The procedure is tailored to the tumor’s location, stage, and patient health:

1. Before Surgery Evaluation:
   
   • Diagnosis:
     
     • Colonoscopy with biopsy confirms rectal cancer.
     • MRI pelvis assesses tumor depth, sphincter involvement, and lymph nodes.
     • CT/PET scans evaluate metastasis for staging.
     • Blood tests measure CEA (cancer marker) and surgical fitness.
   • Neoadjuvant chemoradiation (4–6 weeks) is often given for T3–T4 or node-positive tumors to shrink the tumor and improve sphincter preservation.
   • Bowel preparation (laxatives, enemas) clears the colon 1–2 days prior.
   • An enterostomal therapist marks a stoma site for a temporary ileostomy.
2. Surgical Techniques:
   
   • Open Ultra-Low Anterior Resection:
     
     • Performed under general anesthesia, lasting 3–5 hours.
     • A midline abdominal incision provides access to the rectum and sigmoid colon.
     • The rectum is mobilized down to the pelvic floor, preserving pelvic nerves to maintain bladder/sexual function.
     • Total mesorectal excision (TME) removes surrounding fat and lymph nodes to reduce recurrence.
     • The rectum is resected just above the anal sphincter (distal margin 1–2 cm).
     • The descending colon is anastomosed to the anal canal (coloanal anastomosis) using a stapling device or hand-sewn technique.
     • A temporary loop ileostomy is created in 70–90% of cases to protect the anastomosis, reversed after 3–6 months.
   • Laparoscopic Ultra-Low Anterior Resection:
     
     • Minimally invasive, using 4–5 small incisions, a laparoscope, and instruments.
     • Suitable for early-stage cancers, offering less pain and faster recovery.
     • Takes 3–5 hours; conversion to open surgery is possible if complications arise.
   • Robotic-Assisted Ultra-Low Anterior Resection:
     
     • Uses robotic systems (e.g., da Vinci) for enhanced precision in the narrow pelvis, improving nerve preservation.
     • More expensive, available in centers like Apollo or Medanta.
   • Additional Considerations:
     
     • A colonic J-pouch may be created during anastomosis to improve continence and reduce stool frequency.
3. After Surgery:
   
   • ICU monitoring for 1–2 days manages pain, fluids, and stoma function.
   • Hospital stay: 5–10 days (open), 3–7 days (laparoscopic/robotic).
   • Pathology reports confirm margins, lymph node status, and staging, guiding adjuvant therapy (e.g., chemotherapy).
   • Stoma care training is provided for temporary ileostomy patients.