Information about Low Anterior Resection by Dr Dhaval Mangukiya. Details of Low Anterior Resection(LAR), Arterial Supply, Venous Drainage, Ports, Position, Modified Lithotomy, Vessel Ligation, Lymph Nodes, Nerves Anatomy, Superior Hypogastric Plexus, Lateral Pelvic Nerves, Correct TME, Anastomosis etc. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. LAR
Dr. Dhaval Mangukiya
GI & HPB Surgeon
SIDS Hospital

2. Low Anterior Resection

3. Arterial Supply

4. Venous Drainage

5. Ports

7. Position

8. Modified Lithotomy

9. Vessel Ligation

10. Lymph Nodes

11. Nerves Anatomy

13. Superior Hypogastric Plexus
• Ligation of the IMA should be
performed 1.5–2 cm from its aortic
origin
• Avoid mass clamping of the IMA
which may increase damage to the
left trunk of the SHP
• Preserve Gerota’s fascia during
mobilisation of the ureter and
gonadal vessels as these contain SHP
fibres
• To avoid the wrong plane of
dissection, it is important to dissect
only immediately posterior to the
superior rectal artery

14. Lateral Pelvic Nerves
• The adherent nerves can be eased off the mesorectal fascia laterally
• The surgeon should avoid hooking the tissue laterally
• Neither should there be a need to cross-clamp the middle rectal
pedicle to avoid damaging the nerves

15. Urogenital nerves
• cavernous nerves which are responsible for erectile function and run
laterally outside Denonvilliers fascia, lie at the lateral corners of the
seminal vesicles at the 2 and 10 o’clock positions and eventually lie
anterior to the postero-lateral border of the prostate and continue
onto the periprostatic plexus

16. LAR Video

17. LAR Video

18. TME - a specimen oriented surgery

19. Correct TME

20. Anastomosis

21. Anastomotic Leak
• low anastomosis has a leak rate of about 15%–20%
• 5%–10% leak rate for intraperitoneal colorectal anastomoses

22. Indo Cynin Green & Infra Red Light
• ICG is a sterile, water-soluble tricarbocyanine compound that absorbs
near infrared light with a peak spectral absorption at 800 nm.
• ICG is injected intravenously, which rapidly and extensively binds to
plasma protein
• It can be cleared by the liver in 3 to 5 minutes into the bile
• It is a nontoxic and nonionizing agent with a maximal daily dose of
2 mg/kg

23. ICG in Colorectal Surgery

28. Surg End. 2017 Mar;31(3):1061-1069.
Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis
Kenji Kawada, Suguru Hasegawa, Toshiaki Wada, Ryo Takahashi, Shigeo Hisamori, Koya Hida, Yoshiharu Sakai
• ICG fluorescence imaging resulted in a proximal change of the
transection line by more than 5 mm in 26.5 %
• More than 50 mm in 4.4 %, compared with the initially planned
transection line.

29. LN mapping
• Injected in 4 quadrant of tumor locally
• LN uptake