Mobilizing the Mesorectum

Mobilization of the mesorectum is performed in low anterior resection, abdominoperineal resection, and total proctocolectomy cases.

KEY STEPS

1. Insertion of ports: 10-mm umbilical Hasson technique; 12 mm at right iliac fossa; 5-mm right upper quadrant; 5-mm left iliac fossa.

2. Patient rotated to the right and steep Trendelenburg position.

3. Greater omentum reflected over the transverse colon and the small bowel moved to the right upper quadrant.

4. Dissection behind the rectum down the presacral space.

5. Division of peritoneal attachments on the right and left sides of the rectum, and anterior mobilization beginning at the peritoneal reflection.

6. Rectum mobilized to the anal canal at the pelvic floor and divided, after ensuring adequate distal margin.

ADDITIONAL ADVICE

1. Commence the mesorectal dissection posteriorly, using firm anterior and superior retraction of the rectosigmoid to place the loose areolar tissue under tension and facilitate dissection.

2. Firmly pulling the mesentery superiorly, and medially away from the lateral pelvic sidewall, facilitates the lateral dissection.

3. The anterior dissection is commenced 1 or 2 mm anterior to the apex of the Pouch of Douglas. This enters the correct anatomical plane, keeping the anterior mesorectal fascia intact.

4. Dissection is completed within the anal canal, after seeing the levators curve down into the anal canal, and after confirming an adequate distal margin by digital rectal examination, or endoscopy.

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