Specimen Extraction for Very Low Tumors and Handsewn Coloanal Anastomosis
KEY STEPS
1. Intersphincteric dissection is completed from below.
2. Specimen extracted transanally or through ostomy site.
3. Handsewn coloanal anastomosis.
ADDITIONAL ADVICE
1. Dissection is performed from below in prone or lithotomy position. Prone position is sometimes used initially for tumors within 1 cm of the dentate line.
2. Once an adequate amount is mobilized, the distal rectum is closed with 3/0 polyglycolic acid before completing the remaining dissection.
3. Dissection joins the abdominal dissection.
4. Most specimens can be removed through the anus, transected, and anastomosed.
5. In more obese patients, the specimen may not fit through the anal sphincters and is removed through the ostomy site. The bowel is then transected with a TA stapler, and reinserted in the abdomen, and drawn down to the anal canal for anastomosis.
PROCEDURE
At this point, adequate reach of the proximal bowel into the pelvis has been assured, and the anastomosis is now going to be performed. For lesions within 1 to 2 cm of the dentate line, a transanal approach is used with the patient usually in lithotomy position. This is usually performed after the abdominal laparoscopic mobilization. The perineum is prepped and draped routinely and strapped apart. For lesions within 1 cm of the dentate line, particularly anterior lesions, the transanal dissection is performed at the start of the operation, and using a prone approach.
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