How I do it: Nerve-sparing laparoscopic low anterior resection: Step by step nerve identification and preservation

Advances in surgical techniques, together with the widespread use of neoadjuvant and adjuvant therapies, have markedly improved disease-free and overall survival in patients with rectal cancer. Nevertheless, urogenital dysfunction remains a significant source of postoperative morbidity, primarily due to the anatomical location of the rectum and its close relationship with the autonomic pelvic nerves. Although the incidence of urological complications has declined to below 10%, sexual dysfunction continues to affect approximately one-quarter of patients. Nerve-sparing total mesorectal excision, performed without compromising oncological principles, has therefore become a critical component of contemporary rectal cancer surgery. Minimally invasive video-assisted techniques, offering magnified visualization and enhanced precision during pelvic dissection, facilitate the accurate identification and preservation of autonomic nerve structures. However, current evidence indicates that awareness and consistent application of nerve-sparing principles remain suboptimal, even among experienced colorectal surgeons. This video systematically demonstrates the key anatomical landmarks and stepwise surgical maneuvers required for effective nerve preservation during total mesorectal excision, aiming to reduce urogenital functional morbidity.