IndicationsThe key of modern rectal surgery has been the advent of total mesorectal excision (TME) [1]. Laparoscopic colorectal surgery is proven to be equivalent [2]. The Anterior Perineal Plane for Ultralow Anterior Resection of the Rectum (APPEAR) technique [3] allows a coloanal anastomosis by safe mobilization of the distal rectum and the pelvic floor musculature under direct vision, especially for the puborectal muscle and the external anal sphincter (EAS). As the APPEAR technique has only been combined with the abdominal part performed in the conventional "open" manner, we report the first case with previous laparoscopic mobilization of the rectum with TME plus mobilization of the left colon and the splenic flexure.A 69-year-old male without further medical history presented with a circular rectal adenocarcinoma (G2, M0), 5 cm from the anal verge. Digital rectal examination revealed an almost circular ulceroinfiltrative lesion with restricted mobility (Mason 3) about 5 to 6 cm from the anal verge centered on the anterior rectal wall. There was no clinical evidence for sphincter involvement neither under resting pressure nor under squeeze. The endoscopic ultrasound (EUS) staged the tumor as uT3 uN+. The high-resolution MRI report of the pelvis concluded that the lesion was stranding the perirectal fat tissue but not the mesorectal fascia; the anterior aspect of the circumferential margin was not at risk. Further there were obvious signs of lymphadenopathy (T3 N2) without pelvic wall infiltration or inguinal lymph nodes, verifying the results of the EUS.For restaging after neoadjuvant treatment, the patient presented without side effects in excellent condition. The high-resolution MRI showed good tumor response (yT3 yN0) with considerably regressive mesorectal infiltration. The tumor was mobile in the pelvis (Mason 2) and during EUS the aboral tumor margin presented 5 cm oral of the anal verge and 2 cm oral of the puborectal muscle, showing sufficient resection margin for this tumor grading (G2). The patient was then referred to our department and scheduled for laparoscopically assisted low anterior resection. Perineal approach was considered as a valuable alternative to intersphincteric resection. The patient gave surgical consent to undergo any surgical procedure necessary to treat his rectal cancer, preferably preserving anal continuity. MethodAfter preoperative insertion of a peridural catheter according to our standard "fast-track" scheme, the patient was placed under general anesthesia in the lithotomy position and received prophylactic antibiotics on induction. The laparoscopic anterior resection was performed by a fourtrocar approach (Fig. 1). TME was performed preserving the autonomous nerves. In the prerectal space, the seminal vesicles were separated while the filmy Denonvillers' fascia was preserved. In this manner the spatium between the prostate and rectum was entered and dissected towards the pelvic floor. As the tumor was filling almost all pelvic space, neither a linear nor an angular stapler...

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