Abstract
PurposeDistal rectal stapling is often challenging because of limited space and visibility. We compared two stapling devices in the distal rectum in a cadaver study: the iDrive™ right angle linear cutter (RALC) (Covidien, New Haven, CT) and the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH).MethodsTwelve male cadavers underwent pelvic dissection by 4 surgeons. After rectal mobilization as in a total mesorectal excision, the staplers were applied to the rectum as deep as possible in both the coronal and sagittal positions. The distance from the pelvic floor was measured for each application. A questionnaire rated the visibility and access of the stapling devices. Measurements were taken between pelvic landmarks to see what anatomic factors hinder the placement of a distal rectal stapler.ResultsThe median (range) distance of the stapler from the pelvic floor in the coronal position for the RALC was 1.0 cm (0-4.0) vs. 2.0 cm (0-5.0) for the CC, p = 0.003. In the sagittal position, the median distance was 1.6 cm (0-3.5) for the RALC and 3.3 cm (0-5.0) for the CC, p < 0.0001. The RALC scored better than the CC in respect to: 1. interference by the symphysis pubis, 2. number of stapler readjustments, 3. ease of placement in the pelvis, 4. impediment of visibility, 5. ability to hold and retain tissue, 6. visibility rating, and 7. access in the pelvis. A shorter distance between the tip of the coccyx and the pubic symphysis correlated with a longer distance of the stapler from the pelvic floor (p = 0.002).ConclusionsThe RALC is superior to the CC in terms of access, visibility, and ease of placement in the deep pelvis. This could provide important clinical benefit to both patient and surgeon during difficult rectal surgery.
Highlights
Oncologic outcomes after surgical treatment of rectal cancer have been improved by techniques such as the total mesorectal excision (TME) [1,2]
Surgeons trained in deep pelvic surgery may deal with a close distal margin utilizing a handsewn coloanal anastomosis, where the rectum is amputated from the anus through a transanal approach, and an anastomosis is established between the colon and anal canal using manually placed sutures
Visual impediment was rare with both stapling devices placed sagittally. (Table 5) Superior visibility was experienced with the stapler in the coronal compared to sagittal position with the right angle linear cutter (RALC) in 67% of the applications (32/48), and in 96% (43/45) of the applications with the curved cutter (CC). (Table 7) Overall, the surgeons rated the best position for the RALC as coronal in 73% (35/48), and in 98% (44/45) with the CC. (Table 7)
Summary
Oncologic outcomes after surgical treatment of rectal cancer have been improved by techniques such as the total mesorectal excision (TME) [1,2]. The ability to place a stapling device deep in the pelvis with good visualization could determine whether a sphincter-preserving operation is performed, or whether an Surgeons trained in deep pelvic surgery may deal with a close distal margin utilizing a handsewn coloanal anastomosis, where the rectum is amputated from the anus through a transanal approach, and an anastomosis is established between the colon and anal canal using manually placed sutures. This approach remains the gold standard in cases of a threatened distal margin. A stapling device should be easy to apply, but must be reliable since failure to form a proper staple line could lead to serious adverse outcomes such as an anastomotic leak
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