Low section of the rectum during laparoscopic total mesorectal excision using the ContourTM device

Abstract

The advantages of the laparoscopic approach for colon cancer have been clearly demonstrated, and there is now growing evidence for the possible role of this type of surgery for rectal cancer [2, 3]. Initial reports show the technical feasibility of total mesorectal excision, with adequate oncologic clearance and optimal immediate and long-term outcome. The conversion rate ranges between 0% and 20%, and anastomotic leakage is below 20% [1–4]. The laparoscopic approach facilitates the procedure, as magnification permits dissection of the lower rectum as far as the supra levator level. Local anatomy (male versus female pelvis, prostate volume, and size of the tumor) may impair adequate dissection, but the most challenging step could be the transection of the lower rectum. Available devices (30, 45, or 60 mm endostaplers, straight or flexible) reach the transection line in an oblique direction when introduced through the right iliac fossa or through a suprapubic trocar. More than one staple loader is usually required to complete the transection, obtaining a zigzag staple line. The distal rectal stump acquires an asymmetric trapezoidal shape whose corners may be poorly irrigated. The usual neoadjuvant therapy with chemoradiotherapy may increase the risk of staple line failure. A stapler and cutting device for section of the distal rectum has recently been designed for open surgery (Contour, Ethicon). Using the curved end of this instrument makes it possible to encircle the distal rectum and perform a uniform horizontal stapling line with a single shot. Despite its shortcomings as a device specifically designed for open surgery, the Contour device may be adequately adapted to endoscopic surgery. This report aims to show the possible utility of this device in endoscopic surgery and illustrate the need for improved staplers to ameliorate the complexity of the surgical task when operating in the low rectum.