Laparoscopic Low Anterior Resection with en bloc Small Bowel Resection and Difficult Takedown of the Splenic Flexure

Deborah S Keller, MD, Justin K Lawrence, MD, Conor P Delaney, MD, MCh, PhD

University Hospital- Case Medical Center

This 65 year-old man presented to the emergency room with 2 weeks of abdominal pain, bloating, and constipation. His history was significant for 2 previous abdominal operations and 40-pack years of smoking. A CT-scan showed circumferential sigmoid thickening. He subsequently underwent a colonoscopy, where an obstructing sigmoid mass approximately 20cm from the anal verge was unable to be traversed. Biopsy demonstrated poorly differentiated adenocarcinoma. The patient was referred to colorectal surgery for management. A pelvic MRI was performed, demonstrating transmural infiltration into the pericolic fat, with distal ileum adherent to the mass. After consent was obtained, the patient was scheduled for a laparoscopic low anterior resection.

The patient was positioned in modified lithotomy, and access to the abdomen was obtained through an open Hassan approach. On inspection, a large, bulky mass was visualized, with distal small bowel adhered, very deep in the pelvis. The small bowel was divided to gain access to the dissection planes around the large mass. A lateral to medial dissection was initially performed to define the presacral plane, avoiding the ureter, nerves, and area of mesorectal invasion. A high division of the IMA was performed, then a medial to lateral dissection was done. The splenic flexure was noted to be high and very close to the colon, making its takedown difficult. Once complete, the rectal planes were well visualized. A total mesorectal dissection was performed, mobilizing the rectum to the anal canal posteriorly. Anteriorly, the pouch of Douglas was incised to aid circumferential mobilization. The rectum and its mesentery were divided at the peritoneal reflection. The small bowel was then externalized through a midline incision, and a stapled side-to-side, functional end anastomosis was performed. The divided rectosigmoid was then exteriorized, and transected proximal to the mass. The EEA anvil was placed, and the sigmoid returned to the peritoneal cavity. A transversus abdominus plane block was placed. Then, a stapled colorectal anastomosis was completed, verifying integrity with a negative leak test. Final pathology on the specimen was T4N2bM0 (Stage IIIC). The patient’s hospital length of stay was 2 days.

Session: Podium Presentation

Program Number: V022