Low Anterior Bowel Resection

Clinical Scenario
 A 65-year-old obese male, former college biology professor,
presents with 30 pound weight loss, fatigue, with inconstant
occult bleeding and diarrhea of 4 months duration. He
denies having any pain or tenesmus before, during or after
urination and defecation. Patient’s 45-year-old sibling
suffered from ulcerative colitis. Physical examination was
unremarkable except for a guaiac positive stool.
Differential Diagnosis
 Colorectal carcinoma
 Diverticulosis
 Familial Adenomatous Polyposis (FAP) syndrome
 Neoplastic polyps like tubular adenoma, villous adenoma
 Hyperplastic non-neoplastic polyps
Required Tests
 Complete Blood Count (CBC)
 Flexible Sigmoidoscopy
 Colonoscopy
 Carcinoembryonic Antigen (CEA) test
 Immunochemical Fecal occult blood test (iFOBT)
 Digital rectal examination
 Fecal DNA test
 Double contrast barium enema and X-ray films
Test Results
 Hematocrit 30%, hemoglobin 9.8 gm/dl.
 Chest X-ray was unremarkable.
 Sigmoidoscopy revealed a lesion 20 cm above the anus.
 CEA positive.
 Further evaluation shows no evidence of lymph node
involvement or distant metastases.
Differential Diagnosis
 Colorectal carcinoma
 Diverticulosis
 Familial Adenomatous Polyposis
 Tubular adenomas
 Hyperplastic polyps
Colorectal Cancer Characteristics
 3rd most common cancer and cause for cancer death in both males
and females in the United States
 Highest incidence in high socioeconomic populations
 Etiology: dietary, hereditary, colorectal adenomas, ulcerative colitis
 Peaks in the 7th decade and localized mostly in the rectosigmoid
 Left side lesion: gross blood in stools, obstructive symptoms,
encircling lesion
 Right side lesion: iron deficiency anemia, weakness, weight loss,
right lower quadrant pain. Large sessile lesion
 Positive CEA is a reliable indicator of recurrent tumor
 Surgery procedure: Low Anterior bowel Resection (LAR).
- Removing the diseased portion of the colon and rectum
- En-bloc resection of mesentery and lymph nodes to
reduce local recurrence
- Anastomosing the remaining parts to create a functioning
 Technique: Hand-Assisted Laparoscopic Surgery (HALS)
 Chemotherapy and/or Radiation
- Adjuvant therapy
Patient and OR team position in
 Patient is placed in a supine, 30 revered trendelenburg position and both
legs are kept straight and slightly open to allow passage of the circular
EEA stapler.
 The arm and hand of the left site of the planned resection are tugged by
the patient's side.
 The surgeon initially stand on the left side of the patient for the
sigmoidectomy and on the right side of the patient for the anterior
resection and anastomosis.
 The surgeon assistant stands on the right side of the surgeon on either
side of the patient.
 The scrub nurse and instrument table is positioned at the left lower
extremity of the patient.
 Monitors are placed on both sides of the patient at the level of their
OR Set-up
Surgical equipments
Electronic CO2 laproflattor
Laparoscopic suction irrigation machine
Nasogastric tube and urinary catheter
5 mm and 10 mm trocars and cannula
Gelport hand-access device
30- degree digital laparoscope connected to a fiber-optic cable machine
Maryland dissector
Harmonic scalpel
Endo GIA universal stapling system.
Electrosurgical knife
EEA stapler
Bowel grasper, scissors, rainer and spreader
Incisions and trocar
 Midline umbilical incision (6-7 cm long) for placement of the
Gelport hand-access device. Port is also used to insufflate the
abdomen to 8 mmHg with CO2.
 Two 5 mm trocars were inserted on the left and right upper
quadrant – used for non-traumatic bowel grasping, dissection and
electrosurgical devices.
 A 10 mm trocar was placed infraumbilically – used for the digital
 A12 mm trocar were placed on the right-lower quadrant – used for
dissection, electrosurgical, clipping and stapling devices.
Port Placement
Surgical Procedure
The dissection starts by medial to lateral dissection using the scissors, grasper and knife after pedicle ligation.
The rectosigmoid and descending colon are mobilized by transecting the splenocolic ligament and the left
colic branch of the inferior mesenteric artery with an electrosurgical cutter while preserving most of the
mesentery to supply the anastomosis with the rectum.
The colon is transected, with a GIA stapler, distal to the lesion at the planned site for the anastomosis
The tumor –bearing segment is exteriorized through the hand Gelport site after application of a wound
protector device and remove of the Gelport hand-access device.
The diseased segment (colon and rectum) is resected extracorporeally with a GIA stapler
The side of the stapler is secured with a purse-string around the distal colonic end, which is returned into the
The pneumoperitoneum is then established and the bowel end-to-end continuity is restored using a EEA
stapling device through adequately irrigated rectal stump.
All left-sided colonic and rectal anastomosis were carried out intracorporeally
All left-sided anastomosis were tested for proper integrity. A drain was placed selectively if indicated and
wounds were then closed in layers
Post-operative care
 Patient allowed sips of water orally on the evening of
the operation
 Free oral fluids are allowed on the first day, soft diet on
the second day, and full diet and discharge on the thrid
Complications of HALS
 Wound infections
 Anastomotic breakdown leading to abscess or fistula formation and/or
 Bleeding with or without hematoma formation
 Ischemic stricture, could be due to the stretch on the proximal colon
during the extracorporeal anastomosis
 Incisional hernias at port site, from the continuous and persistent stretch
or dehiscence (bursting of wound)
 Postoperative ileus
 Intraabdominal adhesions with minimal future risk of small bowel
Benefits of HALS
Restored tactile feedback
Improves hand-eye coordination and allows safe finger dissection and retraction.
Reduces hospital stays and rate of infections
A mini-laparotomy hand Port incision.
Reduced conversion rate in total laparoscopy.
Enhanced safety and efficiency allowing the completion of the operation with a
hand inside.
Maintenance of the intra-abdominal pressure to facilitate the better view and
magnification of laparoscopic telescope.
Improving the steep learning curve for inexperienced general surgeons.
Promising reduced cost-benefit ratio
Limitations of HALS
 Fatigue of the surgeon since surgery last 4 hours on average
 Possible impaired tactile feedback through a lengthy
complex procedure and
 Minor ergonomic restriction due to the crowdedness of the
hand with the instruments.
 Not wells accepted by patient and surgeons because there is
already a mini laparotomy.
 Cosmetically inferior than total laparoscopic surgery.
 Vargas HD. Video on Low Anterior Bowel Resection using handassisted laparoscopic surgical technique. Department of Surgery,
University of Kentucky.
 Ringley C, Lee YK, Igbal A, Bocharev V, Sasson A, McBride CL et
all. Comparision of conventional laparoscopic and hand-assisted
oncologic segmental colonic resection. Surg Endosc 2007; 21:2137-41
 Meshikhes AN, Tair ME, Ghazal TA. Hand-assisted laparoscopic
Colorectal Surgery: Initial Experience of a Single Surgeon. SJG 2011;
 Cima R, Pemberton J. how a hand-assist can help in lap colectomy.
Cont. Surg 2007; 63;1:19-23
 Loungnarath R, Fleshman JW. Hand-assisted laparoscopic colectomy
techniques Semin. Laparoscop Surg 2003; 10;4:219-230
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