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Lar Procedure
Lar Procedure
Lar Procedure
Laparoscopic low anterior resection (LAR) is used for removal of rectal cancer and
benign diseases with the intent of removing the rectum and restoring the continuity of
the bowel with an anastomosis in the pelvis. The LAR has been a standard of care for
high and mid rectal cancer for many years and, with certain modifications, is now
available to individuals with low rectal cancer. This chapter deals with the routine
removal of the rectum and its mesentery and the reconstruction of continuity within the
pelvis above the anal canal.
PREOPERATIVE PREPARATION
Individuals with rectal cancer, diverticulitis, endometriosis, or other less common tumors
will require preoperative imaging with computed tomography (CT) scan or transrectal
ultrasound to stage the disease and help plan the procedure. In many instances,
patients with rectal cancer will require neoadjuvant chemoradiation, which adds another
level of complexity to the procedure and will sometimes influence the surgeon to protect
the pelvic anastomosis with a temporary diverting loop ileostomy.
The patient is maintained on bowel rest after midnight before the operation. Broad-
spectrum IV antibiotics with coverage of gram-negative aerobes and anaerobes and
gram-positive anaerobes are administered prior to incision. Patients are also given
subcutaneous low-molecular-weight heparin preoperatively.
ANESTHESIA
General anesthesia with endotracheal intubation is necessary for this operation to
provide complete neuromuscular blockade. The patient is supplemented with narcotic
analgesia during the anesthetic portion of the procedure to allow a smooth transition to
the awakened state. Occasionally, the patient may benefit from an epidural analgesic
supplement because of severe chronic obstructive pulmonary disease (COPD).
Ketorolac is a reasonable supplement to the narcotic analgesia provided after surgery, if
the field is very dry and there is no contraindication to this medication.
POSITION
Laparoscopic LAR is performed in the lithotomy position using Allen stirrups to position
the patient (Figure 1). Sequential compression devices are placed on the calves at the
time of entering the room before anesthesia induction. A beanbag is very helpful to fix
the patient in position because gravity will be used for retraction. The patient will be
tilted back and forth from right to left and placed in steep Trendelenburg and even in
reverse Trendelenburg positions at times. The beanbag is curled up around the sides
and shoulders of the patient, and a tape is placed across the chest ...