Introduction

Ernest Miles [1] postulated that adequate treatment of rectal cancer, regardless of the site and apparent progress of the tumour, in all cases necessitated a wide excision of the entire anorectum and establishment of a permanent colostomy by an operation involving both an abdominal and a perineal dissection. Lloyd-Davies confirmed this statement, advocating the synchronous combined technique that became by far the most popular method of dealing with rectal cancer worldwide.

However, from the early 1940s onward, sphincter-saving methods, even low anterior resections, were put on trial by several surgeons [2]. The results for growths of the rectosigmoid and upper third or half of the rectum proved to be good and with the passage of time surgeons were encouraged to extend the use of these methods to yet lower lesions. One disadvantage was that low-sited tumours were often inaccessible for technical reasons, and many different techniques were used to overcome this problem [3, 4]. Moreover, a handsewn anastomosis was often associated with a high incidence of leaks, fistulae, abscesses and anastomotic strictures, and the functional results were often unsatisfactory. Although patient satisfaction was stated to be positive in the majority of patients, flatus and/or faecal incontinence were common. Based on a careful assessment of the functional results after low anterior resection, Goligher et al. [5] concluded that if a rectal stump of at least 6-7 cm could not be preserved, the patient would be better treated by abdominoperineal resection (APR).

With the advent of stapling instruments allowing mechanical construction of the colorectal anastomosis and the contribution of the colon pouch, ultralow anastomoses have become routine procedures performed by most general surgeons. Anterior resections (ARs) with anastomosis are now possible at a level that could never be performed by handsuturing. The lowest rate of permanent stoma formation for rectal cancer in the literature is below 10%, in a unit routinely employing a stapled anastomotic technique for low anterior resection [6], and other specialist units have reported similar low rates [7], figures that differ greatly from the more common rates of about 30% [8].

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