GI Cancer Surgery in Gandhinagar & Ahmedabad | Niraaya Hospital

Laparoscopic colectomy for colon cancer involves complete mesocolic excision (CME) - the meticulous dissection and en-bloc removal of the colon and its mesentery along embryological fascial planes, with central vessel ligation (CVL) at the origin of the feeding artery. CME maximises the number of lymph nodes harvested (a minimum of 12 lymph nodes is the oncological standard, but 20-25 nodes in a high-quality CME resection is achievable) and reduces local recurrence by removing the entire lymphovascular drainage of the tumour.

Procedures performed:

• Right Hemicolectomy (with CME): For cancers of the caecum, ascending colon, and hepatic flexure - central ligation of the ileocolic, right colic, and right branch of the middle colic vessels; specimen extracted through a small periumbilical minilaparotomy; ileo-transverse anastomosis (stapled or hand-sewn)
• Extended Right Hemicolectomy: For hepatic flexure and proximal transverse colon cancers
• Left Hemicolectomy: For descending colon cancers - central ligation of the left colic vessels
• Sigmoid Colectomy: For sigmoid cancers - central ligation of the inferior mesenteric artery (IMA) at its origin, high ligation with the sigmoid colon and upper rectum resected; colorectal anastomosis
• Transverse Colectomy: For mid-transverse colon cancers - less commonly performed due to anastomotic tension; extended right or left hemicolectomy is often preferable

All specimens are extracted through a small (4-6 cm) periumbilical or Pfannenstiel (bikini line) minilaparotomy - keeping cosmetic benefit while allowing safe specimen retrieval.

Low anterior resection is the surgical procedure for cancers of the upper and middle rectum - preserving the anus and sphincter mechanism while achieving total mesorectal excision (TME), the oncological standard for rectal cancer surgery.

Total Mesorectal Excision (TME):

The mesorectum - the fatty envelope containing lymph nodes and blood vessels surrounding the rectum, enclosed by the mesorectal fascia - is dissected and removed en-bloc with the rectum along sharp, anatomically defined fascial planes under direct laparoscopic vision. TME reduces local recurrence rates from 20-30% (without TME) to less than 5-8% (with high-quality TME), representing one of the most significant improvements in cancer surgery outcomes of the past 50 years.

Surgical technique:

The left colon is mobilised laparoscopically, the inferior mesenteric artery is divided at its origin with preservation of the superior hypogastric plexus (the autonomic nerve plexus controlling bladder and sexual function - nerve preservation is critical), the rectum is fully mobilised to the pelvic floor following the mesorectal plane, the rectum is divided at an appropriate level below the tumour (minimum 1 cm distal margin for mid-rectal cancers; 0.5 cm is acceptable for very low cancers), and a circular stapled colorectal anastomosis is fashioned.

Defunctioning loop ileostomy:

For most low and mid-rectal anastomoses - where the anastomosis is under tension or close to the sphincter - a temporary defunctioning loop ileostomy (a loop of terminal ileum brought to the skin surface) is fashioned to divert the faecal stream away from the healing anastomosis. The ileostomy is reversed (restored to continuity) at 6-8 weeks - a planned second short laparoscopic operation.

Neoadjuvant therapy:

Many mid and low rectal cancers (T3T4 or node-positive on MRI) are treated with pre-operative chemoradiation (long-course) or short-course radiotherapy before surgery - to downstage the tumour, reduce circumferential resection margin involvement, and increase the likelihood of sphincter preservation. Dr. Patel co-ordinates pre-operative MDT (Multi-Disciplinary Team) discussion and treatment sequencing for every rectal cancer patient.

Abdominoperineal resection (APR) is the surgical procedure for very low rectal cancers (within 1-2 cm of the external sphincter or involving the levator ani muscles) where sphincter-preserving surgery is oncologically inappropriate - because achieving a negative distal margin would compromise the sphincter mechanism and result in unacceptable functional outcomes.

APR involves two simultaneous surgical components:

• Abdominal component (laparoscopic): The sigmoid colon is divided, the rectum is fully mobilised laparoscopically to the pelvic floor, the inferior mesenteric vessels are ligated, and a permanent end colostomy is fashioned in the left lower quadrant
• Perineal component: A second surgeon (or the same surgeon, repositioning the patient) makes an incision around the anus, excising the anus, external sphincter, and levator ani muscles together with the fully mobilised rectum - achieving an en-bloc resection

Extralevator APR (ELAPR): A technical modification for very low tumours threatening the sphincter - the levators are divided at a much wider margin in the sitting position, reducing the risk of positive circumferential margins in this most challenging anatomical location.

The permanent end colostomy created during APR requires stoma counselling, pre-operative stoma siting, and post-operative stoma education - all provided at Niraaya Hospital, Gandhinagar.

Surgical resection of small bowel tumours - GISTs, carcinoids, adenocarcinomas, and lymphomas requiring surgery - involves laparoscopic segmental resection of the tumour-bearing bowel with an adequate margin of normal bowel on each side, primary hand-sewn or stapled anastomosis, and for malignant tumours, removal of the regional mesentery and its lymph nodes.

GIST resection: No lymph node dissection is required (GISTs do not spread to lymph nodes) - only a clear resection margin is needed. Most GISTs are amenable to laparoscopic wedge resection or segmental resection with primary anastomosis. High-risk GISTs (size above 5 cm, mitotic rate above 5 per 50 HPF) receive adjuvant imatinib for 3 years post-resection.

Carcinoid (NET) resection: Regional mesenteric lymphadenectomy is required alongside segmental ileal resection - mesenteric node metastases are common even with small primary tumours (carcinoids can metastasise when as small as 1 cm). The mesentery in the region of carcinoid tumours is often fibrotic and foreshortened (from the desmoplastic reaction these tumours trigger) - making dissection technically demanding.