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296
J.R. Izbicki and K. Bachmann
38
38.1 Timing an Indication
of the Operation
e selection of the procedure and the timing of
the intervention in diverticulitis are varying
extremely between dierent centers which is
rarely found in any other disease. Concerning the
operation, it has to be distinguished between elective and emergency procedures. e presence of
perforated diverticulitis is an absolute indication
for surgical intervention, while the indication for
surgery in chronic recurrence of diverticulitis is
discussed controversial as the operation is not
focusing on the treatment of an acute inammation but on the prevention of recurrence with
potential complications. e risk of recurrence is
5–43 %.
A complicated course of the disease with
abscess, stulas, or perforations, requiring surgical intervention, was found in 15–20 % of the
patients. e treatment of those patients is associated with a considerable morbidity and mortality, in perforated patients up to 30 %. is has to
be in balance to the perioperative risk of elective
resection with a morbidity of 15–20 and mortality of 0–17 %. e assessment of these facts leads
to controversial point of view regarding the optimal timing of the resection; the majority of
experts recommend the resection aer the rst to
fourth attack. Another problem is that no denition of an acute attack exists, resulting in the
question if the history of pain in the le lower
quadrant or proof of diverticulitis by CT scan or
colonoscopy is necessary for the statement that
an attack is present.
The “American Society of Colon and Rectal
Surgeons” recommends a decision case by case
for the indication of surgical resection in diverticulitis. In patients with complicated, nonperforated diverticulitis, the indication for
resection is seen after the first episode of diverticulitis, as a correlation of the severity of the
attack and the risk of recurrence and complicated courses including perforations were
described.
e elective sigmoid resection was traditionally performed 6–8 weeks aer an acute attack
and initial antibiotic treatment. During the last
years, the early elective resection was established
as an alternative. Aer 2–5 days of antibiotic
treatment, the resection is performed minimally
invasive.
e outcome of both approaches is comparable, while the early elective resection is associated
with an increased rate of complications. But in
patients with complicated non-perforated diverticulitis, it has to be considered that the risk of
need of urgent surgery due to perforation within
the waiting period of 6–8 weeks is relevant.
38.2 Tactics of the Operation
In patients with non-perforated diverticulitis, the
laparoscopic resection is the gold standard.
Single- incision laparoscopic surgery (SILS) or
NOTES procedure are described but at present
not the therapy of choice. In patients with perforated diverticulitis with peritonitis, open access is
indicated.
Independently from the access to the abdominal cavity, a decision has to be made for primary
anastomosis, anastomosis with loop ileostomy, or
Hartmann’s procedure.
38.3 Loop Ileostomy
e loop ileostomy can reduce the clinical impact
of anastomotic leakage leading to a lower operative re-intervention rate, as the patients remain
clinical stable, but the loop ileostomy cannot
reduce the number of anastomotic leakages aer
descendorectostomy.
It has to be considered that a second operation
is necessary for the reversal of the loop ileostomy,
which is associated with complications especially
anastomotic leakage as well. Additionally the
impairment of the quality of life during the presence of the ileostomy must be taken in consideration, and the increased risk of dehydration with
acute renal failure is relevant. Due to higher rates
of complications of a reversal procedure, a loop
colostomy is not recommended.
38.4 Hartmann’s Procedure
e Hartmann’s procedure without reconstruction of the continuity is associated with shorter
operating time and lower risks. It prevents from
the development of an anastomotic leakage, as no
anastomosis is performed. But the risk of an insufciency of the rectal stump and higher rate of
Surgical Technique and Difficult Situations from Jakob R. Izbicki
297
38
complications of reversal operation compared to
loop ileostomy have to be pointed out.
In summary the indication for the Hartmann’s
procedure are the presence of perforated diverticulitis with fecal peritonitis with planned
abdominal lavage or septic shock or patient’s associated factors such as incontinence, or very old,
immobile and in need of care patients, where not
reversal of a stoma will be performed.
38.5 Laparoscopic Sigmoid
Resection
e laparoscopic sigmoid resection is normally
performed in general anesthesia, and an epidural
catheter is placed to ensure fast recovery and
mobilization according to a fast track concept.
Patients were operated in lithotomy position with
pads at the shoulders, allowing a Trendelenburg
position during the operation. Previous to incision of the skin, cefuroxime (1.5g) and metronidazole (500mg) were administered as antibiotic
prophylaxis.
e surgeon and assistant stand on the right
side of the patients. e optic trocar (10/12mm)
is placed 2cm above the umbilicus. Aer installation of the pneumoperitoneum, a camera is
inserted and an explorative laparoscopy is performed. e local situation of the sigma is evaluated as well as signs of abdominal malignancies,
especially at the liver and peritoneum. Aer
exploration and decision for laparoscopic preparation, additional trocars (5 mm right upper
quadrant and 10mm right lower quadrant and
5mm le lower quadrant) were placed.
e sigmoid colon is moved with atraumatic
grasper to medial. e lateral adhesion to the
abdominal wall of the colon was mobilized in the
vessel-free layer with the harmonic scalpel. e
preparation is continued to the le exure, which
is mobilized as well. e extent of the mobilization is depending on the length of the colon and
extent of the diverticulosis.
Aer that, the mobilization is continued caudal
to the upper third of the rectum. e le ureter is
identied and secured with a yellow vessel loop.
Adhesions to the bladder, abdominal wall, and
adnexa are mobilized; aer that, the mesosigma is
dissected close to the colon. e sigmoid artery and
vein are identied and selectively transected with a
scissor between titan clips (two central, one distal).
e preparation is supported by the assistant
by pulling the sigma to the abdominal wall by
placing a grasper below the mobilized part of the
colon. e preparation is continued to the upper
rectum. Aer incision of the peritoneum, the
mesorectum is dissected. e superior rectal vessels are indented and closed with titan clips and
cut through. e fatty mass dorsal of the rectum is
dissected to the gut wall, and the wall of the upper
rectum is identied circular, below the lower end
of the diverticulosis. It is important to resect the
high pressure zone of the rectosigmoid junction.
e extent of the resection should be the same in
open and minimally invasive surgery.
Aer complete dissection, a transverse transection of the rectum is performed with a curved
Endo GIA stapler (blue), which is introduced in
the 10 mm trocar in the right lower quadrant.
Aer that, the planned proximal transection line
of the colon is transposed to the transection line
of the rectum to test that this is possible without
tension. Otherwise the le exure/transverse
colon was mobilized additionally. Aer ensuring
a tension-free transposition, a grasper is placed at
the planned transection line and secured. e
pneumoperitoneum is blown o, and the incision
of the 10 mm trocar in the lower right part is
enlarged to medial to 4cm including a transection of the rectal muscle. A circle enforced wound
protection sheet is placed and the colon with the
grasper is moved to the incision and the sigmoid
is pulled out of the abdominal cavity.
e colon is closed with a so clamp and transected with the diathermia. A tobacco pouch is
laid around with Prolene 2/0 (ensuring enough
serosa is used), and die head of a circular stapler
(CEEA) is introduced. e tobacco pouch is
closed and sutured. e clamp is removed and the
colon is repositioned into the abdominal cavity.
e incision is closed with Vicryl. Aer restoration of the pneumoperitoneum, the colon is
placed to the rectum to test the tension-free position.
Transanally the circular stapler CEEA is introduced (generally 31 mm), to ensure sucient
lumen and avoid stenosis. Under direct view to
the end of the rectal stump, the spike is moved out
close to the brackets of the transection line, while
the gut wall is stabilized with the laparoscopic
grasper. e spike is removed and directly recovered out of the abdominal cavity. e spike is connected with the head and under direct view. e
298
J.R. Izbicki and K. Bachmann
38
colon and rectum are approximate making sure
that the gut is not twisted. e circular stapler is
closed while the surrounding fat tissue is kept
away. Aer closing the stapler, it is red and held
for a few seconds. It is important to maintain the
stapler in a constant position to avoid traction on
the anastomosis. Aer that, the stapler is opened
two complete turns and the stapler is removed
carefully in circulation movements. e rings of
the anastomosis were checked for completeness.
e anastomosis is inspected; if indicated, additional sutures are placed laparoscopically. No
standard testing for insuciency is performed.
Finally a lavage of the abdominal cavity and
control of hemostasis are carried out. A drain is
placed close to the anastomosis. Trocars were
removed under direct vision and the pneumoperitoneum is blown o. e fascia and skin are
closed followed by sterile adhesive bandage.
38.6 Loop Ileostomy
Aer completion of the colorectal anastomosis,
the distal ileum is identied. 30cm proximal of the
valve of Bauhin, the ileum is crossed below with a
grasper and a loop is used to rein the ileum. Both
ends are placed in a grasper. Aer lavage and
placement of the drains, the pneumoperitoneum
is blown o. At the preoperatively marked position
in the right part of the abdominal wall (marked in
sitting and lying position), a circular excision of
the skin and subcutaneous fat tissue is performed,
followed by a crosswise incision of the fascia. e
rectal muscle is divided bluntly to medial and lateral, followed by an incision of the dorsal fascia.
e orice should be easily traversable with two
ngers. In case of visualization of the epigastric
vessel, they should be ligated to avoid bleeding.
e selected part of the ileum is extracted in front
of the abdominal wall using the placed loop. It is
important to avoid twisting of the ileum or tension
on the future ileostomy. e discharging channel
of the loop ileostomy is placed cranial and the
delivering channel caudal. If indicated, a rider is
used to prevent a retraction of the ileum.
Aer normal completion of the operation and
sterile draping, the gut lumen is opened with a
diathermia. And the loop ileostomy is sutured to
the skin in single-stitch technique. A stoma bag is
trimmed to cover the skin completely.
38.7 Hartmann’s Procedure
In patients that underwent laparoscopic resection of the sigmoid colon with an existing indication for Hartmann’s procedure, the planned
resection margin of the proximal colon is marked
with clips or a stitch aer transection of the upper
rectum with the Endo GIA.e distal end of the
sigmoid colon is grabbed with a grasper. Aer
lavage and placement of the drains, the pneumoperitoneum is blown o. At the preoperatively
marked position in the right part of the abdominal wall (marked in sitting and lying position), a
circular excision of the skin and subcutaneous fat
tissue is performed, followed by a crosswise incision of the fascia. e rectal muscle is divided
bluntly to medial and lateral, followed by an incision of the dorsal fascia. e orice should be
easily traversable with two ngers. e grabbed
end of the sigmoid colon is extracted in front of
the abdominal wall.
It is important to avoid twisting or tension on
the future colostomy. e colon is transected in the
marked area, the specimen is resected, and a terminal colostomy is xed in single-stitch technique.
A stoma bag is trimmed to cover the skin
completely.
38.8 Open Resection of the Sigmoid
Colon
An open sigmoid resection is performed in general anesthesia, and an epidural catheter is placed
to ensure fast recovery and mobilization according to a fast track concept. Patients were operated
in lithotomy position with pads at the shoulders
allowing a Trendelenburg position during the
operation. Previous to incision of the skin, cefuroxime (1.5g) and metronidazole (500mg) were
administered as antibiotic prophylaxis.
e surgeon stands on the right side of the
patients, the rst assistant on the le side, and the
second assistant between the legs. A median laparotomy is performed and the local situation of the
sigma is evaluated as well as signs of abdominal
malignancies, especially in the liver and peritoneum. Aer exploration and decision for resection, a Bookwalter retractor is placed for optimal
exploration. e small intestine is placed in the
upper right part of the abdomen.
Surgical Technique and Difficult Situations from Jakob R. Izbicki
299
38
e colon sigmoid is moved to medial, and
the lateral adhesion to abdominal wall of the
colon was mobilized in the vessel-free layer with
the harmonic scalpel. e preparation is continued the le exure, which is mobilized as well.
e extent of the mobilization is depending on
the length of the colon and extent of the
diverticulosis.
Aer that the mobilization is continued caudal
to the upper third of the rectum. e le ureter is
identied and secured with a yellow vessel loop.
Adhesions to bladder, abdominal wall and adnexa
are mobilized; aer that the mesosigma is dissected close to the colon. e sigmoidal artery and
vein are identied and selective sutured. Proximal
and distal resection margin were dened. e gut
wall is crossed below with an overholt and the
colon is transected with a GIA 80 (blue).
e preparation is continued to the upper
rectum. Aer incision of the peritoneum, the
mesorectum is dissected. e superior rectal vessels are identied and sutured. e mesosigma is
transected close to the wall of the gut. e fatty
mass dorsal of the rectum is dissected to the gut
wall and the wall of the upper rectum is identied
circular, below the lower end of the diverticulosis. It is important to include the high pressure
zone of the rectosigmoid junction in the resection. Aer complete dissection a transverse transection of the rectum is performed with a linear
stapler (TEA 45 blue). Aer that the proximal
transection line of the colon is transposition to
the transection line of the rectum to test that this
is possible without tension. Otherwise the le
exure/transverse colon were mobilized additionally.
Aer ensuring a tension-free transposition, a
clamp is placed to avoid contamination with gut
bacteria; the end of the colon is opened with the
diathermia and a tobacco pouch is laid around
with Prolene 2/0 (ensuring enough serosa is
used) and die head of a circular stapler (CEEA)
is introduced. In a narrow pelvis, the use of a
curved contour stapler is recommended. e
tobacco pouch is closed and sutured. e clamp
is removed and the colon is placed to the rectum
to test the tension- free position. Transanally the
circular stapler is introduced (generally 31mm)
CEEA, to ensure sucient lumen and avoid stenosis. Under direct view to the end of the rectal
stump, the spike is moved out close to the
brackets of the transection line, while the gut
wall is stabilized with manually. e spike is
removed and directly recovered out of the
abdominal cavity. e spike is connected with
the head and under direct view. Colon and rectum are approximated making sure that the gut
is not twisted. e circular stapler is closed while
the surrounding fat tissue is kept away. Aer
closing, the stapler it is red and hold for a few
seconds. It important to maintained the stapler
in a constant position to avoid traction on the
anastomosis. Aer that the stapler is opened two
complete turns and the stapler is removed carefully in circulation movements. e rings of the
anastomosis were checked for completeness. e
anastomosis is inspected, if indicated additional
sutures are placed. No standard testing for insufciency is performed. Finally a lavage of the
carried out. Two easy ow drains are place close
to the anastomosis. Closure of fascia and skin
followed by sterile adhesive bandage.
38.9 Open Loop Ileostomy
Aer completion of the colorectal anastomosis the
distal ileum is identied. 30 cm proximal of the
valve of Bauhin the ileum is crossed below and a
loop is used to rein the ileum. Both ends are placed
in a clamp. Aer lavage and placement of the
drains a circular excision of the skin and subcutaneous fat tissue is performed at the preoperatively
marked position in the right part of the abdominal
wall (marked in sitting and lying position), followed by a crosswise incision of the fascia. e rectal muscle is divided bluntly to medial and lateral,
followed by an incision of the dorsal fascia. e
orice should be easily traversable with two ngers. In case of visualization of the epigastric vessel, they should be ligated to avoid bleeding. e
selected part of the ileum is extracted in front of
the abdominal wall using the placed loop. It is
important to avoid twisting of the ileum or tension
on the future ileostomy. e discharging channel
of the loop ileostomy is placed cranial and the
delivering channel caudal. If indicated a rider is
used to prevent a retraction of the ileum.
Aer normal completion of the operation and
sterile draping, the gut lumen is open with a diathermia. And the loop ileostomy is suture to the
38
300
J.R. Izbicki and K. Bachmann
skin in single-stitch technique. A stoma bag is
trimmed to a cover the skin completely.
38.10 Open Hartmann’s Procedure
e resection is previously described. In patients
that underwent open resection of the sigmoid
colon with an existing indication for Hartman procedure, the planed resection margin of the proximal colon is marked with clips or a stitch. Aer
lavage and placement of the drains, a circular excision of the skin and subcutaneous fat tissue is performed at the preoperatively marked position in
the right part of the abdominal wall (marked in sitting and lying position) followed by a crosswise
incision of the fascia. e rectal muscle is divided
bluntly to medial and lateral, followed by an incision of the dorsal fascia. e orice should be easily
traversable with two ngers. e complete colon
sigmoid is extracted in front of the abdominal wall
up to the planned upper resection margin.
It is important to avoid twisting or tension on
the future colostomy; optimal perfusion of the
colon is mandatory. Aer completion of the closure of the laparotomy and skin, the colon is transected in the marked area, the specimen is
resected and a terminal colostomy is xed in
single- stitch technique. A stoma bag is trimmed
to a cover the skin completely.
Difficulty Level I “Ideal Patient”
z
Slim patients, no previous major abdominal surgery, no anticoagulation
Difficulty Level II “ Nearly Ideal Patient”
z
Obese patient, relevant active inammation
Difficulty Level III “Difficult Patient”
z
Immunosuppression; previous surgery especially
laparotomy, presence of sigmovesical stula
Difficulty Level IV “ Very Difficult Patient”
z
Adherence of surrounding organs (small intestine, adnexa) in the inammatory mass
Septic patient with perforated diverticulitis
and shock
Patients with severe pulmonary or cardiac disease are not able to be in a Trendelenburg position. Patients with anticoagulation or Plavix
Difficult Situation
z
Situation: A laparoscopic resection is performed
in a 61-year-old patient with recurrent diverticulitis (up to the upper part of the rectum).
Dilemma: Aer transanal placement and ring of circular stapler, a complete dysfunction of
the stapler is detected. e anastomosis is completely insucient. Fecal contamination of the
abdominal cavity.
Management: Immediate conversion to open
surgery. Resection of the insucient anastomosis
to proximal and distal with linear stapler. Reanastomosis with new CEEA stapler. Intensive
lavage.
Due to deep anastomosis decision for additional loop ileostomy.
Result: Fast recovery of the patients. No postoperative complications. e reversal of ileostomy
was carried out contemporarily.
Analysis: e occurrence of severe problems
or confusing situations in laparoscopic surgery
can be managed by conversion to open surgery.
Conversion is no complication; it is a responsible
surgery.
Individual Surgery for Rectal Cancer
Contents
Chapter 39 Introduction – 303
MichaelKorenkov, Christoph-omasGermer,
andHaukeLang
Chapter 40 Surgical Technique and Difficult
Situations from Matthias Anthuber – 309
MatthiasAnthuber
Chapter 41 Surgical Technique and Difficult
Situations from Markus W. Buechler – 315
AlexisUlrich, P.Antony, andMarkusW.Buechler
301
X
Chapter 42 Surgical Technique and Difficult Situations
from Alois Fuerst (Laparoscopic) – 323
AloisFuerst, ArthurHeiligensetzer,
GudrunLiebig-Hörl, andPeterSauer
Chapter 43 Surgical Technique and Difficult
Situations from Werner Hohenberger
(Conventional) – 327
WernerHohenberger
Chapter 44 Surgical Technique and Difficult
Situations from Rolv-Ole Lindsetmo
(Laparoscopic) – 333
KimErlendMortensen, StigNorderval,
andRolv-OleLindsetmo
Chapter 45 Surgical Technique and Difficult Situations
from Neil Mortensen (Laparoscopic) – 343
J.B.Tuynman andN.J.Mortensen
Chapter 46 Surgical Technique and Difficult Situations
from Amjad Parvaiz (Laparoscopic) – 351
AmjadParvaiz andManfredOdermatt
302
Chapter 47 Surgical Technique and Difficult Situations
from Peter M Sagar (Conventional,
Abdomino-Sacral Resection) – 363
PeterM.Sagar
Chapter 48 Surgical Technique and Difficult Situations
from Juergen Weitz (Conventional) – 371
ChristophReißfelder andJuergenWeitz
Chapter 49 Surgical Technique and Difficult Situations
from Steven Wexner (Laparoscopic) – 377
StevenWexner andMarcOsborne
Chapter 50 Preservation of the Autonomic Pelvic
Nerves for TME-Resection from Werner
Kneist – 383
WernerKneist
303
Introduction
MichaelKorenkov, Christoph-omasGermer, andHaukeLang
39.1 Low Anterior Resection (LAR)
inOpen Technique – 304
39.1.1 Approach – 304
39.2 Low Anterior Resection (LAR)
inLaparoscopic Technique – 306
39.3 Rectum Extirpation – 307
39.4 Classication ofIntraoperative Diculties – 307
39
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_39
M. Korenkov et al.304
Anterior or low anterior rectal resection with a
partial (PME) or a total mesorectal resection
(TME) is currently the standard surgical procedures for rectal cancer. ese operations will be
performed in open or laparoscopic techniques.
e basic operation steps are the following:
1. Mobilisation from sigmoid and descending
colon
2. Transection of inferior mesenteric artery and
vein
3. Transection of descending colon
4. Rectal dissection in PME or TME technique
5. Rectal transection
6. Anastomosis
7. Creation of a protective stoma (optional)
Technical problems and dicult decision situations
occur mostly during a ventral rectal dissection, rectal transection as well as by anastomosis creation.
39.1 Low Anterior Resection (LAR)
inOpen Technique
39.1.1 Approach
for such diculties are previous gynaecological
cancer surgery with a para-aortic lymph node dissection and postoperative radiation as well as previous abdominal aorta surgery.
Seldom there is a worst-case combination of rectal cancer and primary retroperitoneal brosis. In
such situation a preparation technique should be
used according to individual requirements. If a pelvic inltration is less pronounced, we recommend at
rst to create a retrorectal window below of promontorium and aer that perform a colonic mobilisation from the presacral space to cranial direction.
Step 3: Transection ofDescending
Colon
is step is not related with technical problems
and dicult decision situations.
Step 4: Rectal Mobilisation inPME
or TME Technique
is part of operation consists of several substeps:
5 Exposure of the presacral nerves
5 Presacral dissection
5 Lateral dissection
5 Ventral dissection
39
A midline laparotomy is a most common
approach. Some surgeons prefer a le paramedian
laparotomy or a right paramedian laparotomy in
case of planned rectal extirpation for reaching a
sucient distance between the laparotomy wound
and stoma. In order to reach a maximal access, the
aponeurosis should be open till to the symphysis.
Step 1: Sigmoid andDescending
Colon Mobilisation
is step is mostly technical unproblematic.
Technical problem and dicult decision situation
can occur in case of spleen injury as a result of
uncareful bowel traction. In order to avoid such
situations, laparotomy should be long enough to
cranial direction. Combination of rectal cancer
and sigmoid diverticulitis can be also a cause for
technical diculties.
Step 2: Transection ofMesenteric
Inferior Vessels
is step is also mostly technical unproblematic.
Inammatory or brotic retroperitoneal inltration can make an appropriate dissection between
Gerota’s fascia and meso signicant, more dicult or even impossible. e predisposing factors
e exposure of the presacral nerves requires own
technical tips and tricks (see the chapter from
W.Kneist).
A presacral dissection is mostly unproblematic. Technical diculties may occur in case of
locally advanced tumours with dorsal penetration. In such situation a “classic” presacral dissection till to the pelvic oor is not possible. If an
inltration of the presacral fascia is suspected, an
indication to sacral resection should be evaluated.
Lateral dissection can be dicult because of
missing the bordering lamellas and avascular
layer. Locally advanced tumours, narrow pelvis as
well as a post-radiated inltration aer neoadjuvant radiotherapy are predisposing factors for the
technical diculties.
A dicult decision situation can also occur if
the inltration of the lateral wall of the lesser pelvis
is suspected. In such situation a surgeon is facing
the dilemma of either R0 resection will be not
achieved or an expanded dissection of the lateral
wall of the lesser pelvis with possible resection of
iliac vein or rather artery should be considered. e
last option is related with signicantly higher intraand postoperative morbidity and unexplained survival benet. erefore in case of local advanced
Introduction
305
39
tumour is the exactly preoperative work-up examination essential for the planning of surgery.
A ventral dissection can be also connected
with technical problems and dicult decision
situations. Technical steps of this procedure are
dierent for female and male (see a chapter from
Ulrich and Buechler). Denonvilliers’ fascia, which
is applicable as a guide for the ventral dissection,
has a lot of anatomic varieties from the wellpresented multilayered lamella till to the complete
absence of this structure. In the last case, there is
increased risk of an accidental opening of rectal
or vaginal lumen or rather for accidental removing of the seminal vesicle or autonomic nerves. In
order to avoid these complications, the use of rectal and vaginal splinting by female and rectal
splinting by male patient can be helpful.
Step 5: Rectal Transection
e rectal transection during low and ultra-low
anterior rectal resection is related not seldom
with technical problems and dicult decision
situations. e following problems can lead to difcult situations:
5 Problematic stapler placement
5 Not sucient safe distal resection margin
For the distal rectal transection, dierent staplers
(TA45, Contour Stapler, dierent Endo GIA) will
be used. In case of very narrow and deep lesser
pelvis, the use of TA and Contour Stapler can be
most problematic. Also the external compression
of the pelvic oor can’t be always helpful. In such
situation, the use of Endo GIA stapler with roticulated branches can be helpful. In order to avoid
tangential or z-form rectal transection, the stapler
branches should be always placed in 90° position
to rectal axis. Sometimes it is also dicult to place
a 60-mm stapler in a narrow lesser pelvis. In this
situation it is helpful to use a 45-mm Endo GIA
for the rst cutting and 60-mm stapler for recut.
Certainly relates such procedure to higher cost.
A not sucient safe distal resection margin
has a direct relation to problematic stapler placement. In such situation we recommend endoscopic control (exible or rigid rectoscopy) of
stapler position before the transection.
Step 6: Anastomosis
A reconstruction aer low anterior resection
can be performed as end-to-end, side-to-end,
colon j-pouch as well as transverse coloplasty
anastomosis. Creation of colon j-pouch anastomosis can be problematic for patients with a fatty
mesocolon or very narrow deep lesser pelvis.
Technical problems and dicult decision situation
can occur in the following cases:
5 Problematic tension-free placement of the
colon in lesser pelvis
5 Poor blood ow in anastomotic colon
5 Rupture of rectal stump staple line during
transanal introduction of stapler
5 Accidental involvement of the vagina into the
stapler line
Despite of an adequate mobilisation of the splenic
exure, a tension-free placement of the colon in
lesser pelvis by some patients is not possible. Such
problem can take place in obese patients. In this
situation, a transverse colon should be further
mobilised towards the right exure. Sometimes it
is necessary to transect the middle colic vessels.
Such a situation can lead to a vicious circle: further transverse colon mobilisation can lead to a
new insucient blood ow in the distal colonic
segment. is required recut of the distal colon
that can lead to a new problematic tension-free
placement of it. Such a situation requires special
surgical skill and great experience. Sometimes a
temporal cross-clamping of the middle colic vessels can be useful to estimate a surgical situation.
A rupture of the rectal stump staple line during transanal introduction of the stapler is
unpleasant but a solvable problem. To avoid this
situation, we recommend the following measures:
5 Transanal introduction of a circular stapler
before the rectal transection. ereby a jerky
stapler introduction in a very short rectal
stump will be avoided.
5 In case of ultra-low transection, the use of
Contour Stapler should be avoided. ere is
no tissue overage above a staple line aer cutting with this stapler that can reduce a holding
force of a stapler line (the personal opinion of
one of the authors).
5 Severe adhesion process in lesser pelvis aer
amputation of the uterus. In this case there is a
risk of vaginal wall interposition between stapler head and anvil with creation of “colovaginorectal” anastomosis (. Fig.39.1). In order to
avoid this serious complication, it is an obligation to make sure that there is no tissue interposition between the stapler components