Low anterior resection

General remarks

Preoperative therapy

The preoperative type of treatment is based on tumor localization and locoregional involvement. Short term radiotherapy, long term chemoradiation or no neoadjuvant therapy is depending upon local protocols.


A colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results. Because of a reduction in complexity and operating time, a side-to-end anastomosis could be recommended.

Low tie or high tie

Neither the high tie strategy nor the low tie strategy is evidence based. The low tie strategy is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. Therefore, in rectal cancer surgery low tie should be the preferred method.

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

  1. Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial.Machado M et al. Ann Surg. 2003 August; 238(2): 214-220
  2. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review.Lange M et al.Dis Colon Rectum. 2008 Jul;51(7):1139-45
  3. Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group.Kapiteijn E, Kranenbarg EK, Steup WH, Taat CW, Rutten HJ, Wiggers T, van Krieken JH, Hermans J, Leer JW, van de Velde CJ. Eur J Surg 1999 May;165(5):410-20