Four anastomotic techniques following transanal to

Authors: M Penna J J Knol J B Tuynman P P Tekkis N J Mortensen R Hompes

Publish Date: 2016/01/12

Volume: 20, Issue: 3, Pages: 185-191

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Abstract

Transanal total mesorectal excision TaTME is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers To date four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME We present a technical note describing these techniques and discuss the risks and benefits of eachAfter the combined laparoscopic and transanal TME dissection specimen removal and formation of an anastomosis are critical steps of the TaTME procedure In addition to handsewn coloanal anastomosis three stapling techniques for the colorectal anastomosis have been employed a stapled anastomosis using the EEA™ Haemorrhoid Stapler AutoSuture Covidien Dublin Ireland 4 a standard diameter circular stapler either in combination with a guiding 10Fr redivac drain 5 or a pullthrough method In this technical note we describe the different anastomotic techniques in detail and discuss their main differencesIf oncologically safe it is advised to perform a stapled colorectal anastomosis which tends to result in better functional outcome due to higher length of the rectal cuff Compared to standard laparoscopic or open stapling of the distal rectum the TaTME allows stapling techniques with excellent visualisation and avoidance of cross stapling especially in a male patient with narrow pelvis and obese patients As a result the TaTME procedure may lead to lower leakage rates and better functional and oncological outcomes However more data from large international cohorts and randomised trials are awaitedThe main difference for a stapled intestinal reconstruction compared to a standard laparoscopic anterior resection is the open rectal stump after a TaTME procedure A key aspect to ensure a reliable anastomosis is a fullthickness pursestring suture monofilament polypropylene suture 2/0 of the open rectal stump Gaps in the pursestring need to be avoided as this can lead to defects in the anastomosis Furthermore it is important to ensure that only the anorectal wall is incorporated into the pursestring Particularly in female patients the surgeon has to carefully inspect the vaginal wall The pursestring can be placed either through the access channel of the GelPoint Path Applied Medical for a colorectal anastomosis or within the anal canal for a coloanal anastomosis A circular anal dilator can enhance exposure when dealing with a very low rectal cuff which tends to retract into the anal canal 7 After completing the pursestring three different stapling techniques can be applied each with its own advantage points described below As the anastomosis is close to the anal margin it can be inspected after construction and reinforced if required under direct vision with hand placed interrupted sutures The abdominal CO2 allows easy visualisation transanally of any air leak through the anastomosis Similar to handsewn anastomoses a sidetoend colonic Jpouch or straight endtoend anastomosis can be constructedPursestring is placed on the open anorectal stump and the long spindle of the circular EEA™ stapler is brought transanally through the centre of the pursestring suture left image The anvil is connected to the centre shaft of the stapler and the pursestring is then tightened around the centre rod right image

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