Stapled Side-to-side Colo-anal Anastomosis in Middle and Upper Rectal Tumors: A Modification in the Technique

Ashok Kumar¹, Nalinikanta Ghosh², Shomnath Reddy³

^1–3Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Corresponding Author: Ashok Kumar, Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +05222495537, e-mail: drashok97@gmail.com

How to cite this article: Kumar A, Ghosh N, Reddy S. Stapled Side-to-side Colo-anal Anastomosis in Middle and Upper Rectal Tumors: A Modification in the Technique. World J Lap Surg 2023;16(2):110–113.

Source of support: Nil

Conflict of interest: None

Received on: 10 July 2022; Accepted on: 21 August 2023; Published on: 19 December 2023

ABSTRACT

Aim: The aim of reporting this technique is to show the new surgical method and its feasibility.

Background: Stapled colo-anal anastomosis is preferred in laparoscopic and open anterior and low anterior resection (LAR). Placement of purse-string suture around the anvil in the colon is an important step. Failing to place these sutures properly can lead to an incomplete doughnut, which can further lead to an anastomotic site leak and a whole spectrum of complications thereafter.

Technique: We adopted an innovative method, where we inserted an anvil through the specimen site of the colon and brought out its pin through the antimesenteric site of the colon just before the division. It ascertains a complete doughnut each and every time in a quick time.

Conclusion: Stapled colo-anal anastomosis is an easy and quick method with equal safety as a handsewn method; however, failure of the purse-string suture is responsible for an anastomotic leak, which leads to short-term and long-term complications. This could be avoided by our adapted technique.

Clinical significance: This paper describes our technique, which can decrease the incidence of colo-anal anastomosis leak and all the spectra of postoperative complications, most importantly, sepsis and anastomotic stricture.

Keywords: Colo-anal anastomosis, Incomplete doughnut, Low anterior resection.

AIM

The aim of reporting this technique is to show a new surgical method and its feasibility, which is certainly able to get the complete doughnut in lower anterior resection procedure and subsequently decrease postoperative complications.

BACKGROUND

Upper and middle rectal cancer is surgically managed by an anterior or low anterior resection (LAR). The minimally invasive method has been popularized and made easy with the introduction of a circular stapler. The main technical issue is to obtain a complete doughnut. Failing to do so can lead to anastomotic leak, sepsis, and subsequent anastomotic site stricture. This can further lead to poor outcomes in the form of significant morbidity and mortality. Various technical modifications have been advocated by different surgeons across the globe. Herewith, we are presenting a modified, quicker, and easier-to-perform surgical technique to get a complete doughnut each time.

SURGICAL TECHNIQUE

Preoperative Preparation

Patients were kept on a liquid diet for 24 hours, followed by nil per oral for a minimum of 6 hours. Mechanical bowel preparation was done in all patients. Preoperative diverting stoma consent was taken in case of anastomosis below peritoneal reflection, poor nutritional status, and neoadjuvant chemoradiotherapy.

Intraoperative Technique

Patients were positioned in modified Lloyd-Davies position. Compression stockings were applied in all cases. Single doses of antibiotics covering gram-positive and gram-negative bacteria were given at the time of induction. All five standard laparoscopic ports were placed.

Resection

The rectum and descending colon were mobilized, keeping total mesorectal excision (TME) in mind and adequate proximal and distal margin with required lymphadenectomy. The rectum was distally divided with stapler by laparoscopic or open method.

Reconstruction

Reconstruction was done by making enterotomy at a point distal to the anticipatory proximal transection line (APTL), just enough to admit the anvil, and then the anvil was carefully migrated proximally to APTL by gradual milking (Fig. 1). The anvil pin was taken out through the teniae coli at the antimesenteric border of the colon and a silk suture was tied around the pin to avoid displacement inside the bowel lumen (Figs 2 and 3). Thereafter, proximal transection was done at APTL with triple-row NTLC linear cutter stapler (Fig. 4). All the above procedures lead to the internalization of the anvil, and the anvil pin is already out and prepared for colo-anal anastomosis. Thereafter, the standard procedure of colo-anal anastomosis was performed with a circular stapler and did not need any closure of the colonic end after the accomplishments of anastomosis. Checking for doughnuts followed by an anastomosis air leak test was done by us as routine.

Figs 1A and B: (A) Insertion of the anvil and decided transection line (blue line TL); (B) Showing an already placed anvil pin and application of stapler at the proximal transaction line

Figs 2A and B: (A) Making enterotomy over the anvil pin; (B) Complete anvil pin taken out through a small-enough enterotomy

Fig. 3: Represents the anvil pin that already came out through enterotomy with the tying of a silk suture around the pin to avoid displacement inside the lumen

Figs 4A and B: (A) Proximal transection with NTLC linear cutter stapler on the decided transection line (arrow indicating a small enterotomy for anvil insertion); (B) After stapler transaction, showing the proximal-prepared colonic limb and distal specimen limb including the enterotomy site

Postoperative Management

The patient is ambulated and allowed orally early. Drains were placed routinely and removed on the 3rd postoperative day.

DISCUSSION

Rectal malignancy requires multimodality treatment, and surgery holds a key part. Circular stapler has made anterior resection or LAR procedure easier than conventional suture anastomosis. One of the most fearsome postoperative complications is anastomotic site leak, which occurs in around 3–21% of patients.¹ This can lead to postoperative sepsis and anastomotic stricture as a long-term complication. There are many factors responsible for the anastomotic leak, e.g., patients’ clinical profile, tumor type, location, preoperative radiotherapy, and technical factors.² Except for technical factors, all other factors are nonmodifiable. Stapled anastomosis is the norm in the era of minimally invasive surgery, as it has a similar complication rate as handsewn anastomosis.³ There are two methods described for stapled anastomosis, i.e., single-staple and double-staple technique. The single-staple technique is difficult to perform, and the double-staple technique is preferred by most. There are various methods of double-staple technique, i.e., end-to-side or side-to-side. Distal division is followed by placement of anvil at the divided proximal end. After securing the anvil with purse-string suture, end-to-side anastomosis was done by EEA stapler anastomosis. Another technique was described by Baker’s, where the anvil is placed distally. Through the divided end of the colon, the handle of the stapler is introduced and then side-to-side anastomosis is made. The colonic stump is closed at the end.⁴ The first-described method is performed by most surgeons, which needs to take a purse-string suture around the anvil. The main disadvantage is not to get a proper suture around the anvil and an incomplete doughnut at the end. There are few surgeons who perform Baker’s technique also. The main disadvantage of Baker’s technique is to perform difficult closure of the colonic stump at the end in the presence of a narrow pelvis. It will require laparotomy for the introduction of the main component of the circular stapler to orient properly and it cannot be performed with a minimally invasive technique. In stapled anastomosis, the doughnut is important, as it is a surrogate marker of anastomotic integrity. Offodile et al. described that 19% (67/349) patients had technical failure following circular stapler application.⁵ Among them, 19% (13/67) had incomplete and thin doughnuts. So, one among five technical failures is attributable to defective doughnuts. Few studies have shown that incomplete doughnuts can lead to a significant increase in the rate of postoperative anastomosis leak as compared with complete doughnuts. Incomplete doughnut can be due to multiple technical factors like diseased bowel margin, loose application of purse-string sutures, far-placed sutures, and sutures cut through during suture placement. All the above factors can be taken care of by taking out the anvil through taenia, which is the strongest part of the colonic wall. There is no need for placement of sutures around and application of a stapler at the proximal end of the colon. There will always be a good rim of doughnut proximally.

ADVANTAGES OF THIS TECHNIQUE

Easy, quick, and convenient.
No need for purse-string suture application for placement of anvil.
Anvil coming out through the strong part of the colon, i.e., taenia coli.
No issues of incomplete doughnut.
No issues of proximal resection margin.
No issues of blood supply to the distal stump or no mesenteric margin.
Lesser chances of contamination.

In our experience, we have been using this method routinely, and we have not experienced any staple line-related complications as compared with the problems arising due to defective doughnuts. It could utilize any site of gastrointestinal where the circular stapler application is feasible. However, this technique can be practiced before recommending it as a routine practice.

CONCLUSION

Anterior or LAR with sphincter preservation is a standard procedure in carcinoma rectum. The problem of incomplete doughnut is the only modifiable technical factor that significantly increases postoperative morbidity and mortality. The above-mentioned method is easy, quick, and effective in avoiding the problem of incomplete doughnut and ultimately improving the outcomes; however, it further needs practice and evaluation.

Clinical Significance

This article describes our technique that is able to decrease the incidence of coloanal anastomosis leak and all the spectra of postoperative complications most importantly sepsis and anastomotic stricture.

REFERENCES

1. Law WI, Chu KW, Ho JW, et al. Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 2000; 179(2):92–96.DOI: 10.1016/s0002-9610(00)00252-x.

2. McDermott FD, Heeney A, Kelly ME, et al. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015;102(5):462–479. DOI: 10.1002/bjs.9697.

3. Neutzling CB, Lustosa SA, Proenca IM, et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012;(2):CD003144. DOI: 10.1002/14651858.CD003144.pub2.

4. Baker JW. Low end to side rectosigmoidal anastomosis; description of technic. Arch Surg 1950;61(1):143–157. DOI: 10.1001/archsurg.1950.01250020146016.

5. Offodile AC 2nd, Feingold DL, Nasar A, et al. High incidence of technical errors involving the EEA circular stapler: A single institution experience. J Am Coll Surg 2010;210(3):331–335. DOI: 10.1016/j.jamcollsurg.2009.11.007.

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