Plate 81
###### Figure 4

The stapler offers certain advantages in the performance of a low anterior resection, provided the surgeon is thoroughly familiar with the technique. Those favoring this method of approximating the sigmoid to a short rectal stump emphasize the ease of the anastomosis, especially in the narrow pelvis of the male. The time required for the operation may be shortened and the indications for a temporary proximal diverting loop ostomy decreased. Use of the stapler does not alter the principles of adequate resection of tumors at approximately 8 cm or less from the anus. This is because anastomoses lower than 3 cm from the anus may be associated with incontinence and because a distal margin of 2 to 3 cm below the cancer is recommended to minimize the rate of local anastomotic recurrence. The success of a properly performed anastomosis depends on an adequate blood supply to the residual bowel segments, which can be brought together easily without tension. Cancers below the peritoneal reflection in the pouch of Douglas should be evaluated with endorectal ultrasound for their staging and spread. Preoperative radiation therapy and chemotherapy should be considered for these lesions.

An empty colon results from one day of liquid diet. The usual bowel preparation is given the day prior to surgery, while parenteral antibiotics are administered just prior to the start of the procedure. Since the stapler is to be introduced through the anus, it is mandatory that the lower colon and rectum be carefully emptied and cleansed just before the procedure is started. A large mushroom catheter commonly is introduced into the rectum for a saline irrigation until clear. Several ounces of a mild antiseptic solution such as 10% povidone-iodine can be instilled at the time the procedure is started. An inlying bladder catheter is essential for good exposure.

General endotracheal anesthesia is satisfactory.

The patient is placed in a semilithotomy position using Allen stirrups and in a modest Trendelenburg position to enhance exposure of the deep pelvis and permit the introduction of the stapling instrument via the anus.

Not only the abdominal wall from the xiphoid to the pubis, but the skin over the perineum, groin, and especially the anal region are prepared since the instrument will be introduced through the anus.

A long midline incision is made starting just above the symphysis and extending to the umbilicus and around it on the left side to provide easy access to the splenic flexure (Figure 1). The liver ...

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