(BQ) Part 1 book Anatomic basis of tumor surgery presents the following contents: Oral cavity and oropharynx, neck, breast, mediastinum, thymus, cervical and thoracic trachea, and lung, esophagus and diaphragm, stomach and abdominal wall, small bowel and mesentery, colon and appendix, rectum.
Anatomic Basis of Tumor Surgery 2nd Edition W C Wood, C A Staley and J E Skandalakis III William C Wood C A Staley John E Skandalakis (Eds.) Anatomic Basis of Tumor Surgery 123 IV William C Wood, MD, FACS, FRCS Eng [Hon], FRCPS GLASG Distinguished Joseph Brown Whitehead Professor Emory University School of Medicine Department of Surgery 1365 Clifton Road Atlanta, GA 30322 USA Charles A Staley, MD, FACS Holland M Ware Professor of Surgery and Chief, Division of Surgical Oncology Emory University School of Medicine 1364 Clifton Road Atlanta, GA 30322 USA John E Skandalakis, MD, PhD, FACS† Michael Carlos Professor of Surgery and Director, Centers for Surgical Anatomy and Technique Emory University School of Medicine 1462 Clifton Road Atlanta, GA 30322 USA † Deceased August, 2009, as this book went to press First edition published by Quality Medical Publishing, Inc., St Louis, Missouri, USA 1999 ISBN 978-3-540-74176-3 DOI 10.1007 / 978-3-540-74177-0 eISBN 978-3-540-74177-0 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009931707 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitations, broadcasting, reproduction on microfilm or in any other way, and storage in data banks Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag Violations are liable for prosecution under the German Copyright Law The use of general descriptive names, trademarks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book In every individual case the user must check such information by consulting the relevant literature Cover design: eStudio Calamar, Figueres/Berlin Drawings by Blankvisual, Thun, Switzerland Printed on acid-free paper 9876543210 springer.com V Dedication To our best friends Judy, Kim, and Mimi who bring joy to every day Content VII Preface The old saying that “the best anatomist makes the best surgeon” is but a variation on the venerable saw that “you have to know the territory.” Neoplastic disease has no respect for anatomical boundaries, making detailed familiarity with anatomy that exists beyond the margins of a standard surgical method a great facilitator for many surgical procedures The biology of cancer and knowledge of all modalities appropriate for its management continues to define new approaches to both common and rare cancers We are pleased to present this update of Anatomic Basis of Tumor Surgery, the 2nd edition of the book that interweaves the form of an atlas, the shape of an anatomy text, and a pervasive understanding of multimodality therapy in light of the expanding knowledge of oncologic biology In addition to welcoming many new authors to this edition, Charles Staley has joined us as an editor We also honor John Skandalakis for holding aloft the torch of surgical anatomy with so many contributions over the nearly ninety years of his life Many thanks are owed to Sean Moore, Editor for the Department of Surgery at Emory, whose diligent reviews and persistent efforts brought this book to completion Atlanta, Georgia, USA William C Wood Charles A Staley John E Skandalakis † Content Contents Chapter Oral Cavity and Oropharynx John M DelGaudio and Amy Y Chen Chapter Neck Anterior Neck Jyotirmay Sharma, Mira Milas, and Collin J Weber 56 Lateral Neck Grant W Carlson 98 Chapter Breast Breast and Axilla William C Wood and Sheryl G.A Gabram 130 Breast Reconstruction Albert Losken and John Bostwick III 166 Chapter Mediastinum, Thymus, Cervical and Thoracic Trachea, and Lung Daniel L Miller and Robert B Lee 195 Chapter Esophagus and Diaphragm Seth D Force, Panagiotis N Symbas, and Nikolas P Symbas 265 Chapter Stomach and Abdominal Wall Stomach Charles A Staley 300 Abdominal Wall William S Richardson and Charles A Staley 337 Chapter Small Bowel and Mesentery John E Skandalakis 359 Chapter Colon and Appendix Edward Lin 377 IX X Content Chapter Rectum Charles A Staley and William C Wood 409 Chapter 10 Pelvis Shervin V Oskouei, David K Monson, and Albert J Aboulafia 443 Chapter 11 Liver, Biliary Tree, and Gallbladder Juan M Sarmiento, John R Galloway, and George W Daneker 483 Chapter 12 Pancreas and Duodenum David A Kooby, Gene D Branum, and Lee J Skandalakis Chapter 13 Spleen Surgical Anatomy John E Skandalakis 605 Open Splenectomy Lee J Skandalakis and Panagiotis N Skandalakis Laparoscopic Splenectomy John F Sweeney 626 549 619 Chapter 14 Female Genital System Ira R Horowitz 637 Chapter 15 Male Genital System John G Pattaras, Fray F Marshall, and Peter T Nieh 681 Chapter 16 Retroperitoneum Keith A Delman, Roger S Foster, and John E Skandalakis 713 Chapter 17 Adrenal Glands Open Adrenalectomy Roger S Foster Jr, John G Hunter, Hadar Spivak, C Daniel Smith, and S Scott Davis Jr 734 Laparoscopic Adrenalectomy S Scott Davis Jr, C Daniel Smith, Hadar Spivak, and John G Hunter 754 Chapter 18 Kidneys, Ureters, and Bladder Daniel T Saint-Elie, Kenneth Ogan, Rizk E.S El-Galley, and Thomas E Keane 769 Chapter 19 Tumors of the Skin Keith A Delman and Grant W Carlson 819 Contributors XI Contributors Albert J Aboulafia, MD Orthopaedic Surgeon, Lapidus Cancer Institute, 2401 W Belvedere Avenue, Baltimore, MD 21215, USA Former Assistant Professor, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Gene D Branum, MD General and Laparoscopic Surgeon, Harrisonburg Surgical Associates Ltd., Harrison Plaza, 01 N Main Street, Harrisonburg, VA 22802, USA Former Assistant Professor, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA gebra60@yahoo.com John Bostwick III† Grant W Carlson, MD Wadley R Glenn Professor of Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Associate Program Director, Division of Plastic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Professor of Surgery, Department of Otolaryngology, Emory University of Medicine, Atlanta, GA 30322, USA Winship Cancer Institute, 1365C Clifton Road NE, Atlanta, GA 30322, USA carlson@emory.edu Amy Y Chen, MD, MPH Associate Professor, Department of Otolaryngology, Emory University School of Medicine, Emory Otolaryngology, 1365A Clifton Rd NE, Atlanta, GA 30322, USA amy.chen@emory.edu Dr George W Daneker, MD Georgia Surgical Associates, 5667 Peachtree Dunwoody Road NE, Suite 170, Atlanta, GA 30342, USA Former Assistant Professor, Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA S Scott Davis, Jr., MD Assistant Professor of Surgery, Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Emory University Hospital, Room H-124, 1364 Clifton Road NE, Atlanta, GA 30322, USA s.scott.davis@emory.edu XII Contributors John M DelGaudio, MD Associate Professor, Department of Otolaryngology, Emory University School of Medicine, Emory Otolaryngology, 1365A Clifton Rd NE, Atlanta, GA 30322, USA jdelgau@emory.edu Keith A Delman, MD Assistant Professor of Surgery, Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA Associate Program Director, General Surgery Residency Program, Emory University School of Medicine, Atlanta, GA 30322, USA Winship Cancer Institute, 1365 Clifton Road NE, Suite C2004, Atlanta, GA 30322, USA keith.delman@emory.edu Rizk E.S El-Galley, MB, BCh, FRCS Associate Professor, Department of Surgery, Division of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, 1802 6th Avenue South, AL 35249, USA Seth D Force, MD Assistant Professor of Surgery and McKelvey Fellow in Lung Transplantation, Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Surgical Director, Adult Lung Transplant Program, Emory University Hospital, Atlanta, GA 30322, USA seth.force@emory.edu Roger S Foster, Jr., MD Professor Emeritus, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA 395 Stevenson Road, New Haven, CT 06515, USA Sheryl G.A Gabram-Mendola, MD Director, AVON Comprehensive Breast Center, Grady Health System, Atlanta, GA 30322, USA Professor of Surgery, Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA Winship Cancer Institute, 1365-C Clifton Rd, NE, Atlanta, GA 30322, USA sgabram@emory.edu John R Galloway, MD Professor of Surgery, Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Director, Nutritional Metabolic Services, Emory University Hospital, Atlanta, GA 30322, USA Medical Director of Transplant and Surgical Intensive Care Unit, Emory University Hospital, 1364 Clifton Road NE, Suite H-122, Atlanta, GA 30322, USA Associate Section Chief for Critical Care, Nutrition and Metabolic Support, Emory University Hospital, Atlanta, GA 30322, USA galloway@emory.edu Ira R Horowitz, MD Willaford Ransom Leach Professor of Gynecology and Obstetrics and Director, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, Emory University School of Medicine, Woodruff Memorial Building, Room 4307, Atlanta, GA 30322, USA Member, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA Chief Medical Officer, Emory University Hospital, Atlanta, GA 30322, USA ihorowi@emory.edu 428 Chapter Rectum cautery, minimizing the risk of damage to the truncal parasympathetic nerves and sacral structures, preserving any that are coursing in a direction other than toward and into the bowel wall There is no evidence that significant innervation lies anteriorly between the rectum and the seminal vesicles or prostate Consequently, the surgeon need not be concerned that dissection in this region will contribute to sexual dysfunction The twin goals in a meticulous dissection of the lateral ligament are preservation of both sympathetic and parasympathetic nerves and the clearance of lymphatics out to those anterior-posterior, and cephalad-caudad running, longitudinal small nerve trunks This achieves local clearance superior to that achieved with broad clamping and contributes to preservation of function, as demonstrated by the work of both Heald and Enker When dissection has progressed to at least cm beneath the inferior margin of the tumor, the distal rectal is divided with a stapler The 30 mm size will usually fit deeper in the pelvis for a transection as low as possible If the proximal colon will not fit into the pelvis without tension, the splenic flexure will need to be mobilized Many a time, Figure 9.15 Surgical Applications the colon mesentery is the point of tension and requires dividing the more proximal left colic artery to gain length on the mesentery Either stapled or open anastomosis may now be performed Modern circular staple devices allow very low anastomoses with great safety and have virtually eliminated the need for an abdominosacral approach to low tumors A purse-stringing device or manual purse string suture of a 2-0 monofi lament is placed in the cut end of the proximal colon with bites about mm apart Appropriate sizers are then used to size the proximal colon The anvil of the stapler is placed into the proximal colon and the purse string is tied securely The stapler is then introduced through the anus and the spike is brought out near the rectal staple line The anvil is connected to the stapler, closed and then inspected to make sure of the correct mesentery orientation, and to make sure that no additional tissue was incorporated into the anastomosis The stapler is fired and then removed The two rectal doughnuts are inspected for continuity The anastomsis is visually inspected and air insufflated while a bowel clamp is applied to the more proximal left colon and water is placed in the pelvis Any bubbling of air indicates a possible leak Many a time, a visible leak can be sealed with individual sutures If there is any sign of a leak or nonintact rectal doughnuts, a diverting ileostomy should be done The incision is then closed in the usual fashion Coloanal resection is performed after chemoradiation therapy for lesions in the low rectum that regress sufficiently enough for a margin to be obtained above the dentate line The procedure differs from APR in that the sphincteric structures, the levator sling, and the lymphatic and blood vessels below the levator muscles are all spared These must be sterilized with chemoradiation therapy, or the surgery will not be successful in controlling tumors at the level of the low rectum The abdominal dissection is the same as in the low anterior resection however the dissection continues down around the rectum to the level of the levator muscles From inside, the mucosa is taken from the pectinate line up to the superior margins of the sphincter (submucosal infi ltration with epinephrine in saline solution facilitates this dissection); then the entire rectum is circumscribed and excised A finger placed through the wall of the submucosal rectum guides this division The Coloanal Resection Figure 9.16 Bovie pencil 429 430 Chapter Rectum splenic flexure must be freed to allow sufficient colonic length into the pelvis, and the left colon must be divided above the level of irradiation so that the unirradiated bowel is brought down into the pelvis An end-to-end coloanal anastomosis may be made or a J pouch created by stapling the antimesenteric borders together The pouch has been associated with less stool frequency in the early months after the procedure and appears to engender greater patient satisfaction A diverting ileostomy is usually done to allow the coloanal anastomosis to heal Any clinical leak will lead to significant sphincter fibrosis and subsequent anal incontinence Figure 9.17 Surgical Applications The patient is positioned with the legs in Allen or Lloyd-Davies stirrups, and an indwelling Foley catheter is placed A site for a stoma should be chosen and identified prior to making the skin incision The best plan is to bring the stoma through the rectus muscle on the left side to minimize the size of the peristomal hernia and place it in an area where there is sufficient flat abdominal wall (i.e., several centimeters from the umbilicus and anterior superior iliac spine) that a stoma disk can lie flat It must remain in position when the patient is seated and, ideally, not be directly on the beltline but below it After careful exploration of the abdomen, the rectosigmoid colon is mobilized Early division of the sigmoid colon facilitates the pelvic dissection The procedure progresses as described for a low anterior resection The dissection continues circumferentially down around the rectum to the levator muscles To facilitate the perineal dissection, the anus is closed with two purse-string sutures of 2–0 silk In male patients an elliptical incision about the anus is made to remove the pigmented perianal skin In female patients the posterior vaginal wall may be included in the excision if the tumor lies in the anterior rectal wall After posterior vaginectomy, the fourchette is reconstituted, and the posterior vaginal wall may be closed or allowed to heal by second intention The fatty subcutaneous tissue is taken with an electrocautery Vascular bundles representing the inferior rectal (hemorrhoidal) vessels are identified both superiorly and inferiorly on the sides in the ischiorectal fat The dissection is continued posteriorly to the upper part of the coccyx With a scissors or electrocautery, it is possible to divide the rectococcygeus ligament right at the tip of the coccyx With a finger placed into the retrorectal space and swept laterally, the levator sling is divided with 431 Abdominoperineal Resection Figure 9.18 432 Chapter Rectum Figure 9.19 the electrocautery This dissection is carried out on both sides, leaving only the area from 11:00 o’clock to 1:00 o’clock intact anteriorly The rectum should then be passed through from above so that it is only tethered by the puborectalis and rectourethralis muscles anteriorly These are defined sharply by stripping away the overlying fat with scissors or bluntly with a sponge-covered finger Division of these muscles and the tissue immediately behind them is the most difficult step in the operation The proper plane is just posterior to the prostate gland and is defined by palpation of the rectum and prostate in the surgeon’s noncutting hand This cm area of division frees the specimen and completes the dissection Hemostasis is now secured from both above and below The fatty subcutaneous tissue of the perineum is approximated with at least two, and preferably three, layers of absorbable sutures, followed by skin closure Suction drains are placed to prevent a pelvic collection These drains may be brought out through the perineum, but patients are more comfortable when the drains are brought out from above in the lower quadrants of the abdomen The omentum is released from the right and proximal transverse colon, and rotated down the left gutter into the pelvis, to fi ll the empty space This omental flap has been shown to significantly decrease postoperative abcess formation To form the stoma, a skin ellipse of appropriate diameter is excised, and the anterior fascia of the rectus muscle is exposed Either a cruciate incision may be made or a circle excised to allow easy passage of two finger breadths The rectus muscle is spread in the direction of its fibers and the peritoneum is incised When two fingers Surgical Applications Figure 9.20 can pass through very easily, the sigmoid colon is brought out with care to allow it to lie untwisted and without tension It may be brought out lateral to the peritoneum in a retroperitoneal manner to avoid later herniation, or it may be tacked to the lateral peritoneal wall to avoid this site for internal herniation There are no convincing data that either of these maneuvers is of any value, but both are widely practiced It is matured by suturing a single layer of interrupted sutures through the full layer of the bowel wall and full thickness of the skin, once the abdominal incision has been closed 433 434 Chapter Rectum Figure 9.21 Total Pelvic Exenteration Rectal cancers invading centrally and free of the pelvic sidewall and major vessels may be appropriate for a pelvic exenteration This procedure combines en bloc APR with cystectomy in male patients and hysterectomy and vaginectomy in female patients if the tumor extends beyond the posterior vagina or uterus The appropriate chapters should be consulted for more detailed descriptions of the anatomic details that influence these procedures From below, the ellipse of skin excised includes the vagina and the urethra in female patients Abdominally from the aortoiliac bifurcation into the sacral hollow and the pelvic sidewalls, all soft tissues are resected The sacral plexus is spared, but all anterior tissues are cleared The ureters are divided and anastomosed to an ileal conduit Surgical Applications Colostomy site marked preoperatively Ileostomy site marked preoperatively Figure 9.22 Although a majority of patients with rectal cancer will require a radical resection, a small subset of carefully selected early tumors may be managed by local procedures The advantages of the local approach include avoidance of a colostomy, improved quality of life and avoidance of the morbidity and mortality associated with radical rectal surgery, particularly urinary and sexual dysfunction Local excision has always been an accepted alternative for patients unfit for a radical operation due to advanced age or multiple comorbidities The optimal treatment of rectal cancer through a transanal approach requires consideration of the tumor size, location, depth of invasion, nodal status, and histology, as well as patient-related factors A digital rectal exam can confirm location, size and whether or not the lesion is fi xed Rectal endoscopic ultrasound (EUS) is the most accurate preoperative method of determining the depth of invasion and presence of lymph nodes An analysis by Solomon and McCleod showed that the accuracy of determining that a tumor was not penetrating outside of the rectal wall was 97% Favorable lesions for transanal approach by endoscopic rectal ultrasound (EUS) include lesions in the last distal 6–8 cm from the anal verge, 435 Transanal Excision 436 Chapter Rectum Figure 9.23 Obturator vessels Obturator n Internal pudendal vessels Colostomy Ureter Surgical Applications Figure 9.24 tumors less than cm in size, and tumors that are limited to the bowel wall and have no lymph node involvement The depth of invasion is particularly important given the fact that the incidence of lymph node metastasis increases with tumor penetration into the different layers of the rectal wall The incidence of lymph node metastasis ranges from to 12% for T1 tumors, 20 to 26% for T2 tumors, and 51 to 66% for T3 tumors Histopathologic features provide further information and are associated with the risk of lymph node metastasis Tumors that have poor differentiation or are undifferentiated, lymphovascular invasion, or mucinous histological features are associated with a high risk of lymph node metastasis and are poor candidates for transanal excision To perform a transanal excision, the patient undergoes either a full mechanical bowel preparation and/or enemas The patient is positioned in either a lithotomy or a prone position, depending on the location of the rectal tumor For posterior lesions, the patient is placed in lithotomy and for anterior lesions, the patient is placed prone The key to a successful transanal excision is adequate exposure The combination of self-retraining anal retractors and/or a speculum can be used to adequately expose the tumor Stay sutures are routinely placed around the lesion to be excised The lesion is then circumferentially excised with a 1-cm margin as a full thickness excisional biopsy all the way through to the periorectal fat The specimen is then taken to pathology for orientation If there are any close margins, additional tissue is obtained as a new margin After achieving hemostatis, the rectal wall is reapproximated, either obliquely or transversally to prevent stricturing of the rectum The transanal excision is usually a well tolerated procedure requiring at most an overnight admission Potential but rare 437 438 Chapter Rectum complications include bleeding, urinary retention, fecal incontinence, rectovaginal fistula, and rectal stricture The results of local excision for rectal cancer are difficult to interpret in the literature due to small retrospective studies and widely varied indications for the procedure Given these limitations, the majority of studies indicate adequate local control and survival rates for T1 tumors compared to radical resection However, local excisions for T2 tumors have unacceptably high local recurrence rates of 11–45% and in many studies, inferior survival to radical resection Other investigators have shown that adjuvant therapy after the local excision of a T2 cancer with either radiation or chemoradiation improves local recurrences There is a current ACOSOG trial looking at neoadjuvant chemoradiation for patients with T2 rectal tumors that then undergo transanal surgical resections With the improvement of systemic therapy for rectal cancer, there is considerable interest in a neoadjuvant approach for T3 lesions followed by local excision, however further trials need to be done In summary, radical resections of rectal tumors that widely excise the primary tumor and a complete mesorectal excision is still the gold standard, however in selected early, localized tumors, local excision may be equal Inclusion criteria for local excision include well and moderately differentiated adenocarcinoma limited to the mucosa (T1, N by EUS) without any sign of distant metastasis Tumors need to be in the distal 6–8 cm of the rectum and not have poor histological prognostic factors which include lymphovascular invasion or mucinous histology If the final pathology indicates more advanced tumor invasion, including T2, T3, T4 or any nodal involvement or any poor histological variable, the patient should be offered a radical resection Transphincteric Approach The sphincter of the rectum may be divided as advocated by York-Mason, the tumor size, as in the transanal approach, and the sphincter pared meticulously in layers Later morbidity resulting from scarring in some patients makes this approach less appealing than the transanal approach The transphincteric route also requires complete division of the anal sphincter, which may result in fecal incontinence At present, there is no reason for performing this approach Kraske’s Approach A combination of per anal excision, low anterior resection, and coloanal resection, this approach has been relegated largely to historical considerations It is mentioned because it provides a splendid view of the retrorectal anatomy The patient is placed prone with a roll beneath the pelvis The skin incision extends from the coccyx to just outside the anus The anococcygeal ligament is incised vertically, and the levator ani deep to that is divided in the midline (vertically) Beneath the perirectal fat lies the posterior wall of the rectum, which can be entered or a sleeve of the rectum can be excised After the repair of the rectum, the tissues divided originally are reapproximated This procedure has been associated with fecal fistula in approximately 10% of cases Surgical Applications Gluteus maximus m Levator ani m Rectum Puborectalis m External sphincter m Rectal wall Submucosa Figure 9.25 439 440 Chapter Rectum Anococcygeal ligament Levator ani m Anococcygeal ligament Levator ani m Posterior rectal wall Villous adenoma Figure 9.26 Anatomic Basis of Complications ¼ Exact location of the level of rectal tumor and assessment of its mobility allow use of the resection procedure with least morbidity ¼ Injury to the hypogastric nerves diminishes sexual function ¼ Failure to resect the mesorectum and achieve full radial clearance increases the likelihood of local recurrence of tumor ¼ Resection of the presacral fascia increases the risk for bleeding from sacral veins ¼ Incorrect positioning in lithotomy or poor placement of rigid retractors can result in neuropathies in the legs Key References Levator ani m Posterior rectal wall Figure 9.27 Key References Cohen AM, Winawer SJ Cancer of the colon, rectum and anus New York: McGraw-Hill; 1995 This is a superb, comprehensive, multidisciplinary treatise on the subject Enker WE Sphincter-preserving operations for rectal cancer Oncology 1996;10(11):1673–84 This is a fi ne review of surgical technique for sphincter-sparing surgery by a superb practitioner of these techniques Gordon PH, Nivatvongs S Principles and practice of surgery for the colon, rectum, and anus 2nd ed St Louis: Quality Medical Publishing; 1999 This beautifully illustrated text focuses on surgical aspects of the management of colon and rectal disease, both benign and malignant Heald FJ, Ryall RDH Recurrence and survival after total mesorectal excision for rectal cancer Lancet 1986;1:1479–82 The case for careful sharp dissection of the entire mesorectum and the description of the approach are found in this classic paper Kapiteijn E, Margnen CAM, Nagtegall ID, et al Pre-operative radiotherapy combined with total mesorectal excision for resectable rectal cancer NEJM 2001;345:638–46 Randomized trial demonstrating the benefit of preoperative radiotherapy in addition to TME in local control of rectal cancer Sauer R, Becker H, Hohenberger W, Rodel C, et al Preoperative versus postoperative chemoradiotherapy for rectal cancer NEJM 2004;351:1731–40 First significant randomized trial of preoperative vs postoperative chemoradiation for rectal cancer 441 442 Chapter Rectum Shafi k A A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation IX Single loop continence: a new theory of the mechanism of anal continence Dis Colon Rectum 1980;23:37–43 This classic paper in surgical anatomy relates the anatomy of the anal sphincter to its function Vernava AM III, Moran M, Rotheberger DA, Wong WD A prospective evaluation of distal margins in carcinoma of the rectum Surg Gynecol Obstet 1992;175:333–6 The paper provides the results of a prospective evaluation of margins The measurements were based on fi xed tissue and must be understood to translate to somewhat larger margins in fresh tissue A 1-cm margin in the fi xed specimen proved adequate distal clearance Suggested Readings Boxall TA, Griffiths JD, Smart PJG The blood supply of the distal segment of the rectum in anterior resection Br J Surg 50:399, 1973 Crane C and Skibber J Preoperative chemoradiation for locally advanced rectal cancer: rationale, technique, and results of treatment Semin Surg Oncol 2003;21:265–70 Gamagami R, Liagre A, Chiotasso P, Istvan G, Lazorthes F Coloanal anastomsis for distal rectal cancer: prospective study of oncologic results Dis Colon Rectum 1999;42(10):1272–5 Goligher JC Surgery of the anus, rectum and colon 4th ed London: Bailliere Tindall; 1980 Goligher JC The blood supply to the sigmoid colon and rectum Br J Surg 1949;37:157–62 Lee JF, Maurer VM, Block GE Anatomic relations of pelvic autonomic nerves to pelvic operations Arch Surg 1973;107(2):324–8 Moore H, Riedel E, Minsky B, Saltz L, Paty P, Wong, D et al Adequacy of cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy Ann Surg Oncol 2003;10(1):80–5 Moore H, Guillem J Local therapy for rectal cancer Surg Clin N Am 2002;82:967–81 Oh C, Kark AE The transphinteric approach to mid and low rectal villous adenoma: anatomic basis of surgical treatment Ann Surg 1972;176(5):605–12 Pearlman NW, Donohue RE, Stiegmann GV, Ahnen DJ, Sedlacek SM, Braun TJ Pelvic and sacropelvic exenteration for locally advanced or recurrent anorectal cancer Arch Surg 1987;122(5):537–41 Rullier E, Goffre B, Bonnel C, Zerbib F, Caudry M, and Saric J Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum Ann Surg 2001;234(5):633–40 Willett CG, Wood WC Update of the Massachusetts General Hospital experience of combined local excision and radiotherapy for rectal cancer Surg Oncol Clin N Am 1992;1:131–6 ... Professor of Surgery, Department of Surgery, Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Director of Research, Department of Surgery, ... Glenn Professor of Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA Associate Program Director, Division of Plastic Surgery, Department of Surgery, ... of Tumor Surgery, 2nd Edition DOI: 978-3-540-7 417 7-0 _1, © Springer-Verlag Berlin Heidelberg 2 010 5 17 21 21 22 51 52 53 1 Chapter Oral Cavity and Oropharynx Introduction Malignant tumors of the