Most low anterior resections are performed for rectal carcinoma. A standard preoperative evaluation is performed by most surgeons. Other indications include large rectal polyps not amenable to endoscopic or transanal approaches, completion proctectomies for inflammatory bowel disease, and redo pelvic operations for prior failed anastomoses.

Regardless of indications, certain preoperative considerations are necessary for all patients and conditions. Because the rectal reservoir will be removed completely or in part, the status of the anal sphincters is important. This issue can be addressed by preoperatively questioning the patient regarding bowel function and continence and assessing sphincter tone by digital rectal examination and by anal manometry.

Rectal reservoir replacement should be considered and discussed with the patient. Postoperative function can be improved by the addition of a colonic J-pouch. Otherwise, use a side-to-end anastomosis
in patients with less than 5 cm of rectum remaining after low anterior reaction. The major impact on function is seen in the first 2 years after the operation.

At or below 4 cm, the colorectal anastomotic leak rate is as high as 16-25% and a diverting ileostomy should be discussed and an enterostomal therapy consult and informed consent obtained.

If the patient has a rectal cancer, preoperative local staging, with a high-resolution, small-field pelvic magnetic resonance imaging is recommended. Local staging with endorectal ultrasound is still acceptable. Preoperative considerations for neoadjuvant chemoradiotherapy should be based on National Comprehensive Cancer Network guidelines. Presentation before a multidisciplinary tumor board as noted in the Standards Manual of the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer should be undertaken. Staging for metastatic disease with carcinoembryonic antigen blood testing and a computed tomography scan of the chest, abdomen, and pelvis should also be utilized in all patients.

Prior pelvic surgery, remote use of radiation therapy, a large mass overlying a ureter, or involvement of other pelvic structures should lead one to consider cystoscopy and ureteral stent placement in an effort to reduce and identify ureteral injuries.

Thorough discussion and informed consent regarding cancer-specific outcomes, functional outcomes, sexual and urinary function following surgery, adjuvant therapy, and other complications should be held at the time of informed consent.

Preoperative preparation includes full oral antibiotic and mechanical bowel preparation, prophylactic intravenous antibiotics, deep vein thrombosis prophylaxis with standard unfractionated heparin, and pneumatic antiembolism stockings. Positioning, padding, and operative preparation are the same in hand-assisted surgery as with multiport laparoscopy. Patients are positioned in lithotomy position on the operating room table using Allen (Allen Medical Systems, Inc. Acton, MA) or Yellowfin (Allen Medical Systems, Inc. Acton, MA) stirrups. Both arms are tuned on foam pads. The chest is padded with foam pads and then secured to the bed using 3-inch silk tape. An orogastric tube and a urinary catheter are placed. The rectum is irrigated at the beginning of the case with saline and then with Betadine solution. Transverse abdominis plane blocks are used selectively in addition to an aggressive preoperative and postoperative enhanced recovery after surgery (ERAS) protocol.

If the patient has had prior abdominal surgery, initial peritoneal access is achieved, depending on the type(s) of prior abdominal incisions. Diagnostic laparoscopy is performed looking for evidence of carcinomatosis, ascites, or liver metastases. Additional ports are placed. A lower midline incision is made to accommodate the hand-assist device. The incision for the device needs to be 0.5 cm larger than the glove size of the surgeon whose hand will be placed in the device.

In patients who have not had prior surgery, the band access incision is made as the first step of the procedure. Once the wound component of the Gelport (Applied Medical, Rancho Santa Margarita, CA) is placed, a 10-/12-mm camera port is placed under hand-directed control in the infra- or supraumbilical position. Making a fist under the site of trocar placement, the trocar can be safely placed with the trocar tip entering the top of the closed fist. The cap is then placed and uniform pneumoperitoneum to 15 mm Hg achieved. A 30-degree 10-mm scope, 5-mm scope, or flexible tip scopes can be used alternatively. Next, accessory trocars are placed. Three other ports, two 5-mm ports in the right and left lower quadrants and a 5-mm Airseal port (Conmed, Utica, NY) in the right upper quadrant (Fig. 18-1), are used. The Airseal port allows for excellent smoke and plume evacuation with a very steady and stable pneumoperitoneum. If needed, further 5-mm accessory ports can be placed for added retraction, but this is rarely utilized.