In this presentation, I have shown how to do open anterior resection both high and low varieties in a step-by-step manner with clear pictures as if reading an atlas of operative surgery.

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

2. OPEN 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. OPEN ANTERIOR RESECTION
• INDICATIONS:
Carcinoma of rectum- High anterior
resection for rectosigmoid and upper rectal
tumors. Low anterior resection for mid
rectal tumors.
• ANESTHESIA:
 GA/ETT
• POSITION:
 Lloyd– Davies- Lithotomy in padded
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. • Incision: Access
 Midline extending above and below
umbilicus
 Left para-median
• Position
 Lloyd-Davies- lithotomy with padded
stirrups
 Surgeon should stand on the right side
OPEN ANTERIOR RESECTION

6. • Exposure
 Assess the position and resectability of the
tumour. Assess liver and peritoneum for
metastatic deposits and colon for
synchronous tumours
 Using diathermy divide the peritoneum
along the ‘white line of Toldt”
• Exposure
 Table may be tilted to right side
 Surgeon stand on right side
 Abdominal pack over small intestine and
retract to right side
OPEN ANTERIOR RESECTION

7. • Mobilisation of Left Colon
 Incise the whiteline of Toldt upto
splenic flexure
 Mobilise Lt Colon from
retroperitoneal structures
• Mobilisation of Left Colon
 Avoid injury to Lt Ureter and Lt
Gonadal vessels by placing a right
angle clamp or your finger
 This mobilisation is Mattox Maneuver
OPEN ANTERIOR RESECTION

8. • Mobilisation of splenic flexure
 Divide the spleno-colic ligament
• Mobilisation of greater omentum with
Transverse Colon
 Separate the greater omentum from the distal
transverse colon and continue the dissection
laterally towards the splenic flexure.
OPEN ANTERIOR RESECTION

9. • 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.
• Transaction of Colon
 Transect the colon to ensure adequate blood
supply with GIA stapler
OPEN ANTERIOR RESECTION

10. • Rectal dissection
 Trendelenburg position
Surgeon on left side
Extend the lateral fascial incision upto
upper rectum
• Rectal dissection
 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.
OPEN ANTERIOR RESECTION

11. • 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
• Posterior Rectal dissection
 The mesorectum is divided laterally either
with clamps and sutures or with a vessel sealer
device, such as LigaSure.
 Aim for a 2cm clearance below the distal margin of
the tumour and a 5cm clearance of the mesorectum.
 High anterior resectionPartial mesorectal excision
 Low anterior resection Total mesorectal excision
OPEN ANTERIOR RESECTION

12. • Anterior Rectal dissection
 The rectum is mobilized ventrally by dividing
the rectovaginal septum in females or the recto-
vesicle space in males.
 In males, the dissection plane is ventral to
Denonvillier fascia, preserving the seminal
vesicles.
OPEN ANTERIOR RESECTION

13. • Transaction of Rectum
 The distal rectum is closed with a linear
stapler- TA55, approximately 2 to 5 cm distal to
the tumor at the pre-selected area.
 Apply a right-angle clamp 2 cms proximal to
the staple line
• Transaction of Rectum
 Divide the rectum with a scalpel in between the
stapler line and the right-angle clamp
OPEN 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
 The anvil is detached and placed within the
proximal colon, and the purse-string is tied
around the anvil
OPEN 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
 Integrity of the anastomosis can be evaluated by
gentle insufflation of the rectum with saline to rule
out any leak and by examining the tissue doughnuts

15. • Hand sewn Colo-rectal anastomosis
 Can do for high anterior resection but difficult
for low anterior resection
OPEN ANTERIOR RESECTION
• Alternate Colo-rectal anastomosis
 J pouch colorectal anastomosis also can be created

16. • Great omental cover
 Mobilise greater omentum with vascularity,
bring it down and keep it over the anastomosis
to prevent any leak
OPEN ANTERIOR RESECTION
• Defunctioning/Diverting Ileostomy
 Create a loop ileostomy to divert fecal stream to
protect the anastomosis

17. • Closure of Laparotomy
 By mass closure with 1-0 prolene or PDS
OPEN ANTERIOR RESECTION

18. 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.
OPEN ANTERIOR RESECTION

19. Pearls & Pitfalls
 The mesorectal dissection should be performed sharply under direct vision and not bluntly with
the hand.
 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 identifi ed and repaired
primarily. A protection loop ileostomy may be indicated for diffi cult or low anastomosis (<5 cm)
and for patients who underwent preoperative chemoradiation treatment.
OPEN ANTERIOR RESECTION

20. THANK YOU