Laparoscopic low anterior resection is a challenging procedure that requires high surgical skills.Furthermore, the role of laparoscopy in the treatment of rectal cancer in not yet well defined. The video shows a low anterior resection for mid rectal cancer performed under HD videoendoscopic guidance using US dissection and a curved cutter for the anastomosis.

A 3 port approach is carried out, starting with the medial-to-lateral mobilization of the splenic flexure.Ultrasonically activated scissors enhance dissection throughout the whole procedure.Inferior mesenteric vessels are dissected free and divided, the vein at the level of Treitz, the artery - after sub-adventitial dissection - sharp the aorta, carefully preserving the hypogastric nerves. The dissection is furthered along the plane between Gerota and Toldt fascia and then downward, along the holy plane.The Rectal dissection is performed with total mesorectal excision and maximum care not to enter the mesorectal fascia, reaching the plane of the levator ani. Rectum is dissected free at its junction with the anal canal and then closed-transected with a new curved cutter designed for open surgery, inserted laparoscopically with an original technique. The bowel is then withdrawn through the minilaparotomy used to insert the stapling device,protected by the steri-drape. Finally,a double stapled anastomosis is performed and a loop ileostomy constructed for its protection.

Postoperative course was uneventful. Patient was discharged a p.o. day 5.

Use of advanced technologies may improve safety and accomplishing a laparoscopic low anterior resection following the oncologic principles of a no-touch technique with adequate lynphadenectomy.