversal question. Closure is a real operation with its own leak rate, and a third of 'temporary' Hartmann's stomas prove permanent: honesty at the first consent saves grief at the second.

  Used byHartmann's procedureLow anterior resection with TME

Operative photo

On the tray

No instruments are tagged to this specialty’s operations yet.

Anaesthesia

The airway, the depth, the haemodynamics and the analgesia: the head of the bed has its own rooms.

Enter anaesthesia

• Watch

  Right hemicolectomy explained

  The operation drawn and narrated by surgeons who teach it: mobilisation, vessels, anastomosis.

  Watch for

  • The lateral-to-medial mobilisation and the duodenum behind it
  • Ileocolic pedicle ligation
  • Ileocolic anastomosis options

  Source: School of Surgery · Watch on YouTube
• Watch

  Low anterior resection: surgical management of rectal cancer

  The University of Toronto atlas explaining the resection, the mesorectal plane and the anastomosis.

  Watch for

  • The holy plane and what lies outside it
  • Why the mesorectum is taken intact
  • When a defunctioning ileostomy is added

  Source: TVASurg, Toronto Video Atlas of Surgery · Watch on YouTube
• Watch

  Hartmann's procedure explained

  Sigmoid resection, rectal stump and end colostomy, and the reversal that may or may not follow.

  Watch for

  • Why the anastomosis is not made in the emergency
  • Preparing the rectal stump
  • Siting the end colostomy

  Source: School of Surgery · Watch on YouTube
• Watch

  Diverticulitis: Hartmann's procedure, or is a washout all you need?

  The evidence on laparoscopic lavage versus resection for perforated diverticulitis.

  Source: SAGES · Watch on YouTube
• Watch

  Perirectal abscess drainage

  A colorectal surgeon's own teaching on draining perianal sepsis and what to look for at EUA.

  Watch for

  • The cruciate incision close to the anal verge
  • Breaking loculations without creating a fistula
  • When not to probe for a tract

  Source: Karen Zaghiyan MD FACS FASCRS · Watch on YouTube

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