There are many potential benefits to the laparoscopically of performing rectal surgery. Recent meta-analysis of studies of nonrandomized trials comparing laparoscopic versus open surgery showed the usual benefits associated with laparoscopy after laparoscopic rectal surgery for cancer: shorter time to bowel function and shorter length of stay (1). In addition, compared to open surgery, laparoscopy can provide unprecedented, unobstructed views of the rectal dissection planes even in a patient with narrow pelvis, not only for the surgeon but also to the entire surgical team. Despite these potential advantages, application of laparoscopic techniques during rectal dissection has been limited partially because of technical challenges in providing adequate exposure, retraction of the bulky rectal specimen, and laparoscopic distal rectal stapling.

In order to retain some of the benefits of laparoscopic surgery while not compromising oncologic rectal dissection, some surgeons have advocated performing hybrid procedures in which colonic portion of the surgery is performed using the “pure” laparoscopic technique and rectal dissection is performed open through a limited low midline or Pfannenstiel incision (2). Alternatively, hand-assisted laparoscopic techniques can be used for rectal cancer surgery. In comparison to hybrid procedure where the incision is not created until the end of the procedure, the hand-assisted technique utilizes the incision from the very beginning of the procedure by placing the hand into the abdomen by using an access device. As shown in several studies, hand-assisted compared to “straight” technique may result in shorter operative time based on colonic portion of the operation alone (3,4).

In hand-assisted laparoscopic rectal surgery, rectal exposure and dissection can be either directly performed through the incision using the open techniques or laparoscopically undertaken. Because open rectal dissection technique has been well described in other sections, it will not be reviewed in detail in this chapter. During hand-assisted laparoscopic rectal dissection, the surgeon’s hand can be utilized to retract and expose the rectal tissue planes during laparoscopic dissection. However, in patients with narrow pelvis, the hand can sometimes get in the way of dissection by obscuring laparoscopic view. Ergonomically it can be extremely awkward to use the hand to retract the rectum for long periods of time.

We previously described a novel method of laparoscopically exposing the rectal dissection planes by using a Gelport® device and exteriorizing the colorectal stump (5).
In this technique, the end of divided sigmoid colon stump is exteriorized through a Gelport® device. The property of the device maintains pneumoperitoneum during the procedure. A gentle traction on the rectal stump creates tension and exposure for posterior and lateral rectal dissection. This simple traction maneuver can be easily accomplished by even a less experienced member of the surgical team. In addition, by using this technique, distal rectal stapling can be performed using an open approach directly through the incision. This may allow us to take advantage of unmatched laparoscopic view while performing oncologically equivalent exposure and dissection techniques as in the open surgery. By performing distal rectal division directly through the incision using the open surgical staplers, hand-assisted laparoscopic rectal surgery may result in lower anastomotic leakage rate. In this section, laparoscopic rectal dissection using this technique will be described in detail.