Right colonic transposition technique: when the left colon is unavailable for achieving a pelvic anastomosis.

PURPOSE: On occasion, the left colon is not available for rectal or low pelvic anastomosis either because of synchronous pathology, previous resections, or inadequate blood supply. The short middle colic pedicle prevents use of the transverse colon for this purpose. In this situation, the right colon is a good anastomotic conduit. The aim of this video is to demonstrate the right colonic transposition technique. METHODS: Intraoperative footage was filmed and edited in a multimedia format. Operative details were as follows: the diseased left colon and transverse colon are excised; the right colon is fully mobilized and transposed 180 degrees anticlockwise around the axis of the ileocolic pedicle, so the hepatic flexure reaches into the pelvis without tension. The hepatic flexure is then used for anastomosis within the pelvis either to the residual rectum or anus (see Supplemental Digital Content, Videos 1-3, http://links.lww.com/DCR/A46, http://links.lww.com/DCR/A47, and http://links.lww.com/DCR/A48). Case notes were reviewed to analyze clinical outcome and bowel function. RESULTS: Three patients underwent the technique, 2 females and 1 male (median age, 45 (range, 30-55) years). Median operating time was 98 (range, 95-114) minutes. There were no anastomotic failures or other major complications. One patient had a superficial wound infection. The median in-hospital stay was 7 (range, 7-8) days. The median time to first bowel movement was 3 (range, 3-4) days; the median daily stool frequency was 4 (range, 3-4) on discharge, decreasing to 2 daily stools 12 months after surgery. Stoma formation and total colectomy were successfully avoided in each patient. CONCLUSIONS: Right colonic transposition is a useful technique to enable the construction of a tension-free rectal anastomosis with a good blood supply. The use of the right colon in these clinicopathological situations can be achieved with low morbidity and results in good short- and long-term bowel function in these patients. Careful preservation of the ileocolic pedicle and division of the right colic vessels are essential to facilitate successful anastomosis.

Anterior Perineal PlanE for Ultralow Anterior Resection of the Rectum (the APPEAR Technique): a video demonstration.

BACKGROUND: Sphincter-saving rectal resections have become commonplace in the surgical treatment of malignant rectal pathology. However, restoration of gastrointestinal continuity by means of conventional techniques proves technically challenging in cases of very low rectal pathology, with resultant variable requirements for a permanent stoma. The APPEAR procedure (Anterior Perineal PlanE for Ultralow Anterior Resection of the rectum) is a novel sphincter-saving resection technique to restore gastrointestinal continuity in those who would otherwise require a permanent stoma with conventional abdominal resections. It ensures that the distal rectum is excised and the anastomosis is constructed under direct vision while simultaneously preserving the anal sphincter and its somatic nerve supply in their entirety. INDICATIONS: This procedure is indicated in the following instances: proven lower-third rectal carcinomas where anatomical restrictions prevent satisfactory rectal dissection and/or transection with a potential inadequate distal clearance margin; ileoanal pouch formation for ulcerative colitis or familial adenomatous polyposis where retained rectal tissue is at risk of future malignancy; short or strictured rectal stumps where pelvic dissection is hazardous and thus prevents restoration of gastrointestinal continuity. CONCLUSIONS: The APPEAR technique is a feasible alternative sphincter-saving procedure to further reduce the requirement of permanent stoma in the treatment for ultralow rectal pathology; however, it is appreciated that a larger study group with long-term follow-up is required. This technique should facilitate laparoscopic rectal resection because large and distal tumors can be dissected and excised through the perineal wound, ensuring adequate distal clearance and the anastomosis constructed under vision at an appropriate level. Furthermore, the requirement for an abdominal incision is avoided, improving cosmesis.