25

Low Anterior Resection

Charles M. Friel, MD

INTRODUCTION ● Severe pelvic infection/inflammation causing stricture

(e.g., radiation injury, pelvic inflammatory disease,
Surgical resection of all or part of the rectum with a rectal perforation, previous anastomotic leak)
primary anastomosis is referred to as a low anterior resec- ● Severe endometriosis
tion. This procedure is most commonly performed for ● Upper rectal vaginal fistulas
rectal cancer. However, on occasion, the rectum is ● Other malignancies (e.g., ovarian cancer, retrorectal
removed for a variety of other benign and malignant con- tumors, rectal sarcomas)
ditions. When done for mid and low rectal cancers, the
operation includes a total mesorectal excision1,2 with an
anastomosis at the level of the pelvic floor. For upper OPERATIVE STEPS
rectal cancers, a partial mesorectal excision with a 5-cm
distal and mesorectal margin is probably adequate.3 In this Step 1 Positioning and incision
circumstance, the anastomosis is usually done in the Step 2 Mobilization of sigmoid and left colon
midrectum. When done for cancer, obtaining a negative Step 3 Takedown of splenic flexure
circumferential margin is critical to decrease the likelihood Step 4 Ligation of vasculature
of local recurrence.4,5 Therefore, the dissection must stay Step 5 Rectal mobilization
outside the fascia propria and closer to the pelvic sidewall. Step 6 Anastomosis
This may increase the likelihood of complications, includ-
ing bleeding and autonomic nerve injury. For benign
OPERATIVE PROCEDURE
disease, there is no circumferential margin, so violation of
the fascia propria has no significant implications. There-
Patient Positioning
fore, in benign disease, it is probably better to veer the
dissection closer to the rectum to decrease the probability Patients are placed in a modified lithotomy position to
of these other complications. For the purpose of this dis- perform a low anterior resection. This allows access to the
cussion, it is assumed that the indication for surgery is perineum for a stapled anastomosis. The patient’s arms are
cancer and the technical points will stress adequate onco- usually extended to allow access for the anesthesiologist.
logic technique. These principles are generally applicable In addition, a self-retaining retractor is quite helpful for
to benign conditions as well. However, on occasion, there exposure. Proper positioning of the patient and the retrac-
are differences in patients with benign disease, and this is tor is critical to prevent iatrogenic nerve injuries.
noted in the text.
Peripheral Nerve Injuries
INDICATIONS ● Consequence
Clearly, the consequences of this complication depend
This is a partial list of surgical indications for a low ante- on the severity of the injury. Most peripheral nerve
rior resection. These procedures involve rectal resection injuries occur from prolonged compression or stretch.
and a primary colorectal anastomosis. Often, this is just neuropraxis and will resolve com-
The most common indication is pletely with time. Less commonly, permanent injury
can result that will leave a permanent disability.
● Upper, mid, and low rectal cancer
Grade 1 complication (if resolves); grade 4 (if
Other indications include permanent)
● Large polyp not amenable to other techniques (e.g., ● Repair
endoscopy, transanal, transmission electron microscopy Generally, there is no operative repair for patients with
[TEM]) peripheral nerve injury from compression or stretch.
 274 SECTION III: GASTROINTESTINAL SURGERY
Figure 25–1 Self-retaining retractor. To prevent femoral nerve
injury, great care must be used when placing retractor blades
(marked with an X) in the inguinal region.
Treatment is just supportive, which would include
physical and occupational therapy.
● Prevention
Careful patient positioning is key to prevent injuries.6
Well-padded stirrups are necessary. The patient’s heel
should be placed firmly in the foot of the stirrup so that
the weight of the leg is supported by the patient’s heel.
It is also helpful to tilt the stirrup posteriorly to prevent
pressure from being applied to the posterior and lateral
aspects of the lower extremity, which will aid in pre-
venting common peroneal nerve injury. This area can
be further padded if necessary. To prevent brachial
plexus injuries, the patient’s arms should rest easily and
should not be extended more than 90°.6 Furthermore,
nothing should be placed between the shoulder blades
that can stretch the brachial plexus by elevating the
chest. The anesthesiologist and operating staff should
also monitor the position of the arms because they may
shift during the procedure, particularly if the patient is
placed in Trendelenburg position to gain additional
exposure. Finally, to prevent femoral injuries, great care
must be taken when utilizing a self-retaining retractor.7
Retractors over the inguinal region should be used with
caution, especially in thin patients (Fig. 25–1). How-
ever, if necessary, use the most superficial retractor
available (e.g., the bladder blade) (Fig. 25–2) because
deeper retractors are more likely to compress the
femoral nerve, which runs just beneath the psoas
muscle. If the operation is prolonged, periodically
release and replace the retractors to limit the potential
for prolonged compression to an isolated spot. If a
perineal approach is necessary at any time, take care to
remove the abdominal wall retractors as well. This
injury is more common with a transverse incision,
which is being utilized more frequently as surgeons
adopt a laparoscopy-assisted approach to rectal surgery.
Figure 25–2 Examples of self-retaining retractors. Arrow identi-
fies the retractor with the least depth and, therefore, the least likely
to damage the femoral nerve.
Incision
Most low anterior resections can be accomplished through
a midline incision. Exposure is critical to safely complete
all portions of the procedure. To properly expose the
pelvis, the incision frequently needs to go all the way to
the pubis. This will allow the best visualization of the deep
pelvic structures. For most low anterior resections, com-
plete mobilization of the splenic flexure is also necessary.
Therefore, the upper extent of the incision is often well
above the umbilicus. In patients who are thin or have a
low splenic flexure, the incision may need to extend only
to the umbilical region. It is best to start with a lower
midline incision and then extend as necessary to gain the
required exposure.
Bladder Injury
Although rare, iatrogenic injuries to intra-abdominal
structures can occur while the abdomen is being opened.
Clearly, these injuries are more likely to occur in patients
who have had previous abdominal surgery. However,
when doing a low anterior resection, special consideration
should be given to the lower portion of the incision. While
extending to the pubis, an injury to the dome of the
bladder is possible and care must be taken to avoid this
problem.
● Consequence
Fortunately, an injury to the bladder while making an
incision is usually in the bladder dome. This is generally
readily apparent and can be promptly fixed. When this
is done, there are few long-term consequences, except
for prolonged catheterization. An unrecognized injury
will lead to an intra-abdominal urine leak and can result
in sepsis. Repair is also greatly complicated and will
require long-term bladder drainage.

Figure 25–3 Opening incision. To avoid bladder injury, incise the
anterior fascia all the way to the pubis, staying anterior to the
underlying muscle.
Grade 2 complication (if recognized); grade 3 com-
plication (if not recognized)
● Repair
The bladder dome is easily repaired and generally for-
giving. Closure of the defect is generally done in two
layers with an absorbable suture. Permanent suture is
avoided to prevent future calculi and granulomas. To
keep the bladder decompressed, a Foley catheter is
generally kept for approximately 7 to 10 days.8
● Prevention
When opening the abdomen, it is important to get all
the way to the pubis for proper pelvic exposure.
However, most of the benefit is from incising the ante-
rior fascia. The bladder will lie beneath the pyramidalis
and rectus muscles. Therefore, if the dissection is always
above these muscles, the bladder cannot be injured
(Fig. 25–3). Division of the posterior peritoneum is not
always necessary in this region because it is easily
retracted with a self-retaining retractor. If division of
this peritoneum is necessary, it can be done carefully
layer by layer to identify the bladder dome. Further-
more, the dissection of the peritoneum can veer a bit
off midline, which will help avoid the bladder dome.
Colon Mobilization and Ligation of
the Mesenteric Vessels
In order to perform a low anterior resection of the rectum,
the sigmoid colon must be fully mobilized. Furthermore,
in most instances, complete mobilization of the descend-
ing colon and splenic flexure is also required to perform
a tension-free anastomosis (see later). Most mishaps that
can occur during this portion of the procedure are similar
for any left-sided colonic operation and are well described
in Chapter 24 (Left Colectomy: Open and Laparoscopic).
These complications are briefly reviewed here.
25 LOW ANTERIOR RESECTION 275
Bleeding
● Consequence
If the proper planes are found and dissected properly,
bleeding from colonic mobilization should not be
significant. When bleeding is encountered, the surgeon
should question whether he or she is in the proper
plane and adjust accordingly. Most bleeding is easily
controlled without any significant sequelae. Some evi-
dence suggests that patients who get a blood transfu-
sion are more likely to have a cancer recurrence and/or
an infectious complication of surgery.9–11 Whether this
is due to the immunosuppression of the transfusion or
is just a marker for a difficult case has not been deter-
mined.12,13 Nevertheless, to prevent the unnecessary
risk of a blood transfusion, bleeding should be kept to
a minimum whenever possible.
Grade 1 complication
● Repair
Identification and ligation are all that is necessary for
proper control of bleeding. If necessary, the gonadal
vessels can be ligated once the ureter is clearly identi-
fied. Bleeding from the major vascular structures, such
as the aorta or iliac vessels, is unusual but can be
directly repaired after proper proximal and distal
control.
● Prevention
Proper identification of the avascular planes is necessary
to prevent unnecessary bleeding. The descending colon
and its mesentery lie just anterior to the retroperito-
neum and its associated structures. An areolar plane
exists between the mesocolon and the retroperitoneum
and, when dissected, allows the colon and the mesoco-
lon to be fully mobilized to the midline position. The
dissection is begun by dividing the lateral peritoneum
of the sigmoid and descending colon. Rapid identifica-
tion of the gonadal vessels can be quite helpful because
these vessels are the most anterior of the retroperitoneal
structures and should be swept posteriorly off the
colonic mesentery (Fig. 25–4). Care must be taken to
stay above the gonadal vessels because they are quite
fragile and will bleed with too much manipulation.
However, when this plane is properly identified, there
should be little bleeding; if this plane is followed, the
colon and the mesocolon should be lifted off the left
kidney to prevent inadvertent kidney mobilization. As
the gonadal vessels are swept posteriorly, the mesoco-
lon and, specifically, the inferior mesenteric vessels are
elevated to a midline position. The ureter, which passes
beneath the gonadal vessels, can be identified as it
crosses the iliac vessels. Once the gonadal vessels and
kidney have been swept posteriorly, the peritoneum on
the right-hand side should be divided just at the sacral
promontory and underneath the superior rectal artery.
This will allow entrance into the retrorectal space,
which is also avascular. This dissection should meet the
 276 SECTION III: GASTROINTESTINAL SURGERY
Figure 25–4 Dissection of the gonadal vessels off the mesentery
of the colon. This plane is avascular and will guide the surgeon
to the plane separating the colon and its mesentery from the
retroperitoneum.
B
previous dissection on the left-hand side and create a
window under the superior rectal artery (Fig. 25–5).
The superior rectal artery can then be further dissected
on the right-hand side all the way to the aorta, where
it is now the inferior mesenteric artery (IMA). If the
dissection on the left-hand side was done properly, the
gonadal vessels and ureter should be easily visualized
from the right-hand side underneath the IMA. An avas-
cular window can now be identified through the meso-
colon on the left-hand side of the IMA. The inferior
mesenteric vein (IMV) is just to the left of the IMA
and can be dissected out separately. Care should be
taken to identify the duodenum, which should be
located just superior to the IMA (Fig. 25–6). Once
these vessels are properly identified, they can be divided
and doubly ligated (Fig. 25–7). It is advisable to leave
a stump for the IMA in case vascular control is lost.
Reclamping and ligating the base of the IMA is con-
siderably easier than repairing a defect in the aorta.
Figure 25–5 Mesentery of rectosigmoid colon
from the right-hand side. A, Line shows the
approximate course of the superior rectal artery.
Shaded area represents avascular window poste-
rior to the superior rectal artery at the level of
sacral promontory. B, Avascular window is opened,
posterior to the superior rectal pedicle.

Figure 25–6 Position of the duodenum in rela-
tion to the pedicle of the inferior mesenteric
vessels. Yellow shows the approximate location of
the inferior mesenteric artery (IMA). Note that
the peritoneum to the left of the IMA has been
incised and the IMA is being lifted off the aorta by
the left dissecting hand.
A
B important to remember several principles. The ureter runs
Figure 25–7 Inferior mesenteric vessels are identified and
clamped (A) and then ligated (B). Forceps point to the ureter
and the retroperitoneum, which have been swept posteriorly (A).
Note the proximity of the ureter to the inferior mesenteric vessels
at the point of ligation (B).
25 LOW ANTERIOR RESECTION 277
Great care with the IMV is also critical because this
vessel is prone to retract underneath the pancreas,
which will make vascular control quite difficult once it
is lost. This describes a high ligation of the IMA and
IMV. From an oncologic perspective, this may not
be necessary,14 and division of the IMA and IMV
can be done together with a single clamp just distal to
the takeoff of the left colic artery. However, for a very
low anastomosis, division of these vessels is often
required to provide the necessary colonic length to do
a safe, tension-free anastomosis (see the section on
“Anastomosis”).
Ureteral Injury
An intra-abdominal injury to the ureter is possible when
the sigmoid and descending colon is mobilized. This is
fully described elsewhere in the text so it is only reviewed
here. Clearly, proper identification of the ureter is essential
to preventing injuries. The ureter is usually identified as
it crosses the iliac vessels but must be followed superiorly
and swept posteriorly to prevent injury when ligating the
IMA and IMV. It is important to remember that the
ureter lies beneath the gonadal vessels, so if the dissection
is above the gonadal vessels, the ureter should also be
posterior and out of harm’s way. Sometimes, the ureter is
difficult to clearly identify and is most often confused with
the gonadal vessels. Under these circumstances, it is
longitudinally through the retroperitoneum. It never
branches, as do blood vessels, and when manipulated, it
should show evidence of peristalsis (Fig. 25–8). If the
ureter cannot be identified secondary to inflammation or
tumor, the ureter should be identified higher in the
abdomen, where the anatomy may be more normal, and
followed distally. If it is anticipated that ureteral identifica-
 278 SECTION III: GASTROINTESTINAL SURGERY

Figure 25–8 Retroperitoneum after dissection

and removal of the rectum and associated lymphat-
ics. Note the direction of the ureter, which is
parallel to the aorta, compared with the gonadal
vessels, which veer laterally. Also note that the
ureter passes beneath the gonadal vessels.

tion will be difficult, placing ureteral stents preoperatively

can be quite helpful.
Grade 2 complication

Splenic Injury
When the splenic flexure is mobilized, the spleen can be
injured and cause troublesome bleeding.15 This complica-
tion is possible with any intra-abdominal colon operation
and is reviewed in detail elsewhere. Most splenic injuries
originate from omental attachments to the splenic capsule.
With downward retraction on the colon, these attach-
ments are torn off the splenic capsule, causing bleeding
from the injured spleen. Fortunately, these attachments
are unusual, but when identified, they need to be carefully
divided (Fig. 25–9). If the splenic flexure is torn, trouble- A
some bleeding will ensue. Most of the time, this bleeding
is well controlled with simple packing, but on occasion,
bleeding will persist. Although other maneuvers to con-
trol bleeding are available, the surgeon should not hesi-
tate to perform a splenectomy if the bleeding is not well
controlled.
Grade 1/2 complication

Rectal Mobilization
An understanding of rectal anatomy is critical to proper
rectal mobilization. The rectum is surrounded by a large
amount of fat containing the mesentery and lymphatics to
the rectum itself. This tissue is enveloped by a thin layer
of fascia, known as the fascia propria. An avascular plane
exists between the fascia propria and the presacral fascia, B
which is adherent to the periosteum of the sacrum. The Figure 25–9 Omental attachments to the spleen (A), which
retrorectal fascia, or Waldeyer’s fascia, is a thick layer of needs to be divided (B) to prevent injury to the spleen with down-
fascia connecting the presacral fascia to the fascia propria ward retraction of the colon.
of the rectum. Division of this fascia is necessary to mobi-
lize the distal rectum, and when divided, the rectum will
lift from the sacral hollow and begin a more anterior

approach. This greatly lengthens the rectum, especially
posteriorly. For this reason, a low-lying posterior tumor
may elevate significantly after division of the retrorectal
fascia, allowing for a low anterior resection. Anteriorly,
the rectum is more fixed and will not lengthen as much
with mobilization. Therefore, a low-lying anterior tumor
will more likely require an abdominal perineal resection
than would a posterior-based tumor at the same preop-
erative level.
Rectal mobilization begins by entering the retrorectal
space at the level of the sacral promontory (see Fig. 25–5).
Division of the peritoneum at this level will identify the
avascular plane between the mesorectum and the presacral
fascia. The peritoneum lateral to the rectum is then incised
toward the anterior cul-de-sac bilaterally. Finally, the ante-
rior peritoneum also needs to be divided, which will allow
entrance into the proper plane to mobilize the vagina in
a woman, or the seminal vesicles and prostate in a man.
Once the peritoneum is completely incised, the rectum is
further mobilized by dividing the areolar tissue that exists
between the fascia propria of the rectum and the fascia of
the pelvic sidewall, collectively referred to as the endopel-
vic fascia. This dissection is greatly facilitated by proper
deep pelvic retractors and anterior retraction of the rectum
(Fig. 25–10). This dissection should be continued poste-
riorly and in the midline as deep as possible (Fig. 25–11).
This will help identify the proper lateral plane, which
should continue just adjacent to the mesorectum. Finally,
the anterior plane needs to be developed, separating either
the vagina or the prostate from the rectum (Figs. 25–12
and 25–13). This is greatly facilitated by using a lipped
pelvic retractor and anterior traction on the vagina or
prostate while using the hand for posterior traction of the
rectum. Whereas this description implies that the poste-
rior, lateral, and anterior dissections are done sequentially,
in reality the surgeon needs to constantly adjust her or his
retractors to dissect the area that is currently best exposed
and continue this dissection circumferentially all the way
to the pelvic floor. When this is done properly, there
should be no mesorectum at the pelvic floor, thus com-
Figure 25–10 Deep pelvic retractors.
25 LOW ANTERIOR RESECTION 279
pleting a total mesorectal excision. Therefore, all that
should be left is the rectum itself as it enters the rectal
ampulla between the muscles of the pelvic floor. Division
of the rectum at this level can almost always be done with
one fire of a 30-mm transverse stapling device. Figure
25–14 shows the final appearance of the sacral hollow
after complete removal of the rectum and the associated
mesorectum.
Hemorrhage
Although uncommon, massive and life-threatening bleed-
ing can be encountered with rectal mobilization. This is
most commonly from the presacral plexus and can occur
when the presacral fascia is injured. Bleeding is venous in
nature and can be quite profuse. The bleeding source is
from either the veins just below the presacral fascia or the
basivertebral veins, which are within the sacrum itself.
The basivertebral veins, when injured, will retract within
the sacral foramen and can be extremely difficult to
control. Other sources of major pelvic bleeding include
the vessels of the pelvic sidewall, the most significant being
the internal iliac artery and vein.
● Consequence
Significant and even life-threatening bleeding can occur
from either the presacral plexus or the internal iliac
vessels. In general, significant venous bleeding is more
difficult to control, due partly to the poor exposure of
these venous structures and to the nature of their thin
walls, which can tear easily and cause more excessive
bleeding. Clearly, massive blood loss can be immedi-
ately life-threatening. But even if controlled, this
complication can lead to continued postoperative pro-
blems, including multisystem organ failure and delayed
death.
Grade 2 complication (if quickly controlled); grade
4 complication (if not controlled quickly)
● Repair
When profuse bleeding is initially encountered, direct
pressure is most appropriate. Because venous bleeding
is low, this pressure will quickly control the significant
blood loss. Prolonged pressure may in fact stop the
bleeding but will at least allow the anesthesiologist time
to get proper access and blood products available. To
the surgeon, the bleeding may only seem “brisk,” but
it is important to remember that blood loss of 100 ml/
min will result in a 1-L blood loss in only 10 minutes
and can quickly lead to patient instability. If the bleed-
ing appears to be coming from the presacral veins, no
attempt should be made to dissect this further, because
this generally results in more significant bleeding.
Suture ligation can be quite tempting but often further
disrupts the presacral fascia, potentially exposing the
sacral foramina and the basivertebral veins, resulting in
worsening bleeding.16 Direct pressure and utilization
of any variety of hemostatic products can be used
280 SECTION III: GASTROINTESTINAL SURGERY

Ureter

Figure 25–11 Posterior dissection. A, Pelvic

retractor provides anterior retraction on the
rectum. Yellow line shows the approximate plane
of dissection, dissecting the mesorectum from
the sacral hollow using either sharp dissection
or electrocautery. B, Retrorectal (Waldeyer’s)
fascia in the deep posterior midline. Rectum is
anteriorly retracted and not visible. Yellow line
shows the approximate plan of dissection, which
is done sharply or with electrocautery to minimize
B
bleeding.

Figure 25–12 Anterior dissection in a male.

Pelvic retractor provides anterior retraction on
the seminal vesicles and prostate while the hand is
pushing the rectum posteriorly, exposing the ante-
rior cul-de-sac. Straight arrow shows the point of
dissection. Denonvilliers’ fascia is the white tissue
just posterior to the line of dissection, denoted by
curved arrow.

A
B be ligated without significant sequelae. In these difficult
Figure 25–13 Anterior dissection in a woman with a previous
hysterectomy. A, Lateral peritoneum has already been incised.
Entrance to the rectovaginal septum is obtained by dividing the
peritoneum anteriorly, along the dotted line. B, Demonstration of
the rectal stump, after the rectum has been removed, shows the
posterior vaginal wall. The rest of the vagina is being retracted
anteriorly.
25 LOW ANTERIOR RESECTION 281
Figure 25–14 Sacral hollow after completion of low anterior
resection and simultaneous hysterectomy and oopherectomy,
shows complete removal of the sigmoid and rectal mesentery, the
position of the left ureter and preservation of the hypogastric
nerves.
effectively.16,17 If this is not successful, sterile titanium
thumbtacks can be used to directly compress the bleed-
ing vein16,18 (Fig. 25–15). As a last resort, the pelvis can
be packed and the patient taken to the intensive care
unit for 24 to 48 hours. The patient is then taken back
to the operating room and the packs removed. By that
time, the bleeding has usually stopped and the opera-
tion can be completed.
Bleeding from the internal iliac vessels is also uncom-
mon. It is most likely encountered with a large tumor
adherent to the vessels or with significant pelvic scarring
from previous infection or radiation. For venous bleeding,
proximal and distal control is best accomplished with
sponge sticks and direct pressure.19 The vein lies behind
the artery, so exposure can be difficult. The vein can be
repaired directly if the injury is small and easily visualized.
If necessary, both the internal iliac artery and vein can
situations, an experienced vascular surgeon can be quite
helpful.19
● Prevention
Presacral bleeding usually occurs if the presacral fascia
is disrupted. This is best avoided by using sharp dissec-
tion in the retrorectal space. Blunt dissection should be
discouraged. This is particularly true when dividing the
retrorectal fascia (Waldeyer’s fascia), which is often very
 282 SECTION III: GASTROINTESTINAL SURGERY

tough tissue and is adherent to the presacral fascia (see

Fig. 25–11B). Attempts to bluntly dissect through this
tissue are more likely to disrupt the presacral fascia and
lead to bleeding. To prevent bleeding from the pelvic
sidewall, including the internal iliac vessels, careful dis-
section should be done just adjacent to the fascia
propria of the rectum. Whereas for oncologic reasons,
it is important to keep the fascia propria intact, if the
dissection is done too laterally, troublesome bleeding
can be encountered. Occasionally, the dissection must
be done more laterally to get circumferential tumor
clearance. Under these circumstances, the surgeon
should clearly identify the iliac vessels, including the
bifurcation of the internal and external iliac vessels, well
above the tumor and be prepared to intervene if bleed-
ing from these vessels ensues.

A Sexual and Bladder Dysfunction

Both sympathetic and parasympathetic nerves can be
damaged with rectal surgery. The sympathetic fibers begin
in the aortic plexus near the IMA. These fibers coalesce
to form two main hypogastric nerves, which are readily
identifiable at the level of the sacral promontory (Fig.
25–16; see also Fig. 25–14). These nerves carry sympa-
thetic innervation to the pelvic plexus. Parasympathetic
innervation is supplied by the nervi ergentes, which pass
through the sacral foramen and run laterally and then
forward to also join the pelvic plexus. The pelvic nerves
tend to be lateral, near the pelvic sidewall, but will course
anteriorly as they approach the prostate and seminal ves-
icles, forming the periprostatic plexus. Although the two
main hypogastric nerves can be readily seen during surgery,
most nerve fibers are not identifiable and knowledge of
B their location is necessary to minimize nerve injury.
Figure 25–15 A, Sterile thumbtacks and applicator. B, Close up
of sterile thumbtacks.

Figure 25–16 Position of hypogastric nerves.

Forceps point to the trunks of the hypogastric
nerves.

● Consequence
Injury to the sympathetic and parasympathetic nerves
can cause both bladder and sexual dysfunction. Whereas
the incidences of bladder and sexual dysfunction are
reportedly similar, to most clinicians, sexual dysfunc-
tion seems more common and problematic. This is
probably related to the observation that minor changes
in bladder dysfunction may not be as readily apparent
as sexual dysfunction to the clinician. Sexual dysfunc-
tion in men can be either the inability to have an erec-
tion or the failure to ejaculate fluid despite achieving
orgasm and are related to different types of neural
injuries.20 Woman may experience dyspareunia after
rectal surgery. Bladder dysfunction can present as
urgency, dribbling, leaking, or the inability to com-
pletely void.20 All of these problems are considerably
more common as patients get older and are probably
related to both aging and the use of concomitant radi-
ation commonly employed for the treatment of rec-
tal cancer.20,21 It is important to discuss these issues
with patients prior to surgery and to get a good under-
standing of their preoperative sexual and urologic func-
tion, because sexual and urologic dysfunction is quite
common, especially as people get older.21
Grade 2/4 complication
● Repair
No surgical repair exists for nerve injuries during
rectal surgery. Some problems with bladder and sexual
dysfunction will improve with time.22 The treatment
is symptomatic. Continued bladder dysfunction will
require either prolonged catheterization or a self-
catheterization program. For patients with persistent
sexual dysfunction, both medical and surgical options
exist to improve potency, and a urologic consultation
is warranted.
● Prevention
Precise dissection is the best way to prevent nerve inju-
ries.20,22 When the IMA is ligated, care should be taken
to stay right underneath the vessel because the nerves
tend to course over the aorta. The hypogastric nerves
can usually be seen right at the sacral promontory and
begin to sweep laterally. Gaining access to the retrorec-
tal space right in the midline is less likely to damage
these nerves. Dissection should be right on the fascia
propria, which will ensure that the dissection is anterior
to these nerves. Frequently, the hypogastric trunks will
be adherent to the fascia propria, and they need to be
carefully dissected off and swept laterally. To further
minimize injury to the pelvic nerves, care should be
taken to stay just adjacent to the fascia propria of the
rectum because the nerves tend to be closer to the
pelvic sidewall. This is true for the entire rectal dissec-
tion, but it is most important during the anterior lateral
dissection near the seminal vesicles. Precise dissection
is critical to best preserve nerve function while doing
an oncologically appropriate operation. Clearly, for
25 LOW ANTERIOR RESECTION 283
benign disease, it is best to veer closer to the rectum
to help further decrease the likelihood of permanent
nerve injury.
Anastomosis
Anastomotic Leak
Anastomotic leak is the dreaded complication associated
with colon and rectal surgery and is the most common
cause of death after an elective colon or rectal resection.
For rectal surgery, the incidence can vary from approxi-
mately 3% to 10%, depending on the level of the ana-
stomosis. Very low pelvic anastomoses will leak more
frequently than those performed to the midrectum.3,23
Other factors contributing to a higher leak rate include
pelvic radiation, male gender, and prolonged surgery,23
which is most likely a surrogate for a difficult operation.
The clinical presentation of an anastomotic leak can be
quite varied. Whereas some leaks will present as frank
peritonitis, others can be more subtle, such as a pelvic
abscess. The diagnosis must be suspected in any patient
who has a new rectal anastomosis and has a cardiopulmo-
nary collapse of an unclear etiology. Failure to promptly
make this diagnosis will contribute to ongoing sepsis and
will likely lead to a poor outcome.
● Consequence
The clinical consequences of an anastomotic leak
depend on the severity of the leak itself. For small leaks
resulting in a pelvic abscess, a percutaneous drain may
be all that is necessary, with little long-term signifi-
cance. However, a leak associated with fecal peritoni-
tis is clearly life-threatening. It generally will require
a reoperation and the creation of a diverting stoma.
Intensive care monitoring is often required to deal with
the septic sequelae of the leak. Once a patient does
recover, restoration of intestinal continuity may be
compromised. Some patients will have a permanent
stoma, whereas others will be reversed but fibrosis will
result in an anastomotic stricture or poor function. In
addition to these complications, data also suggest that
local/regional cancer recurrence rates are higher in
patients who have had an anastomotic leak.24,25
Grade 2/4/5 complication
● Repair
If a patient has a well-contained leak without evidence
of systemic illness, percutaneous drainage is appropriate
and often successful. For patients who do not improve
with catheter drainage or those who are systemically ill
at presentation, operative management is warranted.
Reexploration after an anastomotic leak can be very
challenging, because the adhesions can be quite diffi-
cult, especially near the leaking anastomosis. If the
anastomosis can be readily identified and there is a large
dehiscence, resecting the anastomosis and creating an
end colostomy are appropriate. However, the anasto-
mosis frequently cannot be easily seen. Under these
 284 SECTION III: GASTROINTESTINAL SURGERY
circumstances, extensive dissection can be troublesome
and should be avoided. Pelvic drainage and proximal
diversion, with either a loop colostomy or an ileostomy,
can be done.26 Whereas some authors have expressed
concern about ongoing sepsis from a stool-filled colon,
recent evidence suggests that sepsis can be well con-
trolled with proper drainage and proximal diversion.26
Furthermore, with this approach, many low-lying anas-
tomoses that have leaked can be salvaged, thus increas-
ing the likelihood of restoring intestinal continuity.
Occasionally, a small leak is easily visualized. Under
these circumstances, simple repair of the anastomosis is
quite tempting. However, this approach is frequently
unsuccessful, and the consequences of a second leak are
usually devastating. Therefore, simple closure without
proximal diversion should be discouraged.
● Prevention
Proper construction of a low-lying anastomosis is crit-
ical to minimize the likelihood of an anastomotic leak.
For an anastomosis to properly heal, healthy bowel
must be available on either end of the anastomosis in
addition to a good blood supply and no significant
tension. For a low pelvic anastomosis, complete mobi-
lization of the splenic flexure is almost always required.
However, even after all the avascular retroperitoneal
attachments are divided, it still can be difficult to get
the descending colon to reach the pelvic floor. Under
these circumstances, the colon is still tethered by the
colonic mesentery. Therefore, in order to get the nec-
essary length, either the IMA needs to divided at the
aorta or the left colic vessel is divided just as it branches
off the IMA (see Fig. 25–7). Great care must be taken
not to damage the marginal artery, which runs parallel
to the colon and only a few centimeters from the mes-
Figure 25–17 Fully mobilized descending colon,
which will easily reach low in the pelvis. Yellow line
shows the approximate location of the marginal
artery, which must be carefully preserved to provide
adequate blood supply to the mobilized colon.
enteric border of the colon (Fig. 25–17). Once the
IMA or left colic artery is ligated, the entire blood
supply to the left colon is from the middle colic artery
via the marginal artery. If, after dividing the arterial
blood supply, there is still tension, the IMV should also
be divided near the duodenum and pancreas. Once this
is done, the avascular portion of the colonic mesentery
can be divided all the way to the middle colic vessels,
and the colon will have plenty of length to reach the
pelvic floor (see Fig. 25–17). Furthermore, as long as
the marginal artery is not damaged, blood supply to
the distal descending colon will be adequate. An under-
standing of this anatomy and faith in the marginal
artery are paramount to constructing a proper low anas-
tomosis without tension and with good blood supply.
The last factor, ensuring healthy ends of bowel, is
usually not problematic with good tissue handling.
However, because more patients receive preoperative
radiation for rectal cancer, the distal bowel is not
normal, which may impair proper healing.
All distal anastomoses should be thoroughly evaluated
by first examining the integrity of the anastomotic dough-
nuts and then by air insufflation. If a leak is identified,
attempts at suture repair are warranted. If, as is frequently
the case, the anastomosis cannot be visualized, large leaks
may, under some circumstances, be repaired via a transanal
approach. Small leaks that cannot be repaired are best
treated with proximal diversion and drainage. Under most
circumstances, these small leaks will seal on their own and
the ostomy can be reversed at a later date.
Debate continues about whether a low-lying anastomo-
sis should be routinely protected by proximal diversion.
Critics of proximal diversion correctly assert that diversion
itself does not prevent an anastomotic leak.27 Further-
more, there is associated morbidity from the reversal of
 25 LOW ANTERIOR RESECTION 285

the proximal stoma. However, proponents of proximal

diversion will note that in most series a low rectal anasto-
mosis will leak approximately 10% of the time3,28 and that,
although diversion does not prevent an anastomotic leak,
the clinical consequences of the leak are greatly dimin-
ished in patients who are proximally diverted.23,28,29 There-
fore, proximal diversion should be strongly considered for
any patients who have had previous radiation, who have
a low anastomosis, if there is any concern about the integ-
rity of the anastomosis, or who cannot medically tolerate
the significant morbidity of fecal peritonitis.23,28,29

Anastomotic Bleeding
● Consequence
Clinically significant bleeding from a colorectal anasto-
mosis occurs approximately 2% of the time. Fortu-
nately, most bleeding is self-limited and will stop on
it own accord.30 Very rarely, an intervention will be A
necessary.
Grade 1/2 complication
● Repair
If a low-lying anastomosis does bleed, it is usually
readily apparent because blood will pass through the
rectum. Most bleeding is self-limited and will stop.30
Therefore, as long as the patient is hemodynamically
stable, support is all that is necessary. Occasionally, the
bleeding will be persistent and perfuse (Fig. 25–18A).
Under these circumstances, it is best to attempt endo-
scopic management.31 A low-lying anastomosis is easily
seen with the colonoscope and the bleeding identified.
Bleeding can be frequently controlled with epinephrine
injection or with an endoscopically applied clip (see
Fig. 25–18B). If this is unsuccessful or not available,
surgery will be necessary. For an anastomosis in the
upper rectum, simply overseeing the anastomosis may
be all that is necessary. For a very low-lying anastomo-
sis, stitches can be applied via a transanal approach. B
Redoing the anastomosis can be very difficult and
Figure 25–18 A, Anastomotic bleeding. B, Treatment with
should be done only as a last resort. endoscopically applied endoclips.

● Prevention
No good way exists to prevent anastomotic bleeding
for a low pelvic anastomosis.
Anastomotic Stricture
● Consequence
A stricture can have an impact on bowel function. The
clinical impact depends on the severity of the stricture.
Obviously, for very tight strictures, evacuation will be
difficult and, on rare occasions, impossible. Many stric-
tures are mild and can be managed with a combination
of gentle dilation and bowel management, such as a
high-fiber diet and stool softeners. More significant
strictures will require either an endoscopic or a surgical
treatment.
Grade 1/2 complication
● Repair
Only symptomatic strictures should be treated. Gener-
ally, these are in patients in whom, on endoscopic
examination, a standard colonoscope cannot be passed.
Once symptoms do occur, endoscopic management
should be attempted. This is usually accomplished with
balloon dilation and is frequently successful. For very
tight stenosis, the stricture can be partially pretreated
with electrocoagulation or an argon beam coagulator
prior to balloon dilation.32 Other options include self-
expanding colonic stents and endoscopic transanal
resections of strictures. However, the long-term results
of these latter approaches are still unclear.33 For very
tight or long strictures, operative management may
be necessary. This usually involves resection and the
 286 SECTION III: GASTROINTESTINAL SURGERY
creation of a new colorectal or coloanal anastomosis.
These operations are generally reserved for patients
with mid or upper rectal strictures and can be very
challenging.34 Temporary diversion after anastomotic
revision is almost always done. Patients with low-lying
strictures that cannot be managed with endoscopic
means may require a permanent colostomy for symp-
tomatic control.
● Prevention
Many anastomotic strictures are associated with a clin-
ical anastomotic leak. Presumably, many of the other
strictures may be secondary to subclinical leaks,
although this is difficult to demonstrate. Prevention of
anastomotic strictures is, therefore, similar to that for
preventing anastomotic leaks. Proper anastomotic tech-
nique, with particular attention to lack of tension and
blood supply, is critical. Reportedly anastomotic stric-
tures are more common in stapled than in hand-sewn
anastomoses.35 An association also seems to exist
between fecal diversion and an increased stricture rate.36
However, the benefits of diversion may outweigh the
risk of subsequent stricture.
Vaginal Injury and Rectal Vaginal Fistulas
● Consequence
Injury to the vagina and subsequent rectovaginal fistula
are uncommon but have been reported in the litera-
ture.37,38 Whereas some fistulas result from direct injury
to the vagina, others develop from an anastomotic leak
and subsequent pelvic abscess.39 Symptoms will vary
depending on the size of the resulting fistula. For
patients with minimal symptoms, observation and a
bowel-confining program may result in spontaneous
healing. If unsuccessful, operative management will be
necessary.
Grade 2–4 complication
● Repair
If the vagina is injured during the operative procedure,
it can be repaired with nonabsorbable sutures. This may
require careful and additional development of the rec-
tovaginal septum to identify the injury. After the repair
is complete, it is advisable to place well-vascularized
omentum between the anastomosis and the vagina to
help prevent fistula formation. Under these circum-
stances, proximal diversion may also be advised.
Once a rectovaginal fistula is identified, it is critical to
identify the exact location of the fistula. A high fistula may
require further resection and the creation of a coloanal
anastomosis.39 A low-lying fistula may be amenable to an
endorectal mucosal advancement flap39 or a flap using
either bulbocavernosus tissue or the gracilis muscle.
Results from these procedures may be impaired by previ-
ous pelvic radiation. Proximal diversion may be necessary
for symptomatic relief and may, in some situations, lead
to spontaneous healing.
● Prevention
In order to perform a very low anastomosis, complete
mobilization of the rectovaginal septum is necessary.
This is facilitated by using a lipped pelvic retractor and
anterior retraction on the posterior wall of the vagina.
If the surgeon encounters “troublesome bleeding,” he
or she is usually too anterior and may risk injuring the
posterior vaginal wall, which will readily bleed. It is very
important to mobilize the vagina all the way to the
pelvic floor. This will completely separate the rectum
and vagina so that a stapler can be safely placed around
the rectum. When performing the end-to-end stapled
anastomosis, the pelvic retractor should elevate the
vaginal wall and the stapler should be lowered under
direct visualization, taking care that the posterior wall
of the vagina is not inadvertently incorporated into the
stapling device (see Fig. 25–7B). Palpation of the
vagina is recommended prior to firing the stapler to
reassure the surgeon that the vagina is not involved in
the anastomosis.
Lower Ureteral Injury
● Consequence
Unrecognized injury can result in urinary leak and
urinoma. Although uncommon, injury to the lower
ureter usually will occur as the ureter courses more
medially to the trigone and is most vulnerable during
the anterior lateral dissection, especially if there is a
bulky tumor or significant radiation fibrosis.
Grade 2–4 complication
● Repair
Injury to the ureter at this level is problematic and
usually warrants a urologic consultation. When the
injury is recognized intraoperatively, the proximal
ureter can be fully mobilized and often reimplanted
into the bladder in a tunneled fashion.40 Primary repair
over a urologic stent is also possible, but stricture may
result, especially in a radiated field. If the injury is
identified postoperatively, drainage is initially required41
and may necessitate temporary urinary diversion with
a percutaneous nephrostomy tube.42 Occasionally,
the ureteral injury will resolve with proximal urinary
diversion.42 However, if the injury persists, subsequent
operative repairs will include reimplantation using
either a psoas hitch40 or a Boari flap. Another option
involves a ureteroureterostomy43 and, as a last resort,
nephrectomy.
● Prevention
As the rectal dissection continues more distally, the
pelvis becomes more narrow. The ureters, which course
into the pelvis quite laterally, begin to veer more medi-
ally to join the trigone. If the dissection of the rectum
is done just along the fascia propria, ureteral injury
should be avoided because the ureter should stay both
lateral and anterior. If the injury is due to tumor size

or pelvic fibrosis, the dissection is more lateral and the
surgeon should clearly identify the ureter at the pelvic
brim and dissect out the ureter distally for its entire
length. If necessary, the dissection can be done all the
way to the bladder itself. If, after this dissection, it is
determined the distal ureter needs resection to obtain
proper tumor clearance, a controlled resection and
reimplantation can be done. The preoperative place-
ment of ureteral stents can facilitate identification of
the ureter and any intraoperative injuries and should be
considered in difficult cases. The use of intraoperative
indigo carmine can also be employed to identify a sus-
pected intraoperative injury to the distal ureter.
Anterior Resection Syndrome
● Consequences
Many patients after a low anterior resection have imper-
fect bowel function. Common complaints include
increased frequency, urgency, fragmentation, inconti-
nence, and constipation.44 Collectively, these symptoms
have been referred to as the anterior resection syndrome.
Unfortunately, these symptoms can be quite debilitat-
ing and can render a technical success a functional
failure. Functional results seem to deteriorate as the
anastomosis is lower in the pelvis.45–47 Whereas there
is some improvement with time,48,49 many patients
will have permanent and significant alterations of
their bowel function.50 Not surprisingly, bowel func-
tion seems worse in patients who have had pelvic
radiation.45,51,52
Grade 1 complication
● Repair
No surgical solution exists for the anterior resection
syndrome. Symptoms are probably worse in patients
who have had anastomotic complications, but even
those patients with technically perfect operations can
experience poor bowel function. Because improvement
can occur with time, frustrated patients should be
encouraged to persevere for at least 12 months.48
Symptomatic treatment includes the use of antidiarrhea
agents, a high-fiber diet, and the use of barrier creams
to protect the perineal skin. Patients will frequently
need some psychological support and encouragement.53
Whereas many patients have a poor functional outcome,
patient satisfaction is often higher than expected.48,51
This suggests that some patients, despite less than ideal
function, still prefer their situation to the alternative: a
permanent colostomy. Nevertheless, if patients have
continued and life-limiting symptoms, conversion to a
colostomy may be reasonable.
● Prevention
There is no way to completely prevent the anterior
resection syndrome. However, because of these sig-
nificant symptoms, alternative techniques have been
developed. These include the use of the colonic J pouch
25 LOW ANTERIOR RESECTION 287
and coloplasty. Most studies suggest improved func-
tion within the first year, but over time, the functional
outcomes between these alternative techniques and a
straight colorectal anastomosis seem similar. Neverthe-
less, because of the improved immediate result, a
colonic J pouch may be preferred if technically feasible.
A preoperative assessment of anorectal function does
seem warranted prior to performing a very low anasto-
mosis. In patients who have poor anorectal function
prior to surgery, a low anastomosis is likely to provide
poor function and a colostomy may be considered. This
may also be true for patients who have limited access
to bathroom facilities for either personal or professional
reasons. Caution should also be exercised in patients
who are elderly and frail because poor anorectal
function can be extremely debilitating under these cir-
cumstances. Frank discussions about postoperative
function are essential to help patients make informed
decisions.
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