The document provides an overview of laparoscopic anterior resection surgery for rectal carcinoma, detailing its indications, contraindications, anesthesia, and positioning. It outlines the surgical procedure steps, including port placement, tumor mobilization, vascular ligation, excision, anastomosis, and post-operative care. Key considerations and potential complications are also highlighted to ensure successful outcomes and patient safety.

1. LAP ANTERIOR
RESECTION
DR.B.Selvaraj MS; Mch; FICS;
“ Surgical Educator”
Malaysia
OPERATIVE SURGERY

2. LAP ANTERIOR RESECTION
• INDICATIONS:
 Carcinoma of the rectum, where sphincter preservation is possible,
high anterior resection is done for tumours of rectosigmoid junction
and upper rectum which includes partial mesorectal excision.
The anastomosis is made in the region of the junction of the mid and
lower third of the rectum.
Low anterior resection is done for mid-rectal tumors which includes a
total mesorectal excision. The anastomosis is made at the level of the
pelvic floor.
For low anterior resections defunctioning stoma is made- loop
ileostomy

3. LAP ANTERIOR RESECTION
• INDICATIONS:
Carcinoma of rectum- High anterior
resection for rectosigmoid and upper rectal
tumors. Low anterior resection for mid
rectal tumors.
• CONTRAINDICATIONS:
• Big tumors- T4
• Narrow pelvis
• ANESTHESIA:
 GA/ETT
• POSITION:
 Lloyd– Davies- Lithotomy in padded Allen
stirrups
• Diagnosis
 Confirmed by biopsy
 Staging by CECT
• Pre-op preparation
Preoperative chemoradiation treatment is indicated
for patients with T3, T4 lesions or tumors with
enlarged pelvic lymph nodes found on pelvic
computed tomography (CT) scan or endorectal
ultrasound
 Adequate mechanical bowel preparation the day
before surgery with orthograde enema
 Prophylactic IV broad spectrum antibiotics
 VTE prophylaxis with LMWH and pneumatic
stockings
Bladder catheterization
The stoma nurse marks the ileostomy site for
defunctioning.
Intraoperative rigid proctoscopy is performed to
determine the distal extent of the cancer.

4. SURGICAL ANATOMY

5. • Port placement: Access
 10 mm camera port just above umbilicus
 12 mm ports at Rt subcostal area and
suprapubic midline
 5mm ports in both iliac fossae
• Position
 Lloyd-Davies- lithotomy with padded
Allen stirrups
 Surgeon should stand on the right side
LAP ANTERIOR RESECTION

6. • Mobilisation
 Assess the position and resectability of the
tumour. Assess liver and peritoneum for
metastatic deposits and colon for synchronous
tumours
 After retracting the sigmoid colon make an
incision in peritoneum over sacral promontory
and dissect retroperitoneal area
Avoid injuring Lt ureter and Lt gonadal vessels
• Exposure
 Table may be tilted to right side with
Trendelenburg position
 Surgeon stand on right side
 Small bowel swept out to RUQ, adhesions
between small bowel and sigmoid colon are
lysed if any
LAP ANTERIOR RESECTION

7. • Ligation of blood vessels
 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 take-off from
the inferior mesenteric artery and
sigmoidal arteries.
• Transection of blood vessels
 Transect sigmoidal arteries and superior
hemorrhoidal artery
 Spare Lt colic artery
 Avoid injury to Lt ureter and Lt gonadal
vessels during this manuver
LAP ANTERIOR RESECTION

8. • Mobilisation of Left Colon
 Incise the whiteline of Toldt upto splenic
flexure
 Mobilise Lt Colon from retroperitoneal
structures
 Avoid injury to Lt Ureter and Lt Gonadal
vessels
This mobilisation is Mattox Maneuver
• Mobilisation of splenic flexure
 Place the patient in reverse Trendelenburg
position
 Divide the spleno-colic ligament and mobilise
splenic flexure
LAP ANTERIOR RESECTION

9. • Testing possibility of tension free
anastomosis
 Bring down the mobilized colon to
determine possibility of tension free
anastomosis
• Mobilisation of greater omentum from
Transverse Colon
 Separate the greater omentum from the distal
transverse colon and continue the dissection
laterally towards the splenic flexure.
LAP ANTERIOR RESECTION

10. • Posterior Rectal dissection
 Carry on the dissection in the avascular plane
between the meso-rectum and the pre-sacral
fascia posteriorly.
 Carry the dissection through Waldeyer’s fascia
to the level of the coccyx.
 The mesorectum is mobilized laterally toward
both the right and left pelvic side wall,
preserving the hypogastric nerves on the
sacrum and ureters.
 Anterolateral ligament with middle rectal
artery is divided
• Posterior Rectal dissection
 The mesorectum is divided laterally either
with stapler or with a vessel sealer device, such as
Harmonic scalpel/LigaSure.
 Aim for a 2cm clearance below the distal margin of
the tumour in rectum and a 5cm clearance of the
mesorectum.
 High anterior resectionPartial mesorectal excision
 Low anterior resection Total mesorectal excision
LAP ANTERIOR RESECTION

11. • Anterior Rectal dissection
 Trendelenburg position
 Extend the lateral fascial incision upto upper
rectum
 The peritoneum is incised medial to the right
ureter and extended around the rectum to join
the pelvic peritoneal incision on the left
meeting anterior to the rectum
• Anterior Rectal dissection
 In females dissect through recto-vaginal
septum and in males through recto-vesical
space.
 In males this dissection should be ventral to
denonvillier’s fascia to spare seminal vesicles
LAP ANTERIOR RESECTION

12. • Transection of Rectum
 An endo GIA stapler is used to divide the
rectum at the preselected area
 Need multiple firings to completely divide the
rectum.
• Transection of Rectum
 Ensure that vagina in women is not
incorporated in this staple lines
LAP ANTERIOR RESECTION

13. • Exteriorisation of the bowel & it’s resection
 Divided rectum and descending colon are brought out through a paraumbilical
incision protected by a wound protector
Proximal colon is transected at a point that allows tension free reach of
the colon to the pubic bone.
 The anvil is detached and placed within the proximal colon, and the
purse-string is tied around the anvil
LAP ANTERIOR RESECTION

14. • Stapler Colo-rectal anastomosis
 Prior to creation of the anastomosis, the
proximal colon is tested to determine that
adequate length is available
 In selected cases, division of the inferior
mesenteric vein near its origin can facilitate the
colonic mobilization
 Already the anvil is detached and placed within
the proximal colon, and the purse-string is tied
around the anvil
LAP ANTERIOR RESECTION
• Stapler Colo-rectal anastomosis
 After careful deployment of the spike just posterior
to the staple line in the rectum , the stapler is
coupled and fired, completing the anastomosis-
intra-corporeal colorectal anastomosis.
 Integrity of the anastomosis can be evaluated by
gentle insufflation of the rectum with colonoscope to
rule out any leak and by examining the tissue
doughnuts

15. • Alternate Colo-rectal anastomosis
 J pouch colorectal anastomosis also can be
created
LAP ANTERIOR RESECTION
• Defunctioning/Diverting Ileostomy
 Create a loop ileostomy to divert fecal stream to
protect the anastomosis

16. Post-op Care
 No need to continue antibiotics postoperatively unless there is intraabdominal
infection.
Ambulation and incentive spirometry on postoperative day 1 is important for the
prevention of postoperative atelectasis.
Clear liquids are started on postoperative day 1, and diet is advanced as
tolerated.
The Foley catheter is left in place for a few days because of the high incidence of
urinary retention in male patients.
DVT prophylaxis should be continued until the time of discharge and can be
considered as an outpatient in certain subsets of patients.
LAP ANTERIOR RESECTION

17. Pearls & Pitfalls
 The mesorectal dissection should be performed sharply and meticulously.
 The colorectal anastomosis must be tension free, and this may require division of the sigmoid
artery at its origin and mobilization of the splenic flexure of the colon.
 In T3 and T4 rectal cancers, preservation of the pelvic autonomic nerves may not be possible.
 In most patients, the 29-mm circular stapler works well. Using the maximum-size circular stapler
may create radial tension, leading to anastomotic leak.
 If the anastomosis fails the “bubble test,” the anastomotic defect must be identified and repaired
primarily. A protection loop ileostomy may be indicated for difficult or low anastomosis (<5 cm)
and for patients who underwent preoperative chemoradiation treatment.
LAP ANTERIOR RESECTION

18. THANK YOU