Fueled by a greater understanding of pelvic physiology along with an improved comprehension of rectal cancer spread, we are now able to offer most patients restoration of intestinal continuity following oncologic proctectomy. Coloanal or ultralow colorectal anastomosis can be performed in most patients with midrectal cancers, provided that anal sphincter function is not impaired preoperatively. Functional results may be improved by construction of a colonic pouch with pouch-anal anastomosis. Temporary fecal diversion, usually with a diverting loop ileostomy, may be prudent, especially in patients undergoing neoadjuvant chemoradiation.
Mobilization of the left colon. A, Line of incision in the avascular fusion plane between the left colon mesentery and retroperitoneum. B, Left colon reflected medially, exposing retroperitoneum. C, Inferior mesenteric artery divided close to aorta. The arcade of Riolan is preserved and the left colon and its mesentery are divided at the junction of the descending and sigmoid colon. D, Proximal ligation of inferior mesenteric vein for extra mobility.
Pelvic dissection. A, Incision of peritoneum at lateral borders of the mesorectum, just medial to the ureters. B, The areolar tissue plane posterior to the mesorectum is dissected sharply. C, The posterior aspect of the mesorectum appears as a bilobed structure when viewed from above, enclosed in a glistening fascial envelope. D, Anterior peritoneal incision. E, Division of lateral stalks.
Division of distal rectum using linear stapler distally and occlusive clamp proximally.
Colonic J-pouch construction and pouch-anal anastomosis. A, The colon is folded in a J configuration and the stapler is passed through the apex of the pouch. B, The anvil of the stapler is secured at the apex of the pouch with a purse-string suture and the stapler passed through the anus. C, Completed anastomosis.
Completed anastomosis with temporary diverting loop ileostomy.
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