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Climent et al. Mini-invasive Surg 2018;2:45 I http://dx.doi.org/10.20517/2574-1225.2018.62 Page 7 of 13

treatment, pelvic floor rehabilitation, biofeedback and colonic irrigation [49,51] . Some authors have suggested
the use of sacral nerve stimulation after the failure of conservative management, with a success rate of 75%
after a median follow up of 18 months, but its use has been described only in a small series of patients [49,53] .
Further prospective studies are required to assess the success of this technique.

Incisional and port-side hernia
[2]
[54]
Laparoscopic approaches have reduced the incidence of incisional hernia, in 2.3% to 13% depending
on the length of follow-up, but many rectal resections still require an abdominal incision for specimen
[55]
extraction. A multivariate analysis performed by DeSouza et al. identified high body-mass index, wound
infection and diabetes as risk factors for incisional hernia, and the Pfannenstiel incision as independent
protector of an incisional hernia. Many surgeons now choose to avoid a midline extraction site to minimize
this complication. In a review of patients undergoing laparoscopic colorectal surgery, midline incisional
[54]
hernia accounted for 84% of all hernias compared to 4.8% for Pfannenstiel incision . However, authors
report no benefit in extending the left iliac fossa port (transverse incision) rather than a midline incision,
[56]
with similar incidence of extraction site incisional hernia and wound infection rate . In order to avoid
the risk of incisional hernias, some authors suggest the use of prophylactic mesh. A randomized controlled
trial with patients undergoing colorectal surgery through a midline incision shows a reduction of incisional
hernia in the group with a prophylactic overlay large-pore polypropylene mesh by 20.2%, without increase
[57]
of SSIs with no mesh rejection .
Rectovaginal and colovesical fistulas
Rectovaginal fistula (RVF) is thought to be an infrequent complication after LAR, approximately 3%,
[58]
appearing as a late complication, sometimes more than 3 months after surgery . Clinical suspicion is
confirmed by rectal and gynaecological examination, and by endoscopic and radiological investigations.
Traditionally, previous hysterectomy and the experience of a surgeon using the circular stapler were
described as prognostic factors of a RVF. Careful dissection between the rectal stump and posterior
vaginal wall is required and a marked posterior angle introducing the circular stapler in the rectal stump,
[59]
in order to avoid the inclusion of vaginal wall in the tissue rings (doughnuts) . Other authors suggest
malnutrition, neoadjuvant chemotherapy, tumour size ≥ 50 mm, intraoperative bleeding and lateral lymph
[58]
node dissection as risk factors for developing RVF . The American Society of Colon and Rectal Surgeons
recommends delaying surgical intervention for a period of 3 to 6 months to allow possible spontaneous
[60]
healing of the fistula; in the event of acute inflammation, a draining seton may be required . There is
no consensus regarding the need for faecal diversion but in some cases, diversion alone may result in
healing [60,61] . RVF after anterior resection are typically too high to be repaired with a perineal approach and
often requires an abdominal approach, to redo the anastomosis with omentoplasty interposed between the
vagina and the rectum. In refractories RVF, a proctectomy with colon pull-through provides good results,
[61]
with the caveat that functional outcome is suboptimal .
Some authors suggest that the persistence of an AL, even when there is a discrete sinus (1%-5% of LAR)
could be associated to a rectovaginal/rectourethral/colovesical fistula, or also to some degree of stenosis,
[28]
recommending early repair of AL in order to avoid these complications . Urinary sepsis and the presence
of gas in the bladder in absence of catheterisation raise suspicion of colovesical fistula [Figure 2].
Urinary and sexual dysfunction
Autonomic nerves can be damaged during total mesorectal excision. Dissection along the avascular plane
between presacral fascia and mesorectal fascia, the so called “holy plane”, preserves sacral vessels and
autonomic nerves including the superior hypogastric plexus, the hypogastric nerves, the pelvic (inferior
[52]
hypogastric) plexus, the pelvic splanchnic nerves, and the neurovascular bundle of Walsh . However,
the presence of urinary and sexual dysfunction among patients who underwent an anterior resection, as