Rectal resection, open, low anterior with total mesorectal excision (TME) - general and visceral surgery

Median laparotomy starting at the symphysis and terminating a few centimeters superior to the umbilicus. (It is very important to carry the skin incision down to the symphysis because otherwise this would greatly impair access to the lesser pelvis). If necessary, mobilize the bladder somewhat. Insert a circular wound edge protector followed by a retractor. Intraoperative exploration.

Retract the colon mediad and sharply divide the lateral peritoneal adhesions of the colon with the abdominal wall. Carefully ensure that the preparation is not carried too deeply, i.e., down to the psoas muscle and posterior to the kidney, but that only the mesosigmoid will be mobilized. This will automatically expose the left ureter posteriorly which can then be identified. There is no need to dissect the ureter as in ureterolysis.

Mobilize the splenic flexure by alternating between inferiorly dissecting the descending colon off the anterior left kidney in the areolar plane and superiorly by freeing the greater omentum from the transverse colon and entering the lesser sac. As last step divide the links with the spleen.