PURPOSE: Optimal treatment of mid to distal rectal cancers includes total meso rectal excision for oncologic clearance and, where reanastomosis is feasible, a colonic J-pouch-anal anastomosis improves bowel function. There is recent interest in performing an ultralow anterior resection laparoscopically. 1-3 A technique is described that includes specimen extraction through the eventual routine dcfunctioning COlOStOll1Y or ilcosto111Y site. METHODS:Consecutive unselected patients who underwent laparoscopic ultralow anterior resection were recruited. Patients \-vith adenocarcinOlna underwent preoperative endorectal ultrasound to individualize for neoadjuvant chemoradiotherapy, based on local extent and lymph nodes seen. The operative procedures were as shown in the video. Posterior dissection along the "total mesorectal excision plane" included incision ofWaldeyer's fascia. Bowel continuity was restored by an intracoporeal double-cross stapled colonic I-pouch-anal anastomosis, but where not possible a coloplasty with pull-through handsewn coloanal anastOlllosis was performed. (n = I), and carcinoid with local lymph node metastases (n=I). The adenocarcinomas were a median distance of 6 (3-12) cm from the anal verge. Neoadjuvant radiotherapy was given in 12 patients (24 percent) who had preoperative endoanal ultrasound lindings of tumor extension beyond the muscularis propria and chemoradiotherapy in 7 (14 percent) of these patients where the tumor was more bulky and fIxed. Laparoscopic ultralow anterior resection was completed at a median 180 (90-405) minutes, with 53.5 (2-2250) ml of blood loss, and the specimen was extracted Electronic supplementary material The online version of lhis arLide (doi:l0.l007/s10350-008-9322-4) contains supplementary material, which is available to authorized users. through a 4.5 (3.5-11) cm wound. The latter included three cases (5 percent) that were converted. SignifIcant adhesiolysis was required in 29 patients (52.7 percent) because of previous operations. The histologic grading or the adenocarcinoma patients were: Stage I, n=14; Stage II, n=23; Stage III, n= 11; Stage IV, n=3. Of those who underwent curative resection (Stages I-IIO, the distal resection margin was 2.9±0.7 cm (mean±standard error) and the radial resection n1m'gins ,,,ere at least 2 mn1 in all patients. The level of the coloanal anastomosis was a median 3.5 (0-4.5) cm from the anal verge; a coloanal pull-through anastomosis was required in one patient who had a distal cancer. The ileostomies functioned and patients tolerated free fluids at a median of two (1-9) days, and the median postoperative hospital stay was seven (3-22) days. At a median follow-up of 14 (2-33) months, none of the adenocarcinoma patients who had lmdergone curative resection had recurrences. Four patients (8 percent) had postoperative complications that required operativelinvasive intervention (anatomotic leak n=l, proximal bowel ischemia n=l, port site hernia n= 1, pelvic collection n= I). Four other patients had smaller pelvic collections ...