Most higher rectal lesions would be treated today by total rectal excision and a low anterior resection or colo-anal anastomosis. Nevertheless, in a few selected cases trans-sphincteric excision may be useful.
The patient is placed in an appropriate position, depending on the localisation of the tumour. We made a parasacral incision caudally. The peripheral aspect of the incision is deepened to identify the lower fibres of gluteus maximus. Then the somatic and visceral musculature around the anorectum is subsequently divided longitudinally, marking the internal anal sphincter and mucosa separately for subsequent reconstruction. The rectal lesion should then be displayed. Essentially the same technique is used, as described previously for tumour excision, ensuring that a full-thickness disc of rectal wall is removed with the lesion. The rectal wall is then closed transversely in two layers. The anorectum is reconstructed by closure of the mucosa, then the internal anal sphincter and finally the external anal sphincter. Skin closure completes the operation.
This operation barely has a place in the treatment of rectal cancer any longer, but in very special cases it may play a role.
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