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41
318
A. Ulrich et al.
enough to be clear of the distal limit of the tumor.
e intestinal lumen is washed with a 10 %
Braunol solution and sealed below the level of the
mesorectum using a TA-45 linear stapler. e tobe- excised mass is then freed from the stapler
using a scalpel, and the product is analyzed on a
macroscopic level. If necessary, an intraoperative
frozen section analysis is performed. Should further excision prove necessary, a second TA-45 stapler, placed below the initial stapler, is employed,
and the excision margins are adjusted accordingly. e excised tumor mass is additionally analyzed for TME quality and classied in accordance
with the MERCURY criteria.
e reconstructive phase begins with control
of the blood circulation to the descending colon
as well as determination of the necessary colonic
length. If necessary, further colonic tissue may be
removed at this point. e guide plate of a 31mm
circular end-to-end stapler is then inserted and
secured in place using a “purse string” suture of 0
Prolene. Our personal preference is the 31mm
circular stapler produced by Covidien. In order
to ensure adequate and improved stool function
in the rst 12 months postoperatively, our clinic
strives to avoid coloanal anastomoses. Instead,
our clinic favors the use of a transverse coloplasty
pouch (TCP). A 5 cm incision is made in the
descending colon approximately 3cm proximal
to the guide plate and closed laterally by a stapler.
Care must be exercised to make sure that the
mesenteric tissue is not incorporated into the
staple line. According to the surgeons’ preference, the staple line can be sewn over with a 4-0
PDS suture. Alternately, a side-to-end anastomosis can be used. e short arm, of approximately
3cm, serves to prevent anastomotic necrosis. e
guide plate of the circular end-to-end stapler is
inserted in the stapled colonic loop and diverted
in an antimesenteric direction. e colon stump
is sealed using a GIA stapler and sewn over using
a 4-0 PDS suture. e circular stapler is then
inserted through the anal canal so that it abuts on
to the staple line on the rectal stump. is works
best if the rectum has already been expanded
preoperatively. Doing so aer rectum resection
risks destroying the staple line created. e center rod is advanced through the center of the
staple line (. Fig. 41.3). e guide plate is
attached to the center rod, and the staple gun is
red aer ensuring that no fatty or vaginal
. Fig. 41.3 Advancing center rod of a circular stapler
through the center of the staple line (created by a linear
stapler) of a rectum stump
tissuehas been incorporated. In order to prevent
excessive movement of the stapler, it is recommended that the stapler be further stabilized by
the le hand of the surgeon. e integrity of the
anastomosis must then be analyzed. is is easily
done by the insuation of air from the anal
canal, while the pelvis is lled with a sodium
chloride solution.
In cases of ultra-deep tumors, in which the
external sphincter muscle and levator muscle are
not inltrated, an intrasphincteric resection may
be warranted. Here, it is necessary to dissect the
pelvic oor between the internal and external
sphincter muscles, taking care that the rectal wall
and internal sphincter muscle are not injured in
the process. In tumors located up to 1cm above
the dentate line, the rectum can be removed
intersphincterically with a stapler. More distally
located tumors require resection through the anal
canal due to the improved vantage point. In such
cases, a “Lone Star retractor” is placed and the
internal sphincter muscle is incised underneath
the tumor level. e whitish internal sphincter
muscle is easily distinguished from the darker
reddish external sphincter muscle making resection at this level feasible for experienced surgeons
(
. Fig.41.4). At this juncture, it is best to avoid
the use of electrocoagulation, as this may obscure
color distinctions between the two muscle layers.
Aer the tumor mass is removed, a total of 16 4-0
PDS sutures are placed in a circular fashion under
inclusion of the internal sphincter muscle. With
Surgical Technique andDicult Situations fromMarkus W.Buechler (Conventional)
a ligature device. e colorectal anastomosis
takes the form of an end- to- end anastomosis
without a pouch or protective stoma.
Regardless of the type of rectum resection, the
abdominal cavity is carefully irrigated and
checked for the cessation of bleeding. Two easy
ow drains are placed leading from the small
aperture of the pelvis to the le abdominal wall.
is is followed by wound closure in layers with
suturing of the fascia and stapling of the skin aer
instrument removal. Aerward, the wound is
. Fig. 41.4 Intersphincteric resection and severing of the
internal sphincter muscle. The external sphincter muscle
(for ceps) is shown prior to anastomosis formation
the help of these sutures, the coloanal anastomosis
is completed. e descending colon is pulled
externally through the sphincter using Ellis
clamps, which are inserted into the pelvis through
the anal canal. e pouch is created directly at the
point of exit. Here too, the descending colon is
split longitudinally and sealed laterally with a stapler. Again, the staple line is sewn over. Now it is
possible to return the colon to the pelvis, and,
using the prepared sutures, ax it to the internal
sphincter muscles.
All patients receiving a TME in our clinic are
equipped with a stoma. In such cases, we tend to
favor the double-barrel ileostomy, which is generally placed in the right lower abdominal wall.
In order to provide a more complete analysis,
we endeavor at this point to describe the partial
mesorectal excision (PME) used in tumors
found in the upper third of the rectum (12cm
above the anus). Here, it is of tantamount importance that the dissection of the mesorectum be
completed without injury to the pelvic fascia
and extend 5cm below the lower tumor border.
Rectal tissue, as well as the associated perirectal
fatty tissue, found below this point can be preserved, leading to improved functionality. In
addition, in such cases, it is possible to forego
the use of a protective stoma, as the risk of anastomotic insuciency at such heights is signicantly reduced. In order to prevent coning, or, in
other words, the lateral resection of mesorectal
tissue, we prepare the mesorectum laterally at
the level of the resection margin up to the lateral
rectal wall. Here, one is able to carefully remove
the rectum using a TA-45 stapler. ereaer, the
mesorectum is cut and secured using clamps or
covered and the ileostomy completed using everting single-button sutures.
Troubleshooting
z
1. In cases where the staple line at the rectum
tears, a purse string suture can be used. By
pressing the pelvic oor in the direction of the
pelvic aperture with a st, adequate room is
created to safely place the needed sutures.
2. If, aer the le hemicolon has been mobilized
to the middle colic artery, a poor perfusion of
the intestines is observed, it becomes
necessary to remove more tissue. If a
tension-free anastomosis is no longer possible
as a result, one can attempt to lead the le
hemicolon through a mesenterial slit between
the ileocolic artery and the terminal branch of
the superior mesenteric artery. Should this
fail, the only remaining option is to sever the
middle colic artery and rotate the colon in a
counterclockwise direction. is allows for an
ascendo- or transversorectostomy.
41.1 Abdominoperineal Rectum
Extirpation
In cases where the external sphincter or levator
muscles are inltrated, a more radical abdominoperineal resection must be performed. Largescale observational studies, as well as randomized
controlled studies, such as the Dutch radiation
study, have shown poorer outcomes for patients
with an APR compared with those treated with
deep anterior rectum resection. is phenomenon can be partially explained by a higher perforation rate aecting the circumferential resection
margin (CRM). For this reason, our clinic favors
the extralevatory APR with intraoperative repositioning of the patient as described by von Holm
319
41
41
320
A. Ulrich et al.
etal. (Br J Surg 2007). It has been shown that the
resultant larger tissue surface positively inuences
the CRM and rate of perforation.
e operation is performed as follows:
e patient is placed in the lithotomy position,
and the transabdominal portion of the operation
is performed as described in the previous chapter
for TME.Dissection extends to the coccyx. From
this position, the pelvic plexus, in which the nerve
bers of the hypogastric nerve and the pelvic
splanchnic nerves (S2–S4) run, can be seen laterally. Dissection extends below this nerve bundle.
In men, dissection continues beyond the seminal
vesicles to the prostate. In women, the upper third
of the vagina must be separated from the mesorectal plane.
ereaer, an abdominal cloth is placed
between the rectum and the small aperture of the
pelvis. In order to complete the abdominal portion of the operation, the descending colon is led
out the abdominal wall at a predetermined position, in preparation for its use as a colostomy. In
general, a le-sided omentoplasty is favored, as
this allows for the preservation of the gastroepiploic vessels and only the branches leading to the
greater gastric curvature must be removed. From
the right, the gastroepiploic vessels are severed
aer being clamped and ligated. ereaer, the
omentum can be moved along the lateral abdominal wall into the small aperture of the pelvis.
Using a single suture, the apex of the omentum is
xed to the to-be-resected rectum so that it can be
later placed in the pelvis without problem. e
same procedure is repeated for an easy ow drain
which is brought in from the right abdominal
wall. Finally, the abdominal cavity is closed layer
by layer.
Aer the abdominal portion of the operation
is completed, the patient is repositioned in the
jackknife position. is provides optimal access
to the perineal region. e perineal, gluteal, as
well as lower back regions are cleaned and covered. e buttocks is spread and xed in this position with tape. e anal canal is then closed using
a purse string suture. An incision is made from
the middle of the lower back (approximately 3cm
above the tip of the coccyx) to the anus. ereaer,
the incision continues semicircularly along the
sides of the anus coming together behind the
anus. e next step involves dissection onto the
levator muscles and mobilizing the associated
cutis and subcutis layers. In order to ensure that
. Fig. 41.5 Dissection of the subcutis from the levator
muscles through positioning of the patient in the jackknife
position during extralevatory APR.Sutures at the sealed
anus are shown
enough so tissue remains to adequately cover
the defect, it is important to remove as little subcutaneous tissue as possible, assuming of course
that this tissue is not inltrated by tumor cells
(
. Fig.41.5). e coccyx is exposed and separated
from the sacrum using a chisel or strong scissors.
In this manner, one advances into the small aperture of the pelvis until the abdominal cloth previously placed between the sacrum and mesorectum
is reached. At this point, the levator muscle can be
palpated and cut through using a monopolar
electrical cautery. e dorsal gap is thus continuously enlarged, until the rectum can be luxated
out of the pelvis and the surrounding abdominal
cloth can be removed. e sutures to the omentum and easy ow drain are severed, and dissection continuous in the anterior and caudal
direction. e levator muscles are further
removed, and the mesorectum is separated from
the prostate or vagina (
. Fig.41.6). If tumor inl-
tration of the prostate has already occurred, the
lamellar resection of the prostate can be completed
Surgical Technique andDicult Situations fromMarkus W.Buechler (Conventional)
. Fig. 41.7 Formation of a right-sided gluteoplasty in
order to cover the defect left after extralevatory APR is
performed
the resection border, dened by the supercial
transverse perineal muscle running above the
urethra, should be preserved. Now the excised
mass can be disposed of and the abdominal cavity
irrigated and inspected for surgical bleeding.
Closure of the pelvic oor is dependent on the
size of the defect. In some cases, it is possible to
directly readapt the subcutaneous tissue. When
this is not possible, a pelvic oor reinforcement
. Fig. 41.6 Luxated rectum including mesorectum after
transection of the levator muscles on both sides during the
abdominoperineal rectum resection. Using the jackknife
position, visualization of the vagina or prostate is optimal
consisting of a biological implant, such as pig collagen or a composite net can be used. e remaining subcutaneous tissue is closed layer by layer. A
Redon drain is placed subcutaneously. Finally, the
skin is closed using single-button sutures. Such
without problem. In this case, however, a transurethral urinary catheter is placed in order to
serve as a positional control. In men, the preparation must strictly adhere to the mesorectal border
lamella as deviations could risk injury to nerves
running along the prostate to thebulbospongiosus and lead to impotency. e caudal margin of
primary closure is usually easy if the initial inci-
sion is done carefully.
In cases where the skin defect is more substantial, a plastic reconstruction may be necessary. In
such cases, the vertical rectus abdominis muscle
ap (VRAM) or a single- or double-sided gluteal
. Fig.41.7) can be used.
ap (
321
41
323
Surgical Technique
and Difficult Situations
from Alois Fuerst
(Laparoscopic)
AloisFuerst, ArthurHeiligensetzer, GudrunLiebig-Hörl,
andPeterSauer
42.1 Introduction – 324
42.1.1 Position of the Patient in the Operation Room – 324
42.1.2 Insertion of the Trocars – 324
42.2 Operation Technique – 324
42.2.1 Colonic Pouch Following Rectal Resection – 325
42.2.2 Protective Ileostomy – 325
42.2.3 Intersphincteric Rectal Resection – 325
42
42.3 Discussion and Conclusion – 326
42.4 Demanding Situation in Laparoscopic
Rectal Resection – 326
42.4.1 Situation – 326
42.4.2 Solution of the Problem – 326
42.4.3 Analysis – 326
42.4.4 Conclusion – 326
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_42
42
324
A. Fuerst et al.
42.1 Introduction
Standardisation of the laparoscopic surgical procedure in rectal cancer has favourable eects in terms
of security aspects, economic workow and teaching factors. Self-evident the oncological aspects of
surgical quality must be taken into account. e
autonomic nerve-sparing TME technique is the
gold standard in rectal cancer resection even in conventional or laparoscopic procedure. In open surgery, most surgeons start the operation le laterally
mobilising the sigmoid colon rst. In the laparoscopic technique, we recommend the medial to lateral approach starting the preparation at the right
side of the rectum and the sigmoid colon. Following
this approach, the nerve-sparing TME technique
can be performed easier and the identication of
the le ureter may be simplied. Since more than 10
years, we perform a standardised “laparoscopic tenstep TME procedure” in rectal cancer:
1. Medial to lateral preparation of the A. rectalis
superior preserving the autonomic nerves
2. Identication of the le ureter
3. Clip the A. mesenterica inferior
4. Clip the V. mesenterica inferior
5. Mobilisation of the le colon (medial and
lateral)
6. Mobilisation of the le exure (medial/lateral/omental)
7. Preparation along the mesorectal plane
8. Transection of the distal rectum (Endo
Stapler)
9. Extra-abdominal resection of the descending
colon
10. Anastomosis with a transanal stapler device
e sequence of the surgical steps can be varied if
necessary. For example, the mobilisation of the le
exure can be done at the beginning of the operation.
42.1.1 Position of the Patient
in the Operation Room
Lloyd Davis position is the standard position of
the patient. A broad support device is mandatory
at the right side of the patient. A support system at
the shoulders is not recommended. An extreme
Lloyd Davis position (more than 30°) must be
prevented to avoid a compartment syndrome of
the lower extremities. e operating table must
have a multiplane exibility.
. Fig. 42.1 Trocar placement
42.1.2 Insertion of the Trocars
5 For safety reasons we recommend an open
access of the rst trocar. e position of the
camera trocar is located 2cm above the umbilicus. Two trocars are localised at the lower part of
the abdomen and one trocar at the right middle
part. Further trocars are optional (. Fig. 42.1).
42.2 Operation Technique
5 e preparation of the rectum starts at the
right posterior peritoneum. Aer incision of
the peritoneum, the proximal mesorectal
plane can be identied clearly. e autonomic
nerves must be preserved. e right ureter is
located laterally in most cases.
5 e preparation proceeds at the posterior side
of the proximal mesorectum, the le ureter
and the Aa., and Vv. ovaricae resp. testiculares
can be identied.
5 e superior rectal artery has to be elevated
carefully and followed up to the inferior mesenteric artery. Now the retroperitoneal adhesions of the sigmoid colon are dissected, the le
ureter in a save position and the risk of a damage ofthe ureter during preparation at the le
side of the colon is very low. Anatomic variations of the ureter can be recognised easily.
Surgical Technique and Difficult Situations from Alois Fuerst (Laparoscopic)
325
42
5 Clipping of the inferior mesenteric artery should
be done about 1.5cm distal of the aorta and then
dissected.
> On the origin of the A. mesenterica inferior,
the autonomic nerves are localised more
ventrally and should be preserved.
e autonomic nerves along the aorta have to be
preserved. e preparation is orientated behind the
inferior mesenteric vein up to the pancreas. We clip
and transect the inferior mesenteric vein centrally in
order to get an optimal mobility of the le colon.
5 Occasionally some adhesions of the duode-
num have to be mobilised.
5 We proceed the mobilisation of the le colon
as far as possible from medial to lateral, elevating the mesenterium with an atraumatic
Babcock clamp. In general a dened plane
between the le kidney and the mesenterium
of the colon can be found.
5 Finally the colonic adhesions can be tran-
sected easily.
5 An important step is the mobilisation of the le
colonic exure and is sometimes time consuming. One can nd adhesions due to infections in
the patient’s history, adhesions of the omentum
and enteroenteric adhesions. ere are three different options for the mobilisation of the le
exure. One option is the continuous preparation of the exure along the lateral track. e
second option is the mobilisation of the omental
fat and opening the bursa omentalis. An early
transection of adhesions of the spleen is mandatory to prevent a damage of the capsule and
bleeding. An attractive option is the mobilisation of the exure continuing the medial to lateral approach and opening the bursa omentalis
caudally.
5 When the mobilisation of the le colon is com-
pleted, we proceed with the mesocolonic preparation along the mesorectal plane, preserving
the distal autonomic nerves. e mesorectal
dissection starts posterior then laterally and
nally anterior until the pelvic oor is reached.
e nerves along the pelvic oor must be preserved.
5 e transection of the distal rectum has to be done
with the endoscopic linear stapler. In the majority
of cases, we need two cartridges for transection.
5 Using a Pfannenstiel incision and a wound pro-
tecting device, we transpose the rectum and the
sigmoid colon in front of the abdomen wall. We
transect the colon between the descending and
sigmoid colon. A short 5cm long colonic pouch
should be created or a side- to- end conguration can be prepared alternatively inserting the
anvil of the circular stapler.
5 Aer reposition of the colon, the Pfannenstiel
incision will be closed. We use local anaesthetic inltration to minimise postoperative
pain.
5 e colon pouch-anal or side-to-end anasto-
mosis will be performed with a transanal
inserted circular stapler.
5 Finally a “bubble test” will be done to test the
integrity of the anastomosis.
42.2.1 Colonic Pouch Following
Rectal Resection
According to the results of the clinical research, a
neorectal colonic pouch formation is mandatory
even in laparoscopic technique. A signicant better neorectal function can be expected. If the formation of a J-pouch is not possible, a side-to-end
anastomosis is mandatory alternatively. Actually
there is high-level scientic evidence to favour the
J-pouch procedure.
42.2.2 Protective Ileostomy
Aer rectal resection including TME, a protective
loop ileostomy is mandatory according to scientic evidence.
42.2.3 Intersphincteric
Rectal Resection
In patients who need an intersphincteric rectal
resection, we make the transabdominal preparation
down to the intersphincteric level and continue the
operation peranal using the Lone Star retractor.
An attractive variation is the reversed procedure: e operation starts with the peranal intersphincteric preparation using the Lone Star
retractor or using a single-port system. is innovative procedure allows the distal TME continuing
the abdominal operation in a second step. In slim
patients with low-volume mesorectum, we extract
the specimen through the anus and perform the
anastomosis in a handsewn side-to-end technique.
326
A. Fuerst et al.
42.3 Discussion and Conclusion
e value of the laparoscopic rectal resection including TME and ANP was a point of discussion over
many years. e laparoscopic procedure is feasible
and safe according to more than 20 randomised
clinical trials and many case control studies.
If the laparoscopic technique is comparable to
the open procedure, highlighting the oncological
dimension is the most important issue. Up to
date, all published retrospective and prospective
studies demonstrated equivalent results comparing morbidity and mortality in laparoscopic and
open surgery.
Up to date, there are only a few studies presenting long-term data of laparoscopic rectal cancer operations. No dierences were found
compared to open surgery. An actual review from
Gopall etal. in 2012 (22 randomised and 25 nonrandomised studies, 31 case control studies, 14
reviews and one Cochrane analysis) demonstrated the feasibility and “non-inferiority” of the
laparoscopic technique.
All well-known advantages of the laparoscopic
colonic resection were found in laparoscopic rectal cancer surgery. e problems of the dierent
conversion rates and study-related data generated
in the learning course of some surgeons were discussed extensively.
e early results of the largest randomised study
including more than 1000 patients show the “noninferiority” of the laparoscopic operation compared
to the open procedure in rectal cancer (COLOR II
study, published in Lancet Oncology 2013).
42.4 Demanding Situation
in Laparoscopic Rectal
Resection
generated atherosclerosis looks like a slim “perfect
patient” for laparoscopic rectal resection (Level
1). A standardised laparoscopic rectal resection
was started. Aer incision of the peritoneum at
the right side of the rectum and preparation of the
proximal mesorectum preserving the autonomic
nerves, the preparation followed the superior rectal artery up to the inferior mesenterial artery. At
1.5cm distal the origin of the inferior mesenteric
artery, the clipping of the artery was intended. e
atherosclerotic artery was elevated for clipping.
Suddenly there was an unexpected splashing
bleeding at the aortomesenteric angle.
42.4.2 Solution of the Problem
We performed a local compression of the aorta
using a laparoscopic swap. With this manoeuvre the bleeding could be stopped sufficiently.
While compressing the aorta, we converted
the operation. After laparotomy we found a
3mm wide arterial defect at the angle of the
inferior mesenteric artery and the aorta. We
close the aortic defect with vascular sutures
sufficiently. The amount of blood loos was
150ml.
42.4.3 Analysis
A small aortic defect of the atherosclerotic aorta
and a sharp sclerotic plaque at the aortomesenteric angle was found. e plaque had perforated
the aorta while elevating the interior mesenteric
artery obviously.
42.4.4 Conclusion
42
42.4.1 Situation
An underweighted 62-year-old patient (BMI
16,5) presenting with a proximal rectal cancer,
multimorbidity including chronic rheumatoid
arthritis, long-term therapy with corticoids and
A prepared laparoscopic swap is important in case
of unexpected bleeding. e surgeon can compress the bleeding point immediately and have
time to plan further steps to stop bleeding. An
atherosclerotic inferior mesenterial artery has to
be manipulated very carefully.
327
Surgical Technique
andDicult Situations
fromWerner Hohenberger
(Conventional)
WernerHohenberger
43.1 Introduction – 328
43.1.1 When Is aSphincter- Preserving Resection
Technically Still Feasible andFunctionally
Sensible? – 328
43.2 Surgical Technique – 328
43.2.1 Mobilization oftheLeft Colon – 328
43.2.2 Anterior Rectal Resection – 329
43.2.3 Low Anterior Resection – 330
43.2.4 Abdominoperanal Intersphincteric
Rectal Resection – 331
43.2.5 Low Anterior Resection Syndrome – 332
43
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_43
328
W. Hohenberger
43
43.1 Introduction
Rectal resection for cancer including partial or
even more total mesorectal excision has made
most substantial progress in surgery over the last
20 years. Before, enormous decits of standardization and surgical quality had resulted inlocal
recurrence rates up to 50 %. anks to the eorts
of Bill Heald (Heald 1982), worldwide improvement was achieved. However, from personal
experience, there are still decits to be closed.
Apart from that, there is obvious “upcoding”
all around the world with rectal cancer surgery.
Epidemiologic data support that about one third
of all rectal cancers, mainly in the upper third are
nally sigmoid cancers. e reasons are higher
refunding, the need to achieve minimum quantities, and more prominent reputation (“colon cancer, easy; rectal cancer, more dicult”).
erefore, exact designation of the lower border of the tumor measured by a rigid rectoscope is
inevitably needed. In most countries, per denition
the length of the rectum is 16cm, from the anocutaneous line. For cancer of the lower third, the distance to the dentate line shou ld also be documented.
Similar confusion exists with the description
of the extent of the resection. e term “ultralow”
resection increasingly used is more suggestive and
does not exist, ocially. Finally, an “ultralow”
resection is nothing else but a low anterior resection with the anastomosis laying either right
within the dentate line or in distance of less than
2cm. is can most frequently be achieved even
by an abdominal approach, exclusively.
Finally, there are three dierent resections
with preservation of the sphincter:
5 Anterior resection
5 Low anterior resection
5 Abdominoperanal intersphincteric resection
e individual procedure to choose mainly depends
upon the height of the tumor.
43.1.1 When Is aSphincter-
Preserving Resection
Technically Still Feasible
andFunctionally Sensible?
Concerning oncological aspects, sphincter preservation is challenged only with cancer of the
lower rectal third and a minimum distance to the
dentate line of less than 2cm.
Provided that there is no extended invasion of
the levator muscle, neoadjuvant radiochemotherapy may enable a sphincter-preserving operation,
later on, even though this option seems to be
impossible, before. As a relevant remission may
occur even beyond the sixth week aer completion of radiochemotherapy, one should wait up to
12 weeks if necessary. Later on, usually no relevant further regression will be observed.
Broad tumor invasion of the M. levator ani,
the sacrum, or the prostate does not allow sphincter preservation. Nevertheless, these patients, too,
should receive neoadjuvant irradiation, as even in
case of an R0 resection the risk of local recurrence
will be increased due to the small circumferential
margin to be less than 1mm.
Very low resections with an anastomosis right
at the dentate line, and even more if they were
established by a peranal approach, are followed in
at least 20 % of the patients by permanent functional disturbances (low anterior resection syndrome). Incontinence is not the most pronounced
problem, but rather urgency, repetitive and fractionated stool, and disposition to diarrhea. ese
symptoms may be most severe right aer taking
down a diverting stoma. If some degree of incontinence was present already before rectal resection, it may be even worse. erefore, these
patients may do better if sphincter preservation is
omitted just for functional reasons.
e same applies to pronounced brosis of the
levator muscle following excessive remission aer
neoadjuvant radiochemotherapy.
43.2 Surgical Technique
43.2.1 Mobilization oftheLeft Colon
Any sphincter-preserving operation needs complete mobilization of the le colon, to achieve a
tension-free anastomosis. is is even more
essential, if a pouch will be created:
5 is entails full mobilization of the le colon
including the splenic exure with the le
transverse colon with taking down the greater
omentum from it. e transverse mesocolon
is divided right at the inferior border of the
le pancreas (
. Figs.43.1 and 43.2).