Nezar Jrebi, MD
Laparoscopic Low Anterior Resection
Procedure Overview
Laparoscopic low anterior resection, involves removal of the sigmoid colon, upper, or mid and/or lower rectum affected by disease, followed by anastomoses to reconnect sigmoid/descending colon with the mid/lower rectum or anus.
INDICATIONS:
- Rectal Cancer
- Diverticular disease
- Inflammatory bowel disease
- GI bleeding
- Large polyp
- Rectal Prolapse
Relevant Anatomy
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Pre-operative Patient Care
Typical recommendations for pre-operative care may include, but are not limited to, any of the following:
- Cardiac evaluation
- Pulmonary evaluation
- Prehabilitation before surgery as indicated (such as diabetic control, stop smoking, weight loss)
- Bowel prep (mechanical and chemical)
Prep & Patient Positioning
Common patient positioning:
- Typically, the patient is placed in the lithotomy position, with Allen stirrups
- Arms tucked
- IMPORTANT: Patient secured to the table
- OG (oral-gastric) tube
- Foley catheter, possible urethral catheters
- The surgeon is usually on the patient’s right side with the assistant
- Sometimes surgeon will go between the legs for the splenic flexure part of the operation to maintain good ergonomics
Common port placement
- Generally, 4 ports are used: three 5 mm and one 12 mm
- Must know tumor location prior to starting the case for proper trocar placement
- These factors/decisions will affect trocar placement
- Decide if vascular pedicles are stapled or energy is used
- Decide intracorporeal or extracorporeal anastomosis
- Colon extraction site
Common room setup
- Monitor is opposite from the surgeon
- Test all equipment before starting the procedure
- Heat and humidify CO2
- Intraoperative medications such as ICG, liposomal bupivicaine
- Recording device
Operative Steps
Access
Access
- Initial Access to the abdomen is generally obtained by either:
- Veress needle technique.
- Direct trocar view technique.
- Trocar sites are identified, and trocars inserted to gain access to the abdominal cavity.
Repair
Repair
- Access and divide inferior mesenteric artery after identifying the left ureter.
- Gain access to and mobilize distal sigmoid and rectum by dividing the mesentery, performing a total mesorectal excision with an energy device such as ENSEAL™ X1 Curved Jaw Tissue Sealer.
- Perform pelvic dissection.
- Transect rectum, using a stapling device, such as ECHELON™ 3000 Stapler.
- Mobilize the descending colon and splenic flexure with an energy device such as ENSEAL™ X1 Curved Jaw Tissue Sealer.
- Transect the proximal sigmoid colon using a stapling device, such as ECHELON™ 3000 Stapler and remove specimen.
- Perform end to end anastomosis, using a circular stapling device such as ECHELON™ Circular Powered Stapler.
- Consider diverting ileostomy in patients with preop radiation or very low anastomoses.
- Check the anastomosis for bleeding and leakage with a sigmoidoscope or colonoscope.
Closure
Closure
- Remove fluid from wound and close the fascia using synthetic absorbable monofilament, such as PDS™ Plus Antibacterial suture.
- Subcuticular layer and skin are closed using synthetic absorbable monofilament, such as Monocryl™ Plus Antibacterial suture, and any appropriate dressing.
Potential complications include but are not limited to:
- Surgical bleeding
- Staple line Leak
- Wound infection
- Ileus
Post-operative Patient Care
Typical recommendations for post-operative care may include, but are not limited to, any of the following:
- Typical discharge instructions consist of pain management.
- ERAS protocol such as early feeding, ambulation, remove foley catheter, non-narcotic pain control.
Additional resources
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