INDICATIONS

Laparoscopic low anterior resection (LAR) is used for removal of rectal cancer and
benign diseases with the intent of removing the rectum and restoring the continuity of
the bowel with an anastomosis in the pelvis. The LAR has been a standard of care for
high and mid rectal cancer for many years and, with certain modifications, is now
available to individuals with low rectal cancer. This chapter deals with the routine
removal of the rectum and its mesentery and the reconstruction of continuity within the
pelvis above the anal canal.

PREOPERATIVE PREPARATION
Individuals with rectal cancer, diverticulitis, endometriosis, or other less common tumors
will require preoperative imaging with computed tomography (CT) scan or transrectal
ultrasound to stage the disease and help plan the procedure. In many instances,
patients with rectal cancer will require neoadjuvant chemoradiation, which adds another
level of complexity to the procedure and will sometimes influence the surgeon to protect
the pelvic anastomosis with a temporary diverting loop ileostomy.

A mechanical and antibiotic bowel preparation is usually recommended. The rectum

should be emptied of solid stool and irrigated with some form of cytocidal liquid at the
beginning of or during the procedure to wash out any malignant cells if the indication is
rectal cancer. This serves the purpose of reducing the number of viable cells within the
rectal vault, but it has never been definitively shown to decrease the incidence of local
recurrence of rectal cancer.

The patient is maintained on bowel rest after midnight before the operation. Broad-
spectrum IV antibiotics with coverage of gram-negative aerobes and anaerobes and
gram-positive anaerobes are administered prior to incision. Patients are also given
subcutaneous low-molecular-weight heparin preoperatively.

ANESTHESIA
General anesthesia with endotracheal intubation is necessary for this operation to
provide complete neuromuscular blockade. The patient is supplemented with narcotic
analgesia during the anesthetic portion of the procedure to allow a smooth transition to
the awakened state. Occasionally, the patient may benefit from an epidural analgesic
supplement because of severe chronic obstructive pulmonary disease (COPD).
Ketorolac is a reasonable supplement to the narcotic analgesia provided after surgery, if
the field is very dry and there is no contraindication to this medication.

POSITION
Laparoscopic LAR is performed in the lithotomy position using Allen stirrups to position
the patient (Figure 1). Sequential compression devices are placed on the calves at the
time of entering the room before anesthesia induction. A beanbag is very helpful to fix
the patient in position because gravity will be used for retraction. The patient will be
tilted back and forth from right to left and placed in steep Trendelenburg and even in
reverse Trendelenburg positions at times. The beanbag is curled up around the sides
and shoulders of the patient, and a tape is placed across the chest ...

Open Left and Sigmoid Colectomy, Low Anterior Resection, and

Abdominoperineal Resection
In open versions of these procedures, the same preoperative preparation and patient
positioning is used, and the authors follow similar technique. A vertical midline incision
is used routinely. For right and transverse colectomies, two thirds of the incision should
be above the umbilicus and one third of the incision below. The reverse is true for left-
side, sigmoid, and rectal surgery. For coloanal anastomosis or APR, the incision should
be carried down to the symphysis pubis to facilitate pelvic exposure.
After patient positioning and rectal irrigation, a Foley catheter is placed with sterile
technique. The patient is prepared and draped, and the midline incision is made. Once
the incision is open, a wound drape is placed to protect the wound. The authors prefer a
Balfour retractor with a bladder blade and C-arm attachment. The low profile permits a
deeper reach into the pelvis without the need to struggle with the retractor. Others use
the Buchwalter.
A wet lap sponge is placed over the small bowel, which is then placed in the right upper
quadrant, exposing the takeoff of the inferior mesenteric artery (IMA) at its takeoff from
the aorta. Once identified, the IMA is dissected free with long right-angle clamps and
clamped. Prior to clamping and transection, the ureter must be identified, after which the
mesocolon is divided laterally and up to the colon wall. The colon wall is divided with a
stapler. This division is the proximal margin for sigmoid or rectal surgery.
The IMA is then retracted upward, and the plane under it is dissected until the lane
between the mesorectum and the pelvic fascia is entered.
Dissection continues caudally until the distal margin of resection is encountered.
Transection is performed with a stapler at the distal margin for a cancer or at the
coalescing of the taeniae for diverticulitis. For a left colectomy, the initial division of the
bowel is a distal transection. The white line is then mobilized proximally and the splenic
flexure taken down, when indicated, as mentioned above. The distal transverse colon is
transected and the remaining mesorectum divided. Omentum is mobilized off the
transverse colon to facilitate obtaining sufficient length.
Both anastomosis and APR are performed exactly as described for the laparoscopic
technique. Gowns, gloves, and instruments are changed, and the fascia is closed with
running looped suture. The skin is closed with staples.