Complications - Open rectal resection, low anterior with total mesorectal excision (TME)

Severing of the left ureter

• This can be avoided by dissecting in layers and carefully ensuring that only the mesosigmoid is mobilized from the lateral side.
• Furthermore, the ureter should be identified, but to spare the nerve plexus running in this region, no extensive exposure should be performed. Slinging is also not common in our own procedure.

Bleeding from the sacral plexus

• This very serious complication, which can quickly become life-threatening, is avoided by preparing very precisely in the mesorectal sliding layer.
• If bleeding does occur, it is usually not possible to control it by suturing (exception: bleeding after injuries to the internal or external iliac vein). Here it is more sensible to perform tamponade for several minutes early on, as long as the blood clotting is still stable. Smaller bleedings can be reliably controlled by longer-term compression alone.
• If extensive bleeding does occur, it is recommended to complete the rectal resection under temporary compression, to transect the rectum distally with the stapler and to tamponade the pelvis and, if necessary, to initially create the stoma in the sense of a Hartmann operation. If the patient then stabilizes, and the inserted tamponade can be removed at a later time (e.g. after 2 days), the anastomosis should then be performed or in a later interval, depending on the patient's condition.

Anastomotic leakage

• The anastomosis should be created under direct vision and with the stapler, the counter-pressure plate should be tied in very carefully.
• If a leakage does occur, oversewing should be performed where it is present and a protective stoma should be placed for safety.

Anastomotic Insufficiency

• A common and problematic complication after anterior rectal resection is anastomotic insufficiency. This occurs in 10–20 % of cases. Its frequency can be minimized by a tension-free and excellently vascularized anastomosis, which is created with the stapler as a primarily tight anastomosis.
• If it does occur and stool leaks into the pelvis, peritonitis develops, which must be treated by re-laparotomy. At the latest at this point, a stoma must be created.
• If a stoma is placed upstream, and the infection is limited to the pelvis, healing can be achieved by local irrigation and drainage measures incl. Endo-V.A.C.® therapy. As a rule, the stoma must be left in place during this period.

Nerve Damage

• Damage to the sympathetic nerve plexuses pre-aortally results in retrograde ejaculation.
• Nerve damage after the union of sympathetic and parasympathetic fibers at the level of the seminal vesicles leads to erectile dysfunction, impotence, and bladder emptying disorders.

Fecal Incontinence

• Regulate stool consistency 
• Pelvic floor exercises 
• Biofeedback therapy
• In case of therapy resistance and corresponding suffering of the patient or complications (e.g., sacral decubitus), possibly conversion to a terminal colostomy.