The hybrid low anterior resection (LAR), as originally described, is an operation in which the first part of the procedure (left colon and splenic flexure mobilization) is laparoscopically performed and the second part (pelvic dissection) is accomplished using open methods via a Pfannenstiel or lower midline incision. The hybrid approach to sphincter-saving rectal resections was first introduced a decade ago when limited data were available regarding the oncologic outcomes of a laparoscopic approach to colon and rectal cancer cases. The originators of the hybrid method, convinced of the benefits of laparoscopy, sought means of utilizing laparoscopic techniques to significantly decrease overall incision length and physiologic impact, while permitting an open total mesorectal excision (TME) until data was published regarding the oncologic outcomes with laparoscopy. When the results from the Clinical Outcomes of Surgery Therapy (COST), Conventional versus Laparoscopic-Assisted Surgery In patients with Colorectal Cancer (CLASSIC), and COlorectal cancer Laparoscopic or Open Resection (COLOR) trials were published stating that laparoscopic surgery was equivalent to open surgery for colon cancer, several surgeons moved away from the hybrid approach toward a complete laparoscopic technique for both colon and rectal cancer cases.

The hybrid approach, as described in the following text, allows for an open TME while minimizing incision length with a laparoscopic splenic flexure mobilization. In the authors’ view, limiting the incision related to flexure mobilization still provides significant benefit to the patient in terms of cosmetic outcome, decreased recovery time, and decreased narcotic use, all of which advocate for the use of this hybrid approach.

Planning before any pelvic operation should include physical examination, tissue diagnosis, local and systemic staging, and review of any prior imaging and operative reports. If imaging is not recent or adequate, it should be repeated during the preoperative evaluation. Patients should have had a computed tomography scan of the chest, abdomen and pelvis for systemic staging, and a magnetic resonance imaging of the rectum for local staging. Pathology slides should be obtained for review and confirmation by a local pathologist if there is any question of an accurate diagnosis. At the time of the outpatient visit, digital rectal examination should be performed on all patients, regardless of dictated location of the cancer on endoscopy or imaging reports. If unable to feel the lesion in its entirety, we perform a flexible sigmoidoscopy in the office to note the location and size of the tumor. If not already performed, completion colonoscopy should be performed to ensure there are no synchronous lesions.

Because the risk of anastomotic leak for low-to-mid rectal cancer approaches 15%, most patients will be diverted, especially in the setting of preoperative radiation. Therefore, patients should have a clear understanding as to the likelihood of a stoma, and meet with an enterostomal therapist for counseling and marking before their operation. In addition, the risk of converting to an open operation requiring a larger midline incision should be discussed.

The patient is placed in the modified lithotomy position with both arms tucked to the side and a bladder catheter is placed. Standard anesthesia monitoring, perioperative antibiotics, and subcutaneous heparin are administered. A four-port arrangement is utilized by the authors so that both the surgeon and the first assistant have ports available to them. A 5- or 10-mm camera port is placed just caudad to the umbilicus. In the lower part of the right lower quadrant, a 12-mm port (to allow for intracorporeal stapling) is placed at the site of the diverting ileostomy marking. Two additional 5-mm ports are placed; one is in the suprapubic position in the midline and the other in the left lower quadrant (Fig. 19-1).

The splenic flexure is mobilized first because if this portion is not amenable to laparoscopic methods, early conversion can be initiated. There are four basic approaches to flexure takedown: (a) lateral to medial, (b) medial to lateral, starting just caudal to the sacral promontory on the right side of the sigmoid mesentery, (c) medial to lateral, starting at the level of the inferior mesenteric vein (IMV), and (d) starting with the omental “peel” at the level of the distal transverse colon (seldom used). Regardless of the approach that is utilized, the flexure, the descending and distal transverse colon, as well as the mesentery must be fully mobilized (Fig. 19-2).