Video Summary

This video demonstrated a step-by-step technical description of laparoscopic low anterior resection. After mobilization of the left colon, the inferior mesenteric artery and vein are divided. The rectum is mobilized all along to the pelvic floor. Subsequently, what remains is mobilization of the splenic flexure for reach of the colonic segment. After division of rectum, specimen is extracted from left iliac fossa and a coloanal anastomosis is performed. A covering ileostomy is created in the right iliac fossa.

Video

Teaching Points

1. Patient preparation
   1. Preoperative stoma nurse visit. A stoma site is marked in right iliac fossa for covering ileostomy.
   2. Mechanical bowel preparation.
   3. Enhanced recovery pathways for colorectal surgery: carbohydrate loading, venous thromboprophylaxis, and attention to pain control.
   4. Preoperative intravenous antibiotics just before incision. The antibiotic of choice in our center is injection cefuroxime 1.5 g combined with injection metronidazole 500 mg. The dose is repeated after 4 hours.
2. Patient position
   1. Patient is placed in modified lithotomy position, with all pressure points padded and arms tucked by the side.
   2. A soft gel foam bolster is kept below the patient’s buttock which projects beyond the operating table. Ideally, the coccyx should be palpable outside the operating table.
3. Critical steps
   1. Placement of ports: 12-mm umbilical using Hasson technique, 12-mm right iliac fossa, 5-mm right upper quadrant, 12-mm left iliac fossa, and 5-mm left upper quadrant.
   2. Operating surgeon and camera assistant stand on the right side, and the first assistant stands on the left side.
   3. A right downward tilt on the table with steep Trendelenburg.
   4. Creating a window below the inferior mesenteric vein in retroperitoneum to separate the mesocolon from retroperitoneum.
   5. Medial to lateral mobilization of left colon with incision close to inferior mesenteric artery to prevent injury to hypogastric nerves.
   6. High ligation of inferior mesenteric artery after dissecting all nodal tissues until its root. Inferior mesenteric vein is also ligated.
   7. Mobilization of splenic flexure to ensure reach of the colonic segment in pelvic floor without tension.
   8. Mesorectal dissection along the holy planes of Heald until pelvic floor. The levator ani muscles are the inferior landmark where dissection is stopped.
   9. Division of rectum with endostapler.
   10. Removal of specimen from a minilap incision in left iliac fossa.
   11. End-to-end coloanal anastomosis with circular stapler.
4. Technical pearls/tips
   1. Ligate inferior mesenteric vein at the ligament of Treitz to elongate the colonic segment for a tension-free anastomosis. Use of energy device near this segment should be avoided to prevent injury to duodenum.
   2. Left colon mobilization: Medial to lateral mobilization is preferred. In case of colonic adhesion with small-bowel mesentery and redundant sigmoid colon, a lateral to medial mobilization can be done.
   3. Rectal mobilization: Begin with dissection along the presacral holy plane down to the pelvic floor. Ensure that the lateral dissection is medial to autonomic nerves. Similarly, keep anterior dissection behind Denonvilliers fascia unless it is involved by tumor.
   4. Ensure the reach of the colonic segment to the pelvic floor by a simple technique of bringing it to the lower border of the pubic symphysis.
5. Potential areas for injury/complication
   1. Injury to ureters, gonadal vessels, and hypogastric plexus while mobilizing left colon.
   2. Injury to hypogastric plexus while ligating inferior mesenteric artery.
   3. Injury to neurovascular bundle of Walsh while performing lateral rectal mobilization.