low anterior resection, step by step

1. Midline laparotomy
2. Inspection abdomen, check for metastasis
3. Mobilisize sigmoid and descending colon(incise along Toldt's white line)
4. Identify and preserve left ureter
5. Transect sigmoid colon
6. Divide mesosigmoid
7. Identify and ligate superior rectal artery (low tie strategy)
8. Excise mesorectum and preserve sacral plexus
9. Incise peritoneum 1 cm ventral to peritoneal fold
10. Identify and preserve seminal vesicles / uterus and vagina
11. Dissect at least 2 cm distal to tumor
12. Divide mesorectum towards rectum
13. Transect rectum
14. Create tensionfree side-to-end anastomosis
15. Perform leaktest if desired
16. Create deviation ileostomy if needed (e.g. long pre-operative radiation)
17. Close fascia and skin