The preoperative type of treatment is based on tumor localization and locoregional involvement. Short term radiotherapy, long term chemoradiation or no neoadjuvant therapy is depending upon local protocols.
A colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results. Because of a reduction in complexity and operating time, a side-to-end anastomosis could be recommended.
Low tie or high tie
Neither the high tie strategy nor the low tie strategy is evidence based. The low tie strategy is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. Therefore, in rectal cancer surgery low tie should be the preferred method.
Step by step
- Midline laparotomy
- Inspection abdomen, check for metastasis
- Mobilisize sigmoid and descending colon(incise along Toldt's white line)
- Identify and preserve left ureter
- Transect sigmoid colon
- Divide mesosigmoid
- Identify and ligate superior rectal artery (low tie strategy)
- Excise mesorectum and preserve sacral plexus
- Incise peritoneum 1 cm ventral to peritoneal fold
- Identify and preserve seminal vesicles / uterus and vagina
- Dissect at least 2 cm distal to tumor
- Divide mesorectum towards rectum
- Transect rectum
- Create tensionfree side-to-end anastomosis
- Perform leaktest if desired
- Create deviation ileostomy if needed (e.g. long pre-operative radiation)
- Close fascia and skin