Introduction

Minimally invasive treatments or operations preserving sphincter functions are indicated for rectal polyps, rectal carcinoma in situ and low stages of rectal cancer. Local excision of rectal cancer is feasible in only a highly select group of patients. As for our experiences, less than 4-6% of all rectal cancers are amenable to local excision. Only those tumours that involve the mucosa and submucosa and that have not extended beyond lamina propria are suitable. Furthermore, only those tumours that are less than 12-20 mm in diameter are appropriate. It is important to remember that if there is any doubt whatsoever about nodal metastases, it is far wiser to embark on a radical rectal excision than to attempt complete cure by local excision and fail. This is particularly relevant now that sphincter-saving resections are feasible and are relatively easy to perform in these cases. The only exception to this philosophy is the patient in whom a radical rectal excision might be contraindicated because of coexisting disease. These tumours must be very carefully assessed pre-operatively and the precise location within the rectum determined. Intrarec-tal ultrasonography is particularly valuable in identifying T1 and T2 tumours. Information about the upper extent of the lesion is crucial because lesions with an upper margin more than 8-9 cm from the anal verge are unsuitable for local or transanal procedures. Anteriorly placed lesions are best managed with the patient in the prone jack-knife position. Posterior lesions are best managed with the patient in the lithotomy position, although admittedly those lesions lying just beyond the anorectal angle can prove quite difficult to remove peri-anally with the patient in this position. The mobility of the tumour in the submuco-sal plane should be also assessed. Mobile tumours can usually be delivered into the operating field by placing six to eight sutures around the periphery of the tumour, leaving the suture tails long and then gathering the tails together in a manner resembling the cords of a parachute, twisting them and pulling the lesion en masse into the operating field.

Our recent treatment scale of tumour local excision is quite wide:

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