Within last 10-15 years for radical surgical treatment of non-cancerous growth rectal tumor the coretraction of a tumor is used within the limits of the defined stratum or on all thickness of rectal wall with use of an operational proctoscope and corresponding instruments.
At the same time authors mark considerable complexities at realization transrectal endoscope microsurgical operations concerning large non-cancerous growth adenomas when such adenomas expand on all or nearly so on all circle of a rectum when formations of a rectum constrict rectal lumen. It speaks that it happens to detect difficultly edges of such tumor, especially when the slit is progressively augmented, and the preparation should be all time in a zone of immediate
visibility.
Complexities are marked at a stopping intraoperative bleedings, these difficulties are stipulated as by boundedness of the review of a surgery field, technological singularities. And also there are complexities at suturing the big imperfections of a wall of a rectum after an oncotomy. Besides transrectal endoscope microsurgical operations demand different stacking of the patient depending on localization of a tumor, depending on this choice of an anesthesia.
With the purpose of security adequate transrectal access provided good illumination of a surgery field we have developed and applied proctologic tooling "Mini-assistant" to manufacture scientific production association "Liga-7", Ekaterinburg (Fig. 1).
Use of a tooling "Mini-assistant" has allowed by simulation of operational space under a constant direct vision above a concavity of a rectum to create stable, convenient operational space as a frustum of a cone of any shape, using thus blades - retractors of different length and creating curving of each separate retractor under that angle which is necessary. Illumination ensured with the gaffer fixed on a retractor. Surgical manipulations fulfilled the special instruments provided with a necessary curvature for an operation through small approach (Fig. 2).
Transrectal access with use of a tooling "Mini-assistant" us was operated 132 patients concerning rectal tumors. Middle age of patients has made 62±0,9 year (from 36 till 84 years). Among operate patients was men 62, women 70. For realization of operation we used standard stacking patients on an operating table on a spin with «free-floating legs».
To all patients spinal anesthesia was carried out.
After cautious divulsion an anus in a concavity of a rectum established retractors which fixed on a ring. Retractors by different combinations (and lengths of a retractor) established a modification of an angle of a retraction so that the tumor was as much as possible displaced downwards and accessible to surgical manipulations (Fig. 3, 4).
Then in 1,5 cm from edge of a tumor produced a section of mucosal envelopes a L-shaped electrode, planning a line of a resection of a wall of a rectum (Fig. 5).
Further seized a clamp edge of resection rectal wall, and making tractions in a different direction, fulfilled a resection of a wall of a rectum together with a tumor by means of a L-shaped electrode or a bipolar coagulation (Fig. 6, 7, 8).
The stayed imperfection of a wall of a rectum took in separate welds a noninvasive resolving filament in a transversal direction (Fig. 9, 10, 11).
Resection wall of a rectum with a tumor sent on histological research with obligatory research of a line of a resection of a wall of a rectum.
| Localization of neoplasm in relation to a dentate line |
Quanity of observation (in absolute units, %) n=132 |
| 0-4 cm |
28 (21,2%) |
| 4,1-8,0 cm |
48 (36,4%) |
| 8,1-12,0 cm |
38 (28,9) |
| 12,1-14,0 cm |
17 (12,9%) |
| 15 cm |
1 (0,8%) |
| Size neoplazm within the limits of a circle of rectum |
| Within the limits of 1/4 of a circle |
35 (26,5,0 %) |
| 1/4-1/3 of a circle |
52 (39,4%) |
| 1/3-1/2 of a circle |
34 (25,8,2%) |
| 1/2-2/3 of a circle |
8 (6,1%) |
| More then 2/3 of a circle |
3 (2,3%) |
| Microscopic structure of a tumour |
| Villous adenoma |
64(48,5%) |
| Glandular-villous adenoma |
32 (24,2%) |
| Glandular-papillary adenoma |
23 (17,4%) |
| Glandular polyp |
7 (5,3%) |
| Adenomatous polyp |
5 (3,8%) |
| High-grade differentiated adenocarcinoma |
1 (0,8%) |
At 19 patients with villous tumor of a rectum at histological research focal body height of an adenocarcinoma, at 16 has been detected within the limits of a mucous stratum, at 9 within the limits of mucous and submucosal a stratum. The tumor borrowed from all these patients more than m of a circle of a rectum. Thus, body height of an adenocarcinoma has been detected in 25,8 % from 97 operated patients concerning a villous tumor of the big sizes. Body height of an adenocarcinoma within the limits of a mucous stratum is detected at one patient with an adenomatous polyp.
To one patient with high-grade differentiated adenocarcinoma T2N0M0, sizes of 1,5*1,5 cm, 4 cm settled down on distance from a toothed line on a trailing wall, it is carried out transanal a coretraction of a tumor on all thickness of a wall of a rectum, with consequent holding course of radial therapy. On pre-operation stage of the patient has refused radical operation.
At transrectal ultrasound we did not manage to reveal authentic correlation between indications of an invasion of a tumor in submucosal stratum and presence of malignant. Therefore we exsect all non-cancerous growth tumors of a rectum now on all thickness of a wall of a rectum. Such tactics has not affected outcomes of postoperative current.
In postoperative phase we observed one complication after removal of a villous tumor - a postoperative bleeding which has been stopped conservatively. 4 relapses of a villous tumor which have demanded repeated operation though in our opinion it there were left small sites of a tumor after not radical initial operation are detected. These observations concern to patients, who was operated concerning villous tumors of the big sizes and the big remoteness from a toothed line during becoming a technique of operation.
At all patients, operating concerning malignant villous tumors and the patient with an adenomatous polyp at which body height of an adenocarcinoma is detected, in postoperative phase of a recurrent tumor it has not been detected. Phase of
observation from 2,5 months till 4,5 years.
The patient, who was operated concerning an adenocarcinoma of a rectum, is observed by us 2,5 years. In postoperative phase to the patient through 1, 3 and further each 6 months the biopsy of postoperative cicatrix of a rectum, transrectal ultrasound and MRI a small basin was fulfilled. Datas for a recurrent tumor it is not obtained.
Relapse of villous tumors in group of patients (n=42) at which we produced a space from edge of a tumor on 0,5 cm we observed at 9 (21,4 %) patients. In all observations the recurrent tumor has been detected in a line of a resection of a tumor. Relapse has occurred in periods till 2 years.In group of patients (n=77) where we fulfilled a resection of a wall of a rectum in 1,5 cm from edge of a tumor, a recurrent tumor we observed at 2 (2,6 %) patients. At both patients the tumor placed in the anal canal. All patients with relapse of a villous tumor were operated repeatedly.
Thus a principle open endoscope operations and use of retractors such as the "Mini-assistant", permitting to simulate extending cone-shaped operational space, essentially dilates possibilities transrectal operations and creates new possibilities for surgical
treatment of patients with non-cancerous growth tumors of a rectum.
At removal of non-cancerous growth tumors of a rectum with the purpose of a raise of radicalism of operation it is expedient to fulfill a resection of a wall of a rectum through all its stratums in 1,5 cm from edge of a tumor.
