Laparoscopic Low Anterior Resection with Diverting Loop Ileostomy for Rectal Cancer with Conversion to Open Approach
Prabh R. Pannu, MD; David Berger, MD
Massachusetts General Hospital

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, the surgical steps of this procedure are demonstrated and insight is provided into intraoperative decisions.