Anterior Resection with Low Anastomosis
Conor P. Delaney and Victor W. Fazio
ectal cancer has been a difficult surgical problem for
R many years. In 1925, Miles described abdomino-per-
ineal resection of the rectum, which provided the first
effective treatment for many patients. The surgical prin-
ciples espoused were identical to those we hold today,
namely wide resection of the rectum, including the entire
investing fascia with the enclosed mesentery of the rec-
tum. However, Miles never considered anastomosis to be
safe. Since then, the operation went through slight tech-
nical revisions by Lloyd-Davies and others; however, the
main change in approach was when Dixon described the
technique of anterior resection and anastomosis for tu-
mors of the upper rectum and distal sigmoid.1 Since that
time, the operation has changed little, although the indi-
cations for anastomosis have been extended. The current
standards of care for patients with low rectal cancer in-
clude complete excision of the rectum and surrounding
mesorectum, generally ensuring a minimal distal margin
of 2 cm and circumferential radial clearance before per-
forming a colo-anal anastomosis.
PREOPERATIVE IMAGING AND
EVALUATION
Traditional staging of low rectal cancer involved digital
examination at the time of diagnosis, which has an accu-
racy of approximately 75%, depending on the skill and
experience of the examiner. Over the last decade, preop-
erative staging has attained paramount importance to
allow appropriate selection of neo-adjuvant therapy. Op-
tions available include endoanal ultrasound, computer-
ized tomography (CT), and magnetic resonance imaging
(MRI) (with or without a rectal coil), as reviewed re-
cently.2 Accuracy for each modality varies, with CT hav-
ing approximately 50% to 75% accuracy for T staging, and
55% to 70% for N staging. MRI has locally staged tumors
From the Departments of Colorectal and Minimally Invasive Surgery, Cleve-
land, OH.
Address reprints requests to Dr. Conor Delaney, Department Colorectal Sur-
gery, Desk A-30, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland,
OH 44295.
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0504-0004$30.00/0
doi:10.1053/j.optechgensurg.2003.10.002
214 Operative Techniques in General Surgery, Vol 5, No 4 (December), 2003: pp 214-223
with accuracy in the range of 65% to 90%, but recent
meta-analyses suggest 84% T stage accuracy, and 82% N
stage.3 Ultrasound remains the mainstay method of inves-
tigation, because of immediate availability in the clinic
and good overall accuracy, with T stage accuracy gener-
ally ranging from 70% to 90% and N stage from 60% to
75%, although it is very operator dependent. The other
imaging modalities are reserved for stricturing tumors,
and for imaging the liver and other organs. PET scanning
is not routinely used for primary tumors.
Having evaluated the patient, a decision is made re-
garding the surgical approach that will be used. Patients
with advanced age or comorbidities may be considered
for local therapy, as described below. For most cases, a
radical surgical approach is the standard of care. Two
decisions are made at this time. First, whether the patient
requires preoperative adjuvant radiotherapy, and second,
whether the patient is better served by a colo-anal anas-
tomosis or permanent end colostomy.4
The first factor that must be considered is the adequacy
of the patient’s sphincter complex, including manometric
assessment if there is any doubt about adequate function.
Imaging of the sphincter is generally unhelpful if ade-
quate pressures are present. The second factor is the dis-
tance of the tumor from the dentate line. As tumors rarely
spread distally, the traditional distal margin required has
been 2 cm, but over the last 10 years a margin of 1 cm has
been acceptable to preserve continence for T1 and T2
tumors, without any increase in local recurrence rates.5
Indeed, some authors report partial or complete excision
of the internal anal sphincter with intersphincteric dissec-
tion and mandatory hand-sewn anastomosis, to achieve
an adequate distal margin.6,7
PREOPERATIVE THERAPY
This has become a very controversial issue over the last
decade. Traditional guidelines recommended postopera-
tive therapy with radiation and chemotherapy, however
while postoperative radiation reduced local recurrence
rates, it had never been convincingly demonstrated to
improve survival. The Swedish Rectal Cancer Trial pro-
vided important evidence that preoperative radiation
might improve survival,8 supported by subsequent meta-
Anterior Resection with Low Anastomosis
analyses.9 High local recurrence rates in many of these
studies have led to concerns that such improvements in
survival may not be present when adequate surgery is
performed (with adherence to the principle of wide or
“total” mesorectal excision). This issue has recently been
addressed by the Dutch prospective randomized con-
trolled trial10 and other studies,11 which suggest that pre-
operative radiation provides survival and disease control
benefits, even with total mesorectal excision,12 although
it is unclear whether there are subgroups of patients that
derive most or all of the benefit.
The answers to some questions are still awaited, in-
cluding the 5-year results of the Dutch study, whether
there is a benefit of radiation for T1 and T2 tumors,
whether the addition of chemotherapy improves results,
whether short course (25Gy over 5 days) or long-course
(40-45 Gy over 5 weeks) is better, and whether it is safe to
change a preradiation decision for permanent stoma to a
postradiation decision of colo-anal anastomosis based on
response to radiation. Some authors have also raised is-
sues as to whether patients with advanced tumors who
have a good response to radiation may avoid rectal resec-
tion and undergo transanal excision,13 or avoid surgery
completely.14 These policies have not been supported by
adequate prospective studies for use outside of investiga-
tional protocols.
In an effort to minimize postoperative morbidity re-
lated to radiation,9 our practice is to generally reserve
radiation for T3 N0 or greater tumors, within 10 cm of the
anal verge,15 and to make a decision as to the operative
procedure at the time of the initial visit.
ALTERNATIVE TREATMENT OPTIONS
Options for local therapy of rectal cancer have been
available for many years, including local brachyther-
apy, fulguration, and local excision. Generally these
options have been reserved for older patients or those
with comorbidities. Several recent reports of local ther-
apy from experienced authors have shown that local
recurrence rates are on the order of 18% after operation
for T1N0 and 37% for T2N0 lesions.16 Higher cure
rates would be expected with radical surgery. Many
patients who recur are not salvageable with further
therapy. For this reason, local therapy is now generally
reserved for older or infirm patients, or for younger
patients who would otherwise require a permanent
stoma, and who prefer this procedure after understand-
ing the outcome after local therapies.
Trans-anal endoscopic microsurgery (TEMS) has been
used with increasing frequency to perform transanal ex-
cision of polyps and early cancers.17 Although no pro-
215
spective trials show a benefit over traditional transanal
surgery with an operative proctoscope, advocates
strongly support its use, particularly for tumors that are
higher in the rectum that might not be suitable for
transanal approaches.18
Local techniques are generally reserved for well-dif-
ferentiated tumors, without evidence of lymphatic in-
vasion that are T2 or less. Many would advocate adju-
vant chemoradiation for tumors shown to be T2 on
histopathology, and routinely perform adjuvant ther-
apy or radical surgery for pathologically more ad-
vanced lesions.
SURGICAL TECHNIQUE
The operative technique is addressed in the figures; how-
ever, several issues require specific comment. Local re-
currence rates of 25% or more have been reported for
many years. Although practiced in some institutions for
many years, recent emphasis on the accurate and precise
technique of total mesorectal excision (TME) has empha-
sized that complete excision of clear radial margins is
important, and that local recurrence of less than 10% can
be achieved.11,15,19 Anastomosis has traditionally been
performed using an end-to-end colon-to-anal canal tech-
nique. Poor functional results led to the description of a
colonic pouch which has been shown to improve func-
tional outcome in several randomized trials.20,21 Some
authors have also suggested that anastomotic leak rates
may be reduced. However, patients with a markedly fatty
mesentery, a very narrow pelvis, or a very long anal canal
(where the dentate is up to 2 or 3 cm below the anorectal
junction) are not suitable for the colonic pouch. In these
patients a transverse coloplasty may be fashioned, and
this seems to give postoperative function equivalent to
the colonic pouch.22,23 Randomized controlled trials are
underway comparing these techniques.
Recent data suggest that laparoscopic colectomy pro-
vides at least equivalent oncological outcome to open
surgery for colon cancer.24 While there are no prospec-
tive randomized data available for rectal cancer, the tech-
nique has been well described.25-27 While there is no
doubt that laparoscopy gives excellent visualization of
tissue planes, this can be quite difficult in patients who
are obese, have had preoperative radiation, who have
bulky tumors or a narrow pelvis. Until the results of
prospective randomized trials show safety for this patient
cohort, and unless patients are being entered into pro-
spective databases by surgeons with extensive experience
in laparoscopic and colorectal cancer surgery, we recom-
mend open resection for patients undergoing curative
surgery with primary anastomosis for tumors of the mid-
or lower rectum.
216 Delaney and Fazio

TECHNIQUE

1 After making a lower midline incision

and examining the intraabdominal organs
for metastatic disease and other pathology,
the sigmoid colon is mobilized laterally
and extended medially as far as the mid-
line, carefully preserving the parietal layer
of peritoneum covering the ureter and pre-
sacral autonomic nerves. The mesentery of
the distal sigmoid is then elevated from the
retroperitoneum under slight tension. The
peritoneum to the right of the inferior
mesenteric artery (IMA) is opened parallel
to the vessel, allowing the index finger of
the left hand to encircle the origin of the
IMA. The vessel is divided 2 cm below its
origin to protect the para-aortic auto-
nomic nerves, and then the left colic artery
is divided just after its origin, preserving
the bifurcation of that vessel to maximize
blood flow to bowel that will be used as the
neorectum.
Anterior Resection with Low Anastomosis 217

3 Attention is turned to the pelvis, and the small bowel and

descending colon are packed under the abdominal wall, and
held in place with sponges or a malleable retractor. The opera-
tor’s left hand holds the distal sigmoid and rectum anteriorly,
and cautery dissection commences behind the rectum, staying
between the plane of the parietal peritoneum, and the fascial
layer investing the mesorectum. The initial dissection is in the
midline posteriorly, and continues down to the level of the
levators, demonstrating the bi-lobed appearance of the intact
2 After dividing the inferior mesenteric vein (IMV) at the mesorectum. A curved, lighted retractor is used to maintain
level of division of the IMA, the lateral attachments of the adequate distraction of tissues to demonstrate the plane. Dis-
descending colon are mobilized. The greater omentum is then section continues laterally on both sides until the rectum be-
elevated superiorly, demonstrating the avascular plane between comes tethered by the anterior peritoneal attachments at the
this and the transverse colon. This plane is opened, mobilizing pouch of Douglas.
the splenic flexure so that the colon to the left of the midline is
fully freed from its attachments. At this stage the colon is teth-
ered by the IMV as it enters the splenic vein behind the pan-
creas. Therefore, the IMV is divided just below the pancreas
giving several extra inches of reach to allow the descending
colon to reach into the pelvis. The mesentery of the distal
sigmoid is divided, confirming the presence of pulsatile flow in
the proximal marginal artery, and the colon is divided between
clamps.
218 Delaney and Fazio

4 The lighted retractor is then used

to draw the bladder or uterus anteri-
orly, and cautery is used to continue the
lateral dissection around anteriorly,
opening the peritoneum 1 to 2 mm be-
hind Denonvillier’s fascia. The dissec-
tion then continues distally until the
levators are seen to curve distally into
the anal canal. In cases with an anterior
tumor, particularly where there has
been evidence of extension of tumor
through the bowel wall on preoperative
imaging, the anterior dissection is kept
in a plane just anterior to Denonvillier’s
fascia. While placing the anterolateral
nerve bundle at increased risk, this per-
mits greater surgical clearance to be
achieved. For anterolateral T3 tumors,
the fascia is only taken on the side of
the tumor.
5 A bi-manual examination is then performed
to confirm that a complete mobilization has been
performed, and that there is an adequate distal
margin, as discussed in the main text. An angled
clamp is placed across the bowel below the level
of the tumor and the distal rectum is irrigated to
minimize the risk of implantation of tumor cells
in the staple line. A 30 mm linear stapler is then
positioned across the rectum at the anorectal
junction. At this level there is no mesorectum to
divide, and this stapler easily fits around the rec-
tum. The specimen is amputated and removed
from the field, leaving a transverse staple line
that can be easily seen from above, sitting just
into the upper anal canal, ready for a stapled
colo-anal anastomosis.

6 Preoperative evaluation of some pa-

tients, generally before any neoadjuvant
therapy, demonstrates that there is insuffi-
cient distal margin for a stapled anastomosis
(usually less than 2 or 3 cm from the dentate
line). In these cases, the intraabdominal dis-
section proceeds as described above until
the anal canal is reached. At this stage, the
operator moves to the perineum. This often
needs to be re-draped and prepared with
betadine, and effacing sutures are placed
around the anal canal. A Hill-Ferguson re-
tractor is used to visualize the dentate line,
which is opened circumferentially with cau-
tery. The mucosa and submucosa are dis-
sected off the internal sphincter, and at the
top of the sphincter the dissection is contin-
ued outwards reaching the plane of dissec-
tion from above, and the specimen is re-
moved from the field.
220 Delaney and Fazio

7 For tumors within 1 to 2 cm

of the dentate line an inter-
sphincteric proctectomy is per-
formed. Some authors have
described a circumferential in-
tersphincteric dissection, but
generally dissection continues
very much like the mucosec-
tomy-like dissection in Fig 6,
except that the quadrant, or half
of the internal sphincter that the
tumor overlies, is elevated and
resected en-bloc with specimen,
preserving a distal ring of
sphincter.
Anterior Resection with Low Anastomosis 221

9 The colon J-pouch provides improved short-term func-

tional recovery for patients with a colo-anal anastomosis. The
distal 6 cm of neorectum is folded back on the more proximal
colon in a J-shape, and a short colotomy made at its apex along
the antimesenteric border. A 55 or 60 mm linear cutting stapler
is inserted and fired as close to the antimesenteric border as
possible, opening a lumen between the two limbs of bowel. The
8 A straight colo-anal anastomosis is fashioned most easily,
tip of the J-pouch is then closed with a 30 mm linear stapler, the
and may be preferable to a colonic pouch in markedly obese
Bainbridge clamp is removed from the proximal bowel, and a 0
patients or those with a long anal canal often requiring a hand-
polypropylene purse string inserted. The anvil of the desired
sewn anastomosis. For a hand-sewn anastomosis, the operator
circular stapler is inserted (generally a CDH 29, Ethicon Endo-
goes to the perineum and 3/0 polyglycolic acid sutures are
surgery, Cincinnati, OH). The stapler is then inserted trans-
placed through the skin and internal sphincter of the anal canal
anally, if necessary using four Allis clamps for retraction on the
at the eight major points of the compass, and each held with a
anal verge. This sometimes requires a bimanual technique to
hemostat to the drapes. The neorectum is brought into the
prevent the stapler bursting through the anorectal staple line.
pelvis and passed through the anal canal using Babcock clamps
The spike of the stapler is extruded posterior to the staple line,
from below. The eight sutures are passed through the neorectal
and the stapler closed and fired, yielding an anastomosis with-
wall with full thickness bites, using a narrow Hill-Ferguson
out torsion or tension. The donuts are checked for complete-
retractor placed within the neorectum if necessary, and the
ness (and sent for pathological examination for these very low
anastomosis fashioned. A temporary defunctioning loop ileos-
tumors), and the anastomosis tested by insufflation with air. A
tomy is fashioned in all cases.
temporary defunctioning loop ileostomy is fashioned in all pa-
tients.
222
10 A coloplasty is also useful in those with a very narrow
pelvis or long anal canal. A transverse coloplasty is fashioned
using the distal 12 cm of proximal bowel, and the bowel is
marked 4 and 12 cm from the end. Cautery is used to open an 8
to 10 cm linear colotomy along the antimesenteric border be-
tween these two marks. The halfway point on each side is
marked with a suture, and the colotomy is closed transversely
with interrupted 3/0 polyglycolic acid suture in Heinecke-
Mikulicz fashion. The coloplasty pouch is distended with saline
to ensure integrity, and additional sutures are placed as needed,
and the anastomosis fashioned as above. A temporary defunc-
tioning loop ileostomy is fashioned in all cases.
POSTOPERATIVE CARE AND
EVALUATION
There has been an increasing trend to divert patients
undergoing colo-anal anastomosis, particularly when
they have received preoperative radiation. The stoma of
preference is the loop ileostomy, which avoids risk to the
marginal artery of the colon, and appears to be associated
with fewer complications at the time of closure.
Delaney and Fazio
Patients are now managed without nasogastric tubes
and frequently using accelerated care pathways which
allow patients to recover more quickly without increased
complications.28-30 At the time of hospital discharge, pa-
tients are scheduled to return for a gastrografin enema
approximately 6 weeks after operation. Presuming there
is no evidence of anastomotic leak, the defunctioning
stoma is then closed 3 to 6 weeks later.
The benefit of long-term follow-up of colorectal can-
cer patients remains unproven. Nevertheless, patients
are usually seen every 3 months for the first 2 years, and
then every 6 months until 5 years after resection. At
each visit, patients undergo digital examination, proc-
toscopy and CEA monitoring. There has been some
discussion about the use of routine imaging (generally
CT scan, but also endoanal ultrasound) to detect early
local recurrence, but the benefit in patients who have
undergone total mesorectal excision remains un-
clear.31
PROGNOSIS AND FUNCTIONAL
OUTCOME
It can safely be said that we are now at the stage where
primary anastomosis is almost always technically pos-
sible unless the sphincter complex is actually invaded
by tumor. However, problems with ectropion, mucus
seepage and imperfect continence mean that the long
term outlook of all surgical options should be dis-
cussed to permit the patient to make a fully informed
decision. Surprisingly, there are few data comparing
functional outcomes and quality of life (QOL) for those
with ultra-low colo-anal anastomoses versus abdomi-
noperineal resections.32
While there are data showing that patients with a
permanent colostomy have lower than normal QOL
scores, results of a colo-anal anastomosis are not per-
fect. Patients may have 3 or more bowel movements per
day, with “stacking” or “flocculation”, variable incon-
tinence rates depending on the amount of sphincter
resected and anastomotic technique used, with seepage
at night in up to 50% of cases. Results may be further
impaired by anastomotic leakage or radiation after-
effects. Recent reports suggest that QOL scores may be
similar after either operation, however, the level of
evidence is poor.33
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