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Adenocarcinoma of the lower rectum can be resected with a sphincter-sparing procedure but exposure of the lower pelvis may be difficult and sphincter function may be compromised. We have performed a low anterior resection for rectal cancer in a 69-year-old woman with mobilisation of the tumour and anastomosis performed transvaginally without a covering stoma. This way we could get good exposure of the lower rectum and anal sphincters. The patient made an uneventful recovery and was fully continent after surgery. Transvaginal low anterior resection is an alternative route which may be useful in cases of difficult exposure of low rectal cancer.

We performed a low anterior resection of the rectum with a combined abdominal and trans-sphincteric (below the levator level) approach on a 55-year-old male with low rectal cancer. The purpose of this approach is to optimize exposure for low-lying rectal cancer. The patient had been found to have a rectal adenocarcinoma 2.5 cm from anal verge (Fig. 1); T2, N0 on MRI staging.The procedure was performed with the patient in the Lloyd-Davis position. The abdominal part of the procedure was carried out through a midline laparotomy, and the rectum was dissected down to the level of the levator ani muscles. The perineal part was carried out through a vertical incision between the scrotum and the anus (Figs. 2, 3).The levator ani muscles were encountered (Fig. 4). The rectum was dissected circumferentially in the extrasphincteric plane until the perineal and the abdominal dissection were joined (Fig. 5). At this point, the distal rectum was transected transversely just below the tumor, through a transsphincteric approach (Fig. 6). A fresh cadaver dissection demonstrates the anatomic structures encountered with this approach (Fig. 7). A manual anastomosis was fashioned under direct vision (Figs. 8, 9). The wound was closed in layers, and a drain was left in place without a diverting stoma (Fig. 10). Pathological examination confirmed a well-differentiated T2 N0 rectal adenocarcinoma with a 1-cm distal resection margin and a clear tangential margin.The patient is fully continent for solid stool and has occasional incontinence (less then once a week) of liquid stool and flatus. He is tumor free 13 months after the procedure.

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Objective: To define the techniques used in lower rectal cancer surgery, by transvaginal and transperineal approach; extrasphincteric dissection, proximal segmental sphincteric excision and transsphincteric rectal resection. Material and Methods:Between 2007 and 2013, 7 patients (4 female, 3 male with lower rectal cancer were operated by sphincter-saving extrasphincteric disection and proksimal sphincteric excision techniques. After completion of the rectosigmoid dissection and total mesorectal excision up to the puborectal muscle level; extrasphincteric rectal dissection, transsphincteric rectal resection and ultra-low coloanal anastomosis were performed by using the transvaginal and transperineal approach in the sublevator phase of the operation.Results: Seven patients were operated with sublevator access for lower rectal cancer. Bowel contiunity has been provided in all patients. One patient died due to surgical complications in the early postoperative period. One patient deceveloped anastomotic leakage and there were two patients with anastomotic stricture. Circumferential resection margin and tumoral perforation were found negative in all of the patients. Tumoral deposits at the distal resection line was observed in one patient. Conclusion:The techniques of sublevator rectal resection may be considered as an alternative sphincter-saving surgical method, especially in lower rectal cancer surgery.Key Words: Lower rectal cancer, sphincter-saving extrasphincteric dissection, proximal segmental sphincteric excision, transsphincteric rectal resection INTRODUCTIONColorectal cancer is the third most common tumor in men and women in the Western world, while it ranks as the second leading cause of cancer -related deaths (1). In approximately 25-30% of all cases of colorectal cancer, the tumor is located in the rectum (2), and in 70-80% of patients with rectal cancer it is located in the 2/3 of the rectum (3). In 90% of rectal cancer cases, the tumor is limited to the rectum and peri-rectal lymphatic tissue, thus surgical treatment is the primary option. Low rectal cancers have high rates of abdominoperineal resection and local recurrence as compared to those located in other parts (4, 5).The rectum is approximately 20 cm in length from the anal verge, and is evaluated in three sections of equal length (upper, middle and lower) (6). The lower rectum can be divided into two sections depending on the level of the puborectal muscle as supralevator and sublevator. The sublevator section constitutes distal 2/3 of the lower rectum, and is approximately 4-6 cm long. Sublevator access enables direct vision of the rectal segment that is below the levator muscle and performing surgical procedures. The distal rectum at the sublevator level is completely surrounded by the external sphincter complex that is located perpendicularly and shaped as pulleys, forming two intertwined cylindrical muscular structure. According to the anatomy described by Ahmed Shafik (7), the upper and wide portion of the perpendicular seated pulley -like ...