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Rectal cancer: Surgical principles

Ronald Bleday, MD
David Shibata, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD


Surgery is the cornerstone of curative therapy for rectal adenocarcinoma. It can be used alone or in combination with chemotherapy and/or radiation therapy, depending upon the stage of the disease. The primary goal of surgery is the complete removal of the rectal cancer. Secondary goals include preservation of anorectal sphincter function and bowel continuity when possible.

The surgical anatomy of the rectum, principles of rectal surgery for cancer, the choice of operative approaches, and the use of intraoperative adjuncts (eg, imaging and radiotherapy) are discussed here. Specific surgical techniques and their indications are reviewed separately. (See "Rectal cancer: Surgical techniques" and "Overview of the management of rectal adenocarcinoma", section on 'Overview of management'.)


Rectum — The rectum is the continuation of the sigmoid colon leading to the anal canal. It is 12 to 15 cm in length, and lacks taeniae, epiploic appendices, haustra, or a well-defined mesentery (figure 1) [1]. In women, the anterior rectum is in close proximity to the posterior vagina and uterine cervix (figure 2 and figure 3 and figure 4). In men, it is behind the bladder, vas deferens, seminal vesicles, and prostate (figure 5).

Although the precise description of the upper and lower limits of the rectum varies between anatomists and surgeons, it is generally accepted that the upper (proximal) limit of the rectum is at the rectosigmoid junction. The lower (distal) limit of the rectum is at the dentate line, which is located in the middle of the anorectal ring (figure 6). The dentate line is also the point at which columnar mucosa of the rectum transitions to squamous mucosa of the anus.

The upper limit of the rectum is defined operatively as where the taeniae coli of the sigmoid colon splay and become indistinct. Radiographically, the sacral promontory is generally regarded as the upper limit of the rectum. Endoscopically, the upper limit of the rectum is defined as 15 cm from the anal verge on rigid proctoscopic examination [2].

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Literature review current through: Nov 2017. | This topic last updated: Nov 06, 2017.
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