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1. Resection principles: The mesenteric clearance technique dictates the extent of resection and is determined by the nature of the primary pathology, the intent of resection, the location of the lesion, and the condition of the mesentery.

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2. Minimally invasive resection: Laparoscopic and/or hand-assisted laparoscopy has been shown to be both safe and efficacious for colorectal resection.

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3. Function after resection: Bowel function is often compromised after colorectal resection, especially after low anterior resection. For this reason, it is important to obtain a history of prior anorectal trauma and/or incontinence before considering a low anastomosis.

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4. Ostomies: Preoperative marking for a planned stoma is critical for a patient’s quality of life. Ideally, a stoma should be located within the rectus muscle, in a location where the patient can easily see and manipulate the appliance, and away from previous scars, bony prominences, or abdominal creases.

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5. Inflammatory bowel disease: Both Crohn’s disease and ulcerative colitis are associated with an increased risk of colorectal carcinoma. Risk depends upon the amount of colon involved and the duration of disease.

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6. Pathogenesis of colorectal cancer: A variety of mutations have been identified in colorectal cancer. Mutations may cause activation of oncogenes (K-ras) and/or inactivation of tumor-suppressor genes [adenomatous polyposis coli (APC) < DCC (deleted in colorectal carcinoma), p53].

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7. Early rectal cancer: Optimal treatment of very early rectal cancer (T1NXMX) is controversial. Transanal excision alone has been associated with a very high rate of local recurrence. In patients who will tolerate and accept radical surgery, this approach is probably appropriate. Chemoradiation either before or after transanal excision can also be considered, but has not been prospectively studied.

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8. Anal epidermoid carcinoma: Unlike rectal adenocarcinoma, anal epidermoid carcinoma is treated primarily with chemoradiation. Surgery is reserved for patients with persistent or recurrent disease.

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9. Rectal prolapse: Rectal prolapse occurs most commonly in elderly women. Transabdominal repair (rectopexy with or without resection) offers more durability than perineal proctosigmoidectomy, but carries greater operative risk.

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10. Hemorrhoids: Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth muscle fiber. They are thought o play a role in maintaining continence. Resection is only indicated for refractory symptoms.

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11. Fistula in ano: Treatment of fistula in ano depends upon the location of the fistula, amount of anal sphincter involved in the fistula, and the underlying disease process.

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Embryology

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The embryonic GI tract begins developing during the fourth week of gestation. The primitive gut is derived from the endoderm and divided into three segments: foregut, midgut, and hindgut. Both midgut and hindgut contribute to the colon, rectum, and anus.

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The midgut develops into the small intestine, ascending colon, and proximal transverse colon, and receives blood supply from the superior mesenteric artery. During the sixth week of gestation, the midgut herniates out ...

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