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Open Technique for Low Anterior Resection

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Abstract

The most common indication for low anterior resection (LAR) is rectal cancer. Preoperative staging and patient selection is important in deciding candidacy for an LAR. Ensuring a total mesorectal excision during proctectomy is paramount for oncologic outcomes as well as reducing injury to surrounding structures. Diverting loop ileostomy should be considered for any anastomosis less than 5 cm from the anal verge to minimize the risk of pelvic sepsis from anastomotic leak. Sexual and urinary dysfunction can occur postoperatively. However, the majority of these issues can be effectively managed conservatively. These issues will be explored in this chapter.

Keywords

  • Rectal cancer
  • Total mesorectal excision
  • Open technique
  • Low anterior resection

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Correspondence to Ronald Bleday M.D. .

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Key Operative Steps

Key Operative Steps

  1. 1.

    Place the patient in lithotomy position.

  2. 2.

    Perform complete abdominal exploration to rule out metastatic disease

  3. 3.

    Mobilize the colon along the white line of Toldt.

  4. 4.

    Identify the ureter at the bifurcation of the common iliac artery.

  5. 5.

    If necessary, mobilize the splenic flexure.

  6. 6.

    Elevate the sigmoid colon and isolate the inferior mesenteric artery and left colic artery, which should be spared if appropriate. Ligate the superior hemorrhoidal artery at its takeoff from the inferior mesenteric artery.

  7. 7.

    Transect the colon to ensure adequate blood supply.

  8. 8.

    Start total mesorectal excision. Dissect posterior to the rectum between the fascia propria of the rectum and the parietal fascia of the pelvic floor.

  9. 9.

    Carry the dissection through Waldeyer’s fascia to the level of the coccyx.

  10. 10.

    Use electrocautery for anterior and lateral dissection.

  11. 11.

    Transect the rectum once an adequate distal margin has been reached.

  12. 12.

    Assure a tension-free colorectal anastomosis.

  13. 13.

    Create the anastomosis using a circular stapling device.

  14. 14.

    Perform a “leak test” on the anastomosis.

  15. 15.

    Create a diverting ileostomy when indicated.

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Teeple, E., Bleday, R. (2015). Open Technique for Low Anterior Resection. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_20

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_20

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