1. Introduction

2. Access and Placement of Ports

a. Free and Elevate Omentum

b. Pull Transverse Colon Down and Enter Lesser Sac

c. Descending Colon and Splenic Flexion Mobilization

d. Clip and Divide Left Colic Artery

e. Finish Proximal Mobilization

f. Sigmoid Colon and Rectum Mobilization

g. Isolation and Division of IMA Pedicle

h. Continue Distal Mobilization

3. Colon Mobilization

4. Conversion to Open Approach

a. Marginal Artery Division

5. Proximal Bowel Division

6. Extension of Incision

a. Check Tumor Location with Colonoscope

7. Total Mesorectal Excision

8. Division of Rectum

9. Distal Side-to-End Anastomosis with EEA Stapler

10. Test Anastomosis

a. Prepare Loop Ileostomy Exit Site

b. Close Abdomen

c. Staple Port Incisions

d. Inject Local Anesthetic

e. Staple Midline Laparotomy Incision

f. Mature Loop Ileostomy

11. Closure

12. Post-op Remarks

Laparoscopic low anterior resection (LAR) is a complex surgical procedure used for resecting the distal sigmoid colon or rectum while preserving sphincter function. The patient is a 37-year-old, obese male with rectal cancer. Abdominal access is gained through four laparoscopic port sites. The omentum is freed from the transverse colon to enter the lesser sac. The splenic flexure and descending colon are mobilized from the retroperitoneum. The left colic artery is identified and divided. Following proximal mobilization, the dissection is carried towards the pelvis. The sigmoid colon is mobilized, and the presacral space is entered. The inferior mesenteric artery is divided between clips. The dissection in this case could not be carried down low enough in a laparoscopic fashion, and a lower midline incision was made. A suitable area on the descending colon is identified and the marginal artery divided. The proximal bowel is then divided with a stapler. A flexible colonoscope is then used to confirm tumor location and the rectum is divided below the tumor. Finally, a Baker type side-to-end anastomosis is performed with a powered EEA stapler, and its integrity verified endoscopically under water. A diverting loop ileostomy is then created at a previously marked site and the abdomen closed. In this video, we demonstrate the surgical steps of this procedure and provide insight into our intraoperative decisions.

Watch this full-length, narrated surgical video of a laparoscopic converted to open low anterior resection for rectal cancer with a diverting loop ileostomy.

Massachusetts General Hospital