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RECOMMENDEDREFERENCESAND READINGS
HallböökO,PåhlmanL,KrogM,WexnerSD,SjödahlR.Randomizedcomparisonofstraightand
colonicJpouchanastomosisafterlowanteriorresection.AnnSurg1996;224(1):58–65. HoYH.Techniquesforrestoringbowelcontinuityandfunctionafterrectalcancersurgery.World
JGastroenterol2006;12(39):6252–60. HüttnerF,Tenchkhoff,S,JensenK,etal.Meta-analysisofreconstructiontechniquesafterlow
anteriorresectionforrectalcancer.BrJSurg2015;102:735–45. JafariMD,WexnerSD,MartzJE,etal.Perfusionassessmentinlaparoscopicleft-sided/anterior
resection(PILLARII):amulti-institutionalstudy.JAmCollSurg2015;220(1):82.e1–92.e1.
doi:10.1016/j.jamcollsurg.2014.09.015. PersonB,VivasDA,WexnerSD.Totallylaparoscopiclowanteriorresectionwithtransperineal
handsewncolonicJ-pouchanalanastomosisforlowrectalcancer.SurgEndosc
2006;20(4):700–2. TekkisP,TanE,KontovounisiosC,etal.Hand-sewncoloanalanastomosisforlowrectalcancer:
techniqueandlong-termoutcomes.ColorectalDis2015;17(2):1062–70. UenoH,MochizukiH,HashiguchiY,etal.Preoperativeparametersexpandingtheindicationof
sphincterpreservingsurgeryinpatientswithadvancedlowrectalcancer.AnnSurg
2004;239:34–42.
Chapter16
OpenLowAnteriorResection End-to-EndandSide-to-End Anastomoses
RadhikaK.SmithandJuanJ.Nogueras
Thetwoprevailingtechniquesusedtomaintainintestinalcontinuityafter surgicaltreatmentoflowrectaldiseaseareend-to-endanastomosis (EEA)andside-to-endanastomosis.Ratesofsphincterpreservationhave increasedthroughadvancesandadaptationsofnewsurgicaltechniques suchasintersphinctericresection,combinedtransanaltransabdominal approaches,andtransanalminimallyinvasivetotalmesorectalexcision. Additionally,themorerecentutilizationofneoadjuvant chemoradiotherapyhasallowedfordownstagingwithprimary anastomosis.
Althoughthecoreprincipleofsurgicalmanagementisachievingcure withlowperioperativemorbidityandmortality,considerationmustalso begiventopostoperativeurinary,bowel,andsexualfunction.Perhaps themostdebilitatingoutcomeafterlowanteriorresection(LAR)isthe developmentoflowanteriorsyndrome.Lowanteriorsyndromeis characterizedbyincreasedstoolfrequency,urgency,clusteringofbowel movements,andincontinenceandisfelttoresultfromthelossof reservoirfunctionoftherectum.Methodstoreconstructtheneorectum ineffortstoregainstoragecapacityhavebeendevelopedtotrytoimprove function.Theseoptionsincludeside-to-endanastomosis,colonicJ-pouch formation,andtransversecoloplasty.
Inthischapter,wereviewandcomparepreoperativeconsiderations, surgicaltechnique,andcomplicationsafterLARwithEEAandside-to­endanastomosis.

INDICATIONS

CommonindicationsforLARwitheitherEEAorside-to-endanastomosis includemidorlowrectalcancer,endoscopicallyunresectablepolyp,or inflammatoryproctocolitisfromCrohn’sdisease.

CONTRAINDICATIONS

PatientswithathreateneddistalmarginshouldnotundergoLAR.A soundoncologicresectionshouldalwaysmaintainpriorityoversphincter preservation.
Furthermore,anypatientwhoundergoesalowcolorectalanastomosis musthaveadequatepreoperativecontinenceandsphincterfunction.The increasedstoolfrequencyandurgencytypicaloflowanteriorsyndrome canalternormalcontinenceinphysiologicconditionsandcanresultina highlymorbidoutcomewithpoorpreoperativefunction.
Olderpatientsorthosewithdebilitatingmedicalcomorbiditieswho cannottoleratethephysiologicresponseortheadditionalinterventions associatedwithanastomoticleakshouldnotundergothesehigh-risk anastomoses.
PREOPERATIVEPLANNING
Preoperativeoptimizationandinformedconsentareofcentral importanceinallpatientsplanningtoundergomajorabdominopelvic surgery.
Allmodifiableriskfactorsforoperativemorbidityshouldbeoptimized priortosurgery.Examplesincludeobesity,anemia,malnutrition, immunosuppression,tobaccoabuse,andchronicmedicalproblems.
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Informedconsentforproctectomyshouldincludethepossibilityofa permanentstoma.Inpatientswhereproximaldiversionisplannedor permanentstomaisasignificantpossibility,referralshouldbemadeto anenterostomaltherapistformarkingandcounselingwhenpossible.
Attentiontopreoperativesexual,urinary,andbowelfunctionshouldbe discussedanddocumentedandpatientsshouldbeeducatedontheriskof postoperativedysfunction.
Mechanicalandantibioticbowelpreparationshouldbeadministered thedaypriortosurgery.

SURGERY

PatientPositioning
Allpatientsshouldbeplacedinmodifiedlithotomywithcaretopadall pressurepointstoavoidtraumaticperipheralneuropathy.
Abladdercatheterandorogastrictubeshouldbeplaced. Inlaparoscopicapproaches,thepatientshouldbesecuredtothebedand
thearmsshouldbetuckedtotheside. Preoperativeuretericcathetersshouldbeplacedatthediscretionofthe
operatingsurgeonandshouldbegivenstrongconsiderationinthe settingoflargebulkytumors,preoperativeradiation,inflammatory disease,orreoperativesurgery.
MobilizationandResection
Afterexploratorylaparotomy,thesmallbowelispackedawayinthe upperabdomen.
Thesplenicflexureanddescendingandsigmoidcolonaremobilized fromtheirlateralattachments.
Theuretershouldbeclearlyidentified. Highligationoftheinferiormesentericarteryandinferiormesenteric
veinattheinferiorborderofthepancreasshouldbecompletedtoensure atension-freeanastomosis.
ThepatientshouldthenbeplacedinsteepTrendelenburgtoallow unobstructedaccesstothepelvis.
Rectalmobilizationshouldbeginontheposterioraspectinthepresacral space.Mobilizationshouldbedoneusingsharpdissectionor
electrocauterytothelevelofthepelvicfloor.Careshouldbetakento avoidinjurytothehypogastricplexusandthepresacralveins.
Thisdissectionisthenlaterallycarriedaroundthepelvistofreethe peritonealattachmentsoneachpelvicsidewall.Vulnerablestructures
includethepelvicsplanchnicnerves,theureters,andtheiliacvessels. Thedissectionshouldanteriorlyconnectwithcaretotrytoprevent
injurytothegenitourinarystructures.
Partialortotalmesorectalexcisionisdeterminedbythelocationofthe tumor.Oncethedistalresectionmarginischosen,themesorectalfat
shouldbecircumferentiallyclearedtoexposeabaremuscularcuffof rectum.
Alinearstaplerisfiredata90degreeangle,ideallywithonefireofthe stapler.ThisstepcanbeperformedusinganEchelon(Ethicon,
Cincinnati,OH,USA)orEndoGIA(Ethicon,Cincinnati,OH,USA) stapleroropenusingaContourcurvedcutter(Ethicon,Cincinnati,OH, USA)orTAstapler(Coviden,Minneapolis,MN,USA).
End-to-EndAnastomosis
Theproximalmarginofanastomosisischosen.Thiscolonshouldbefree ofinflammationanddiverticulardiseaseandmustreachintothepelvis
withoutanytension. Theremainingmesocolonisdivided.
Thecolonshouldbetransectedattheproximalsitewithcaretoavoid spillageintheunderlyingwoundedgebyusingawoundprotectoror
disposabletowels. Thespecimenisremovedandsentforpathologicanalysis.
Ontheopenproximalendoftheanastomosis,apursestringsuture shouldbesewninarunningfashion.Alternatively,priortotransection,
apursestringclampisplacedontheintactcolonandthecolonis dividedimmediatelydistaltotheclamp.Anonabsorbablemonofilament suturesuchasa2-0Proleneonastraightneedlecanbepassedthrough theclamptomorerapidlycreatethepursestringsuturetosecurethe anvil.
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Thecircularanvilofacircularcircularstaplerstaplerisintroducedinto theproximalbowelheadfirstandthepostissecuredintoplaceusingthe
pursestringsuture. Thereachoftheproximalcolonshouldagainbeverifiedtoensurea
tension-freeanastomosis. Theorientationofthecolonshouldbeconfirmedbyfollowingthecut
edgeofthemesenteryandtheantimesenterictinea. ThestapleristransanallyintroduceduntilthetopoftheEEAreachesthe
mostcephaladextentoftherectalstump. Underdirectvisionthespikeofthecircularstaplershouldbedeployed
adjacenttothestapleline(Fig.16-1).Theanvilshouldbeseatedonthe spikeandthestaplershouldbeclosedwithattentionnottoentrapany additionaltissueinthestaplelineincludingmesentery,epiploicfat,or posteriorvaginalwall(Fig.16-2).Oncefired,thestaplershouldbe partiallyopenedandremoved.
FIGURE16-1Schematicrepresentationofthe
distalrectalstumpwithend-to-endanastomosis staplerintroduced.Thisisusedforbothend-to-end andend-to-sideanastomoses.
FIGURE16-2Schematicrepresentationof
proximalcolonpreparedforend-to-endanastomosis andplacedinproximitytodistalrectalstumpreadyfor staplertobemated.
p.129
p.130
Side-to-EndAnastomosis
Theproximalmarginofanastomosisischosen.Thiscolonshouldbefree ofinflammationanddiverticulardiseaseandmustreachintothepelvis
withoutanytension. Theremainingmesocolonisdivided.
Thecolonshouldbetransectedattheproximalsitewithcaretoavoid spillageintheunderlyingwoundedgebyusingawoundprotectoror
disposabletowels. Thespecimenisremovedandsentforpathologicanalysis.
Thecircularanvilofa28–33mmcircularstaplerstaplershouldbe introducedintotheproximalcolon,leadingwiththepost,andshould
exitthecolonontheantimesentericborder4–6cmfromthecutedgeof
thecolon.Thisendshouldbeclosedusingalinearstapler. Apursestringsutureofa3-0monofilamentsutureshouldbesewn
aroundtheposttoprovideabuttress. Thereachoftheproximalcolonshouldbecheckedoncemoretomake
suretheanastomosisonceconstructedwillbecompletelyfreeoftension. Theorientationofthecolonshouldbeconfirmedbyfollowingthecut
edgeofthemesenteryandtheantimesenterictinea. Thestapleristransanallyintroduceduntilthetopofthecircularstapler
reachesthemostcephaladextentoftherectalstump. Underdirectvisionthetrocarofthecircularstaplershouldbedeployed
adjacenttothestapleline(Fig.16-1).Theanvilshouldbeseatedonthe spikeandthestaplershouldbeclosedwithattentionnottoentrapany additionaltissueinthestaplelineincludingmesentery,epiploicfat,or posteriorvaginalwall(Fig.16-3).Oncefired,thestaplershouldbe partiallyopenedandremoved.
FIGURE16-3Schematicoftheendsofbowel
whentheend-to-endanastomosisstaplerismatedin
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