COLORECTAL   > Laparoscopic Ultra Low Anterior Resection

Patient and Port position: Patient placed in modified Lloyd Davies position.

Pneumoperitoneum created by veress needle through 10 mm Supraumbilical skin incision which is later on converted into 10mm camera port.  10mm RIF port, 5mm right and left lumbar ports, 12mm supraumbilical ports made.

STEPS:
Initial step is to visualize all quadrants of peritoneal cavity, liver surfaces, pelvis for metastasis, lymphadenopathy and ascites.

The left side of the patient is raised up to allow the small bowel to fall out of the pelvis. The apex of sigmoid is held up and to left. The sacral promontory is identified and the peritoneum over is incised on the medial aspect of the mesosigmoid. A window is made in the mesocolon over the IMA.  IMA & IMV dissected, ligated and divided at just distal to their origin the left ureter and gonadal vessels are identified and carefully preserved during this part of dissection. Descending colon mobilized from medial to lateral. The descending colon, splenic flexure and the distal transverse colon are completely mobilized at the end of this phase. This helps to obtain adequate length of proximal colonic segment for tension free anastomosis. Rectum dissected from surrounding structures in anatomical planes upto pelvic floor. Course of ureter traced. Rectal division done by Endo GIA staplers (green) just above ano rectal junction. Rectal mass along with left colon delivered outside through 5cm transverse suprapubic laparotomy. Specimen removed by dividing left colon. Anvil attached to distal end of left colon and returned into peritoneal cavity. No. 29 CDH stapler passed per anus and stapled anastomosis done. Loop ileostomy created 20cm proximal to IC junction at RIF.