Expert Opinion on Low Anterior Resection for Colorectal Surgery: A Stepwise Approach from an Indian Perspective

A BSTRACT Total mesorectal excision forms the mainstay technique for laparoscopic anterior resection (LAR) and is associated with better surgical and oncological outcomes. The major challenge is preserving the integrity of the excised mesorectum and sphincter functioning. An advisory board meeting involving 14 colorectal surgeons was conducted to provide expert opinion on a detailed guide to performing low anterior resection (LAR), along with key tips on practical considerations during surgery. A literature review was conducted using PubMed and Google Scholar, applying Boolean operators and defined keywords. Forty-seven relevant articles were selected, and evidence was compiled through review of key findings to support expert recommendations. Evidence-based expert recommendations were reviewed, discussed, and formulated by the expert panel for each surgical step. The recommendations are (a) mechanical bowel preparation with oral antibiotic prophylaxis is an important preoperative intervention. (b) Magnetic resonance imaging of the pelvis with a rectal protocol is recommended in the preoperative assessment. (c) A 5-trocar technique should be used for port incision and trocar placement. (d) Identification of the inferior mesenteric artery is crucial, and dissecting underneath the rectal vessel is useful in easily entering the plane between the mesorectal fascia and the endopelvic fascia. (e) Preservation of the left colic artery helps in the effective mobilization of the splenic flexure. (f) Distal rectal stump stapling should be performed from the right iliac fossa or suprapubic port, mainly from the right side. (g) Specimen extraction can be done through a Pfannenstiel incision or a lower midline incision. (h) Both end-to-side anastomosis and end-to-end anastomosis can be performed. (i) Postoperative interventions include removing the urinary catheter within 24–48 h after mid/lower rectal resection, early and progressive patient mobilization, and initiation of oral diet as early as 6 h after the surgery. The panel generally emphasized the need for careful examination of the anatomical structures and obtaining patient consent for the surgery.