Low Anterior Rectal Resection: Laparoscopic Technique

Low Anterior Rectal Resection: Laparoscopic Technique

Joël Leroy Didier

Mutter Jacques Marescaux


  • A full history and physical examination will allow the surgeon to determine if a sphincter-sparing operation is possible, whether a temporary ileostomy is likely, and will also aid in discussions regarding postoperative functional status.

  • History elements elicited should include baseline functional status, bowel incontinence, sexual and urinary dysfunction, as well as pain with defecation or tenesmus. Previous history of pelvic radiation and pelvic surgery should also be noted.

  • History of incontinence should prompt discussions regarding postoperative quality of life with a low anastomosis.

  • History of pain or tenesmus suggests involvement of the anal sphincter or a larger tumor. This will alter the course of treatment and a sphincter-sparing operation may not be possible in this subgroup of patients.

  • Physical examination should include a digital rectal exam (DRE), vaginal exam, anoscopy, and a thorough abdominal exam.

  • DRE should assess tumor size, degree of fixation to rectal and pelvic wall, mobility, location (anterior/posterior/lateral), distance from the anorectal ring, and anterior extension into vagina/prostate. Anal sphincter involvement can also be determined by DRE in the majority of patients.

  • Anterior rectal tumors in female patients require a vaginal exam to rule out extension into the vagina.

  • Anoscopy for low rectal tumors may allow for better visualization of the tumor during the physical exam.

  • The abdominal exam should evaluate for liver metastasis. A bilateral groin exam should be performed to evaluate for potential inguinal lymphadenopathy.


  • A colonoscopy with documentation of all polyps should be performed. Suspicious lesions should be tattooed to facilitate localization during surgery.

  • Staging with endorectal ultrasound or rectal magnetic resonance imaging (MRI) should be performed to determine the need for neoadjuvant therapy and to plan operative strategy. A computed tomography (CT) of the chest, abdomen, and pelvis evaluates for potential metastases.

  • A preoperative carcinoembryonic antigen level should be obtained.


Preoperative Planning

  • Informed consent is obtained preoperatively. The patient has been informed of the potential necessity to perform a diverting ileostomy or end colostomy.

  • Potential ostomy sites are marked the evening before the intervention.

  • We follow the Society of American Gastrointestinal and Endoscopic Surgeons’ (SAGES) bowel preparation guidelines.

  • Appropriate intravenous antibiotics are administered within 1 hour of skin incision.

Equipment and Instrumentation

  • 10-mm, 0-degree camera (30-degree camera is optional) with high-resolution monitors

  • Laparoscopic endoscopic scissors and a blunt tip, 5-mm energy device (10-mm can be useful in obese patients)

  • Laparoscopic linear staplers

Positioning and Port Placement

Patient setup

  • Patient setup is a major operative step.

  • The patient should be adequately secured to the table.

  • Adequate padding is essential to prevent nerve and venous compressions.

  • The patient is placed in a supine position with a cushion placed underneath the left flank in order to obtain a moderate lateral decubitus, which will retract bowel loops toward the right part of the abdomen.

  • A rotation to the right and a caudal head tilt (Trendelenburg position) will help to retract bowel loops by means of gravity.

  • The patient’s legs will then be spread apart in a semiflexion using adjustable leg supports to allow for a double abdominal and perineal access.

  • One should control the perfect positioning of the buttocks at the distal edge of the table to allow for an easy access to the anal and perineal area.

  • The arms are padded and tucked.

  • An orogastric tube is inserted; it will be removed at the completion of the surgery.

  • A Foley catheter is inserted; it will be left in place for 24 hours.

FIG 1 • Team setup. Surgeon (1). First assistant (2). Second assistant (3). Scrub nurse (4). Anesthesiologist (5).

Team positioning

  • This procedure is performed with two assistants and a scrub technician.

  • During the abdominal part of the procedure (FIG 1), the surgeon stands on the right flank of the patient, his or her first assistant lateral to the patient’s right shoulder, and the second assistant in between the patient’s legs. The scrub technician is then located to the right of the surgeon lateral to lower limbs.

  • During the perineal part of the procedure, the entire team shifts toward the extremity of the table once the perineum has been exposed.

  • The monitors are placed in front of the operating team and at eye level to improve ergonomics.

Port placement

  • One 12-mm supraumbilical port (port A) is introduced first using a mini-open technique. It will be used to accommodate the camera (FIG 2).

  • Two other ports, a 5-mm port in the right flank (port B) and a 12-mm port in the right iliac fossa (port C), are used as operating ports (FIG 2).

  • The fourth port in the left flank at the level of the umbilicus is inserted through the rectus muscle (port D, 5 mm in diameter), where the colostomy will be performed (FIG 2).

  • The last port introduced in the suprapubic area (port E, 12 mm in diameter) is used for pelvic retraction and for exposure of the sigmoid colon’s root (FIG 2).

  • Port fixation in the wall should be perfect in order to prevent any risk of parietal injury and to prevent increased operative times due to a loss in abdominal pressure. One should not hesitate to fix ports to the skin.

  • Additional ports may be used in case of difficulty in exposure. In this case, a port will be positioned in the right hypochondrium (port F) to retract the ileocecal area. This is particularly useful in obese patients (FIG 2).

FIG 2 • Port placement. Optical port (A). Working ports (B,C). Retracting ports (D,E). Additional retracting port (F).

Jul 24, 2016 | Posted by in GENERAL SURGERY | Comments Off on Low Anterior Rectal Resection: Laparoscopic Technique

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