Colorectal Surgery Clinical Resources for Doctors & GPsFor the doctor who sees the patient first.

Presentation

41-year-old male, three months of tenesmus and bleeding, previously treated as haemorrhoids. DRE revealed a mobile posterior lesion at 4 cm. Biopsy: moderately differentiated adenocarcinoma. MRI: cT3b N1, mesorectal fascia not threatened, no EMVI.

Diagnostic challenge

Distance from the sphincter complex made abdominoperineal excision the default recommendation elsewhere. The patient's priority was avoiding a permanent stoma; the oncological priority was a clear circumferential resection margin in a narrow male pelvis.

Surgical intervention

Neoadjuvant chemoradiotherapy with restaging, followed by robotic total mesorectal excision with intersphincteric resection and hand-sewn coloanal anastomosis, protected by a temporary diverting ileostomy. The wristed instrumentation allowed dissection along the correct embryological plane deep in the pelvis with intact autonomic nerve preservation.

Oncological outcome

R0 resection, complete mesorectal grade, 16 nodes harvested, ypT2 N0. Ileostomy reversed at ten weeks. Continence acceptable at six months with a low-residue routine. Disease-free at last follow-up.

Distance from the verge alone should not decide the stoma conversation. Response to neoadjuvant therapy and the plane achievable robotically often move the goalposts.

Presentation

68-year-old female presenting acutely with a two-day history of absolute constipation and distension. CT: obstructing sigmoid lesion with proximal dilatation, no perforation. Significant cardiac comorbidity and an unoptimised nutritional state.

Diagnostic challenge

Emergency resection in an unprepared, dilated colon in a physiologically fragile patient carries high anastomotic and mortality risk, and frequently ends in a permanent stoma.

Surgical intervention

Endoscopic self-expanding metal stent placement as a bridge, decompression and nutritional optimisation over three weeks, then elective robotic sigmoid colectomy with primary anastomosis and complete mesocolic excision.

Oncological outcome

Elective single-stage resection with no stoma, R0 margins, adequate nodal yield, discharge on day five. Adjuvant therapy commenced on schedule rather than after a delayed recovery.

In the obstructed but non-perforated left colon, buying three weeks converts an emergency Hartmann's into an elective, stoma-free operation.

Presentation

34-year-old male, six months of fatigue and intermittent right iliac fossa discomfort, treated with oral iron for anaemia twice before referral. Colonoscopy: ulceroproliferative caecal lesion.

Diagnostic challenge

Anaemia had been treated without a source being sought. Family history revealed a mother with endometrial cancer at 46 and a maternal uncle with colon cancer at 50 — a pattern nobody had recorded.

Surgical intervention

Robotic right hemicolectomy with complete mesocolic excision and central vascular ligation, plus tumour mismatch repair immunohistochemistry and germline testing after counselling.

Oncological outcome

pT3 N1a, R0, 28 nodes. MLH1/PMS2 loss with a confirmed germline pathogenic variant. Four relatives entered surveillance colonoscopy; one had a high-risk adenoma removed within the first year.

Iron-deficiency anaemia is a symptom with an address. Finding it here did not just treat one patient — it changed the surveillance status of a family.