 Today, we are going to discuss the surgical anatomy for low anterior dissection for cancer of the rectum. One of the prerequisites are that the procedure should be reproducible. It means that if I am able to do, then everyone should be able to do. And that is why we are doing this surgery only with monopolar energy source. The first step is to lift up the sigmoid colon. And by doing so, we also lift up the inferior mesentric artery as shown by the red arrow. The first step is to incise the peritoneum, the visceral peritoneum, just adjacent to the inferior mesentric artery at the level of the promontory. While doing so, you can identify the pre-sacral fascia and the mesorectal fascia now shown by the blue arrow. The pre-sacral fascia is the fascia which is underneath the hypogastric plexus of nerves and the mesorectal fascia is the one which is above it. Now with the monopolar energy source, we are dissecting between the nerve and the mesorectal fascia. The purpose is to identify the loose areolar tissue which is now being shown just underneath the promontory. And now you can see the hypogastric plexus of nerves and the cores. The important thing here is being shown is that the right urator is lateral to the hypogastric plexus of nerves. Now the same dissection is continued upwards to identify the inferior mesentric artery and what lies lateral to the inferior mesentric artery is nothing but the left urator. Now you will be able to see with the medial to lateral dissection, the left urator and the left hypogastric nerve as being shown by the monopolar energy source. So you can see the hypogastric plexus of nerve and the urator lateral to it. Now the dissection is continued cranially towards the inferior mesentric artery. You can see the peristalsis of the left side of the urator, clearly the inferior hypogastric plexus of nerve being shown at the level of the promontory. And now you retract with your left hand forceps the inferior mesentric artery and the dissection is continued with the monopolar cotry cranially to identify and dissect the inferior mesentric artery from all the sides. Remember it is very important to stay close to the inferior mesentric artery at this point of time as the hypogastric plexus of nerves converge at this point of time. Now we have opened the left side of the peritoneum from the medial to the lateral dissection. The lymph nodes right up to the level of the root of the inferior mesentric artery are also removed. You can see the left colic branch taking off from the inferior mesentric artery and distal to the take off of the left colic branch the inferior mesentric artery is clipped and ligated and cut. Once you cut the inferior mesentric artery the assistance should hold the inferior mesentric artery pedicle up because just underneath the inferior mesentric artery pedicle would lie the holy plane of healed. This is an avascular plane. As you can see the rectum is lifted up by the assistant and you can see the loose areolar fatty tissue. As you can see in the PIP diagram we are going to focus on this layer of mesorectal fat. The mesorectal fascia completely encases or encloses this fibro fatty tissue which comprises of the rectum and the perirectal lymph nodes. You can see the loose areolar tissue being cut posteriorly. This is the posterior dissection of the mesorectal fascia or of the mesorectum. At 8 o'clock position you can see the vessels being exposed that is where the presacral fascia was breached mistakenly and now the correction of the fascia dissection more proximal more closer towards the rectum is done. The same mesorectal fascia dissection is continued posteriorly right up to the levator and I and posterior laterally also the bipid of the hypogastric plexus of nerve can be seen on both the sides. Now in this view you can see the left hypogastric plexus of nerve being pulled up and in sometime you will also see the right hypogastric plexus of nerve. The mesorectal fascia is continued posterior laterally now as being done all the dissection needs to be done from the posterior side itself right up to the levator and I and in doing so you can identify the buttocks of an infant hanging down as being shown in the video. This is the right posterior lateral dissection being performed. You can see in the PIP mode now once the posterior and the posterior lateral dissection is done the rectum is pulled by the assistant surgeon and the anterior dissection between the urinary bladder or the seminal vesicle and the prostate and the rectum is performed. This fascia is called as the denonvillus fascia. The anterior lateral dissection is very carefully performed because the sexual fibres or the nerves run laterally near the pedicle of the seminal vesicles. You can see the seminal vesicles and the prostate gland coming up. The denonvillus fascia are basically two fascias which are closely in relation. The posterior or the first layer is in relation to the rectum and the anterior layer is more in relation to the prostate and the seminal vesicle. Now if the dissection is performed in this area then we are going to take the second layer of the denonvillus fascia as well and expose the seminal vesicle and the prostate completely. However because this needs to be preserved the dissection is done in the first layer of the denonvillus fascia that is closer to the rectum. Now you can see this is also the envelope of the mesorectum the same envelope which continues from posterior to the posterior lateral and then to the anterior lateral and then finally to the anterior side. We had already done the dissection of the left side from posteriorly that is the left posterior lateral dissection and hence we just needed to cut the peritoneum. The left lateral dissection of the mesorectum is done by the monopolar forceps again. The whole surgery is performed with monopolar just to make you realize that this is a beautiful envelope which is completely avascular and if you remain in the right plane then all the structures can be done by monopolar and you don't really need big instruments like ligature or harmonic. However in 25% of the cases you encounter the middle rectal artery as is being shown in the PIP mode and in the in the surgery the middle rectal artery is ligated and cut with the ligature and this is an ultra low anti resection and hence the dissection is performed right up to the levator and I which is being cut the superficial fibers of the levator and I so that the whole resection can be done right up to the levator and I or the pelvic floor. By doing so we are not trying to cone down the specimen so the coning of the specimen has to be avoided at all cost. As you can see the dissection is performed from all sides the mesocolic fascia is dissected from all the sides that is the posterior the anterior the posterior lateral and the anterior lateral exposing the posterior surface of the prostate and both the seminal vesicles completely. Now this shows the whole of the surgical anatomy or the facial anatomy for dissection of the cancer of the rectum or the pelvic surgeries. Thank you.