Damage to the Pelvic Autonomic Nerves

Damage to hypogastric and splanchnic sacral nerves during conventional operations for rectal cancer result in very high rates of sexual dysfunction comprising up to 85% of surgery patients [22, 23]. Bladder dysfunction as reported by different Authors varied between 7 and 73% [24, 25]. What is equally important from the oncological radicality point of view are very low local recurrence rates, which are the result of an adequate removal of the tumour using the TME technique and have been reported by several Authors [26, 27].

Performing LAR, an end-to-end anastomosis between descending colon and rectum stump has to be performed. The distal margin should be a minimum of 2 cm; in low-grade tumours this distance can be smaller. A circular stapling device is used to create the anastomosis. Single- or double-stapling technique can be used. In the case of single stapler use, transection of the bowel is performed with a cutter. Purse-string clamps are placed on both proximal and distal stumps (Fig. 1). The anvil is inserted into a proximal stump. The circular stapler (without its anvil) is inserted transanally. After exteriorising the trocar, the purse-string is closed around its base. The last steps of the procedure include closing, firing and removing the stapler (Figs. 2, 3). But the most popu-

Fig. 1. Location of the local tumour in the relation to the mesorectum
Fig. 2. Closing the rectum with the linear stapler

lar technique used worldwide is the double-stapled technique. This entails transection of the rectum distal to the tumour from within the abdomen using a linear stapling device (Fig. 4). The proximal resection margin is divided with a purse-string device. After sizing the lumen, the detached anvil of the circular stapler is inserted into the proximal margin and secured with the purse-string suture. The circular stapler is inserted carefully into the rectum, and the trocar is projected through or near the linear staple line. This is quite an important moment - the trocar

Fig. 3. The anvil is placed into the proximal stump Fig. 4. The circular stapler is inserted transanally

Fig. S. Exteriorised trocar seen from the rectal stump should pierce the anterior wall as close to the staple line as possible (Fig. 5). Then, the anvil is engaged with the trocar and, after completely closing the circular stapler, the device is fired. Two rings of staples create the anastomosis, and a circular rim or donut of tissue from the proximal and distal margins is removed with the stapling device (Fig. 6). The anastomotic leakage rate with this technique ranges from 3 to 11% for middle-third and upper-third anastomoses and to 20% for lower-third anastomoses. For this reason, some surgeons choose to protect the lower-third anastomosis by creating a temporary diverting stoma. This is especially important when patients have undergone a pre-operative RT course. A handsewn anastomosis may be performed; if preferred, the anastomosis is performed as a single-layer technique. Usually the handsewn technique is limited with the location of the tumor - if we really mean LAR, this procedure is usually possible only with stapling techniques. The leak and stenosis rates are the same for stapled and handsewn anastomoses.

Very low rectal cancers, located just above the sphincter occasionally can be resected without the need for a permanent colostomy. The procedure is as already described; however, the pelvic dissection is carried down to the level of the levator ani muscles from within the abdomen. A straight-tube colo-anal anastomosis (CAA) can be performed using the double-stapled technique, or a handsewn anastomosis can be performed transanally. This last option is also a rescue technique when we need to take down stapled CAA, due to some major leak during anastomosis testing. Some surgeons do not want to perform stapled CAA because of the possibility of implantation of malignant cells at the stapled transection line. The first stage of the procedure is to deliver descend-

Fig. 6. Anastomosis done with the stapling technique

ing colon to dentate line without tension. After that, the end of the colon and anal canal mucosa with internal sphincter are sutured using single, full thickness sutures.

The best way to test the anastomosis after LAR is to place a 30 FR catheter through the anal sphincter and fill the pelvis with 0.9% saline. Then with a 250ml syringe, insufflate the rectum with air; the bowel above the anastomosis is held by a noncrushing clamp. If anal anastomosis is checked, it is enough to place the syringe nozzle within the anastomotic area. In case of any doubt about anastomosis consistence, one or two sutures should be added into the site of the suspected leak, and after that the anastomosis should be rechecked. If there is still no evidence of complete anastomosis integrity, a proximal protective stoma should be performed.

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