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BACKGROUND
Laparoscopic total mesorectal excision for rectal cancer is coming out of age with recent publications highlighting its safety, feasibility, sound oncological outcomes, and improved quality of life. Nevertheless, laparoscopic proctectomy remains a challenging procedure. An embedded didactic video demonstrates a step-by-step laparoscopic total mesorectal excision with coloanal anastomosis for a low rectal cancer.

METHODS
A five-trocar technique is shown. The key steps demonstrated are: high division of the inferior mesenteric artery, medial-to-lateral mobilization of the descending colon, high division of the inferior mesenteric vein, take-down of the splenic flexure, total mesorectal excision with division of the rectum at the pelvic floor, and side-to-end coloanal anastomosis. Principles of a good anastomosis and potential pitfalls are described, including protection of the ureter and pelvic autonomic nerves.

RESULTS
A series of ten consecutive patients operated for low rectal cancer with total mesorectal excision is reported. Median (range) operative time and estimated blood loss were 274 (135-360) minutes and 25 (10-50) ml. Median tumor height from the anal verge was 7 (4-10) cm. Reconstruction included three coloanal J-pouch and seven side-to-end anastomosis. Nine anastomoses were performed by using a double-stapled technique. One patient with an intersphincteric dissection required a handsewn anastomosis. A diverting ileostomy protected all coloanal anastomosis. Median length of stay was 3 (range, 2-7) days. One of ten patients was readmitted for a small bowel obstruction. The embedded video demonstrates a total mesorectal excision down to the pelvic floor in a patient who had a T2 cancer 6 cm from the anal verge with prior open cholecystectomy and hysterectomy.

CONCLUSIONS
Laparoscopic total mesorectal excision is a safe and effective procedure. Patient selection and advanced laparoscopic skills are paramount. It is hoped that this didactic video will contribute to a wider and safer practice of laparoscopic total mesorectal excision for low rectal cancer.