Medical Archive

Embryology of the Colon and Rectum

Anatomy of the Colon, Rectum, and Pelvic Floor

Physiology of the Colon

Preoperative Workup and Stoma Planning

Nutritional assessment

Preoperative bowel preparation

???: PEG(polyethylene glycol solution)
??? ???: incision 30? ?? single dose, IV antibiotics

Planning intestinal stomas

• Indications
  • S.colon diverticulum perforation
  • Trauma? ?? ?? ? ??? ??
  • Cancer – APR, D.colon ??, recto-vaginal fistula

Stoma types

Physiologic Considerations and Practical Implications

Colostomy

Ileostomy

Diverticular Disease

Colonic Volvulus

https://hsnowhome.wpcomstaging.com/2020/05/07/c323-acute-intestinal-obstruction/

Treatment

• Cecal volvulus
  • Emergency laparotomy and resection of the volvulized colonic segment.
  • Endoscopic detorsion – not advised (success rate <5%-20%)
  • Viable ?? torsion ??? ?? ?? (cecopexy)
• Sigmoid volvulus 
  • ??? ?? ?? – rectal tube? ??, ???
  • Endoscopic detorsion – first-line treatment (success rate: >75%-90%) prior to elective, rather than emergency, sigmoid colectomy.

Large Bowel Obstruction and Pseudo-obstruction

Inflammatory Bowel Disease

Ulcerative colitis

Crohn’s colitis

Epidemiology and Cause

Pathologic Features

Clinical Presentation

Diagnosis

Medical therapy

Indications for surgery

????? ???? complication? ??? ?.

Surgical procedures

• ?? ??
  • Ileocecal resection with primary anastomosis
    • ???? ileocecal Crohn? ??, most commonly used.
    • ??? ??? ??? ??? ?? ??? ??? ?? ??? ????? ?? ??.
• ?? ??
  • Total proctocolectomy with end ileostomy
  • Total abdominal colectomy with ileorectal anastomosis
• Segmental colon resection

Postoperative recurrence

Infectious Colitis

Ischemic Colitis

Neoplasia

https://hsnowhome.wpcomstaging.com/2020/05/22/c77-lower-gastrointestinal-cancers/

# Polypectomy

• Polyp? ?? ?????.
• 2cm ??: snare polypectomy
• 2cm ??, sessile: EMR or ESD
• ??? ???? ??
  • 3cm ??, sessile
  • ?????? ???? ?? ?. G2(moderately differentiated)~
• Follow up
  • 6?? ? colonoscopy f/u
  • ????? 3??? colonoscopy
  • ??? ???? ????? ????? ?? 1? ? ?? colonoscopy

Submucosa 1,000?m ?? ??? endoscopic, ??? ??? ?? 
Lymphovascular invasion ??? ? ??? ?? 

• AV 10-15cm ??, stage II(T3 or N1) ??? rectal cancer
  • ??? distal 3-5cm? ??: greatest challenge for the surgeon!!
  • ?? ? CCRT? downstaging
    • 5-6?? RTx, ??? RTx ??? 6-10? ? ??.
    • ?? ? ???? ??? ?? ?? diverting stoma (ileostomy or transverse colostomy) ??, ?? 10? ? closure.
  • ??? low half ????? total mesorectal excision(TME) ???? ?

Local exision

This is accomplished through a transanal approach and involves excision of the full thickness of the rectal wall underlying the tumor.
?? ??? ?? ???? ??.

• Mobile tumor, ?? 3cm??, ? ?? 30% ?? ??
• Anal verge 6cm ??
• No vascular or lymphatic invasion. 
• Well or moderately differentiated.
• Rectal – T1N0
  • Confined to the submucosa, ????? ??? 8%.
• Rectal – T2N0
  • ? aggressive Tx ??. Proctectomy + total mesorectal excision (APR or LAR)
  • Local excision with chemoradiation
    • ??? ?? (<3cm), ?? ???? ????, ?????? poor-differentiation? ???, lymphoneural or perineural invasion? ?? ??? ??? ???? ? ??.

Transanal Endoscopic Microsurgery

Fulguration

Abdominal Perineal Resection (APR)

• Anal verge 6cm ????.
• ???, levator ani. ???

Low Anterior Resection (LAR)

• Anal verge 6cm ???. ??? leak? ??

Hartmann’s op

• LAR? ?? ?? ?? but ?? rectal pouch ??
• Indication
  • Obstruction? ???? ?? ? stent? ??. ??? ??, ?? ?? (??? leak? ?? ? ??.)
  • Peritonitis

Sphincter-Sparing Abdominal Perineal Resection With Coloanal Anastomosis

# Colectomy

Right hemicolectomy	IC valve 4-6cm ??? ~ middle colic a.? right branch??? ??? ?? transverse colon ?? ??.
Extended right hemicolectomy	Rt. colic a., middle colic a. ??? ??? ???? ?? ??, terminal ileum? proximal left colon? ??.
Left hemicolectomy	Splenic flexure???? rectosigmoid junction?? ??
Sigmoidectomy	Ileum?? rectum?? ?? colon? ??.
Abdominal colectomy (subtotal or total colectomy)	60? ???? ???? ?. ??? ???/???? ???? ????? ?? ? ??? ???? ?? ? ??. Ix: ??? ?? ??, HNPCC ?? ???, ?? ?? ??? ???? S-colon ca.
Total proctocolectomy	Ix: FAP, UC, ??? polyp? margin (+)

??? ???: pre-op. 30~60? ~ post-op. 24?? ???.

Pelvic Floor Disorders and Constipation