A 56-year-old female diagnosed of high rectal cancer underwent a high anterior resection by laparoscopy, at the postoperative period she suffered an anastomotic leak that was treated with abdominal cavity lavage and a diverting ileostomy.
During the follow up she developed a large stenosis of the anastomosis with a distal margin located at 4 cm from the anal verge, endoscopic dilations were unable to solve the problem.
Combined transanal and transabdominal approach was used. Revision of the pelvis revealed fused anatomical planes, there is a small bowel loop attached to the pelvic wall and adhesions between the uterus and descending colon.
Surgery begins with the individualization of structures by the use of the hook and LigaSure™ to improve the control of bleeding. The descending colon is mobilized from the promontorium down into the pelvis.
At the same time, a transanal surgical team dissects down to up, the distal margin is below the stenosis from the previous surgery were a purse string suture is performed. Healthy mucosa is opened and the mesorectal fat is reached.
Simultaneous workof both teams is essential for success, as they help each other during maneuvers with unfavorable angles and to solve doubts about the correct plane. By this approach the large stenosis was dissected safely.
This is a view of the pelvis after the complete resection, important fibrosis was present. An end-to-end mechanical anastomosis was performed under direct laparoscopic vision as a final step.
There was no intraoperative complications, oral intake started 48 hours after surgery but the patient developed a mild ileus that resolved with conservative treatment and was discharged seven days after the procedure.
Water soluble enema was correct (no leak or restenosis) and she is in the waiting list for reversing the diverting stoma.