Low Anterior Resection

The patient is a [age]-year-old [male/female] with [upper/mid/low] rectal cancer located [___] cm from the anal verge on preoperative staging, with [cT_N_M_ staging]. [Neoadjuvant chemoradiation was/was not completed]. The patient presents for laparoscopic low anterior resection with total mesorectal excision. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.

The rectal tumor was located [___] cm from the anal verge. The mesorectum was [intact/previously irradiated]. The pelvic sidewalls were [free/with adherent tissue]. The left ureter was identified and preserved. The neurovascular bundles were [preserved bilaterally / sacrificed on the [right/left] side given tumor involvement]. No [peritoneal / hepatic / omental] metastases were identified. [Additional findings or none].

The patient was brought to the operating room and placed in modified lithotomy (Lloyd-Davies) position. General endotracheal anesthesia was induced. Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.

The abdomen was prepped and draped in sterile fashion, including the perineum. Pneumoperitoneum was established to 15 mmHg via [Veress needle / optical trocar / Hasson open technique]. A 12-mm umbilical trocar was placed. Four additional trocars were placed: 12-mm right lower quadrant, 5-mm right upper quadrant, 5-mm left upper quadrant, 5-mm suprapubic. The patient was positioned in steep Trendelenburg with left lateral tilt.

Abdominal exploration confirmed no metastatic disease. The sigmoid colon was mobilized and the left colon was fully mobilized with splenic flexure takedown. The left ureter was identified and swept posterolaterally throughout. The IMA was ligated with [hem-o-lok clips] at its origin with high ligation, and the IMV was divided at the inferior border of the pancreas.

Total mesorectal excision was performed in the embryologic avascular holy plane between the mesorectal fascia and the parietal fascia of the pelvis. The dissection proceeded anteriorly behind Denonvilliers' fascia, posteriorly in the presacral space, and laterally preserving the hypogastric nerves and pelvic neurovascular bundles bilaterally. The mesorectum was divided sharply under direct vision [___] cm distal to the inferior tumor margin, maintaining an intact mesorectal envelope.

The rectum was divided [___] cm distal to the inferior tumor edge using a laparoscopic [roticulating] TA stapler, requiring [1/2/3] firings. The specimen was extracted through a Pfannenstiel extraction incision with a wound protector.

An end-to-end colorectal anastomosis was constructed using a [EEA 28/29/31 mm circular stapler] introduced transanally. The anvil was secured in the proximal colon with a [2-0 Prolene] purse-string. The anastomosis was completed, confirmed to be [___] cm from the anal verge. Donuts were confirmed complete. Air insufflation with pelvic saline immersion test revealed [no air leak / air leak that was oversewn].

Given [low anastomosis / prior radiation / anastomotic tension / leak test concern], a diverting loop ileostomy was created through the right lower quadrant trephine site. The terminal ileum was brought up and matured with the proximal efferent limb everted.

The abdomen was irrigated. Hemostasis confirmed. The Pfannenstiel fascia was closed with [0-PDS]. Port site fascias were closed. Skin closed with [4-0 Monocryl]. Ostomy appliance placed.