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Asian J Endosc Surg ISSN 1758-5902
SURGICAL TECHNIQUE
Complete laparoscopic surgery for early colorectal cancer after endoscopic resection Shungo Endo, Yusuke Takehara, Jun-ichi Tanaka, Eiji Hidaka, Shumpei Mukai, Tomokatsu Omoto, Fumio Ishida & Shin-ei Kudo Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
Keywords Laparoscopic colorectal surgery; rectal-prolapsing technique; totally laparoscopic surgery Correspondence Shungo Endo, 21-2 Yazawa aza Maeda, Kawahigashi-machi, Aizu-wakamatsu, Fukushima 969-3492, Japan. Tel: +81 242 75 2100 Fax: +81 242 75 2150 Email: [email protected] Received: 14 April 2013; revised 2 May 2013; accepted 12 May 2013 DOI:10.1111/ases.12045
Abstract Introduction: Laparoscopic-assisted colorectal surgery requires a minilaparotomy to extract the specimen and insert the anvil head of the circular stapler into the proximal colon. However, such a mini-laparotomy occasionally causes local pain and surgical-site infection. To avoid mini-laparotomy, we invented a new laparoscopic technique, complete laparoscopic surgery for colorectal cancer. Materials and Surgical Technique: Sigmoid colon or rectal cancer patients who had undergone colonoscopic excision for T1 cancer and subsequently required bowel resection due to unfavorable histology were recruited. This new procedure used both the double stapling technique and the rectal-prolapsing technique, where the anvil was transanally inserted into the proximal colon and bowel resection was extracorporeally performed after pulling out the colon–rectum via the anus. Discussion: This procedure was attempted in 17 patients and successfully achieved in 13 patients. Total laparoscopic colorectal surgery has some problems such as bacterial contamination or infection, as well as dissemination caused by intraluminal exfoliated cancer cells. This procedure is limited to post-endoscopic resection patients who are suited for reconstruction by double stapling technique, and it may be impossible in patients with thick mesentery or anal stenosis. Moreover, this method resolves issues of peritoneal contamination and dissemination. However, a new protection method for implantation of exfoliated cancer cells needs to be established, so that complete laparoscopic surgery can be employed in patients with small cancers.
Introduction Laparoscopic surgery for colorectal disease has become a standardized procedure. This procedure requires an abdominal incision for extraction of the specimen, and although the incision is smaller than that used in conventional open surgery, the wound occasionally causes postoperative pain, surgical-site infection and incisional hernia, reducing the advantages of laparoscopic surgery. Several reports have described a technique for totally laparoscopic resection and reconstruction in rectal cancer (1,2). To realize reconstruction using a double stapling technique (DST), the intestine is opened intraperitoneally because the anvil head of the circular stapler is introduced into the proximal colon. However, there are concerns
338
about intraperitoneal contamination or infection, as well as dissemination of exfoliated malignant cells. Therefore, we invented complete laparoscopic operation for colorectal cancer (CLOC) that comprises the anvil insertion into the proximal colon, the rectal-prolapsing technique for bowel resection and reconstruction by DST (3). In this paper, details of this new technique are described.
Materials and Surgical Technique Patients This study includes patients with T1 sigmoid colon or rectal cancer who required bowel resection with nodal resection due to unfavorable histology after endoscopic
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Complete laparoscopic colorectal surgery
S Endo et al.
Figure 1 A 12-mm port was placed in the right lower abdomen. Four or five 5-mm ports were placed in the right supraumbilical, right lateral abdominal, left lateral abdominal, and left lower abdominal regions. The supraumbilical port was used as the camera port with a 5-mm laparoscope.
resection. All patients were treated at Showa University Northern Yokohama Hospital (Yokohama, Japan) between August 2009 and March 2012. Surgical procedure Port sites are shown in Figure 1. A 12-mm port was placed in the right lower abdomen by the open method. Then, four or five 5-mm ports were placed. The sigmoid colon and rectum were mobilized up to the peritoneal reflection, even if the tumor was in the sigmoid colon. The CLOC procedure makes it easier to pull the distal transection line extracorporeally through the anus. The hypogastric nerves must be confirmed and preserved dorsally beforehand, because traction for these nerves may occur with eversion. After mesenteric lymph node and vessel dissection, the proximal and distal transection lines were determined, and transection of the mesentery was performed. A trocar was attached to the anvil head of a 28- or 29-mm circular stapler, and the anvil shaft was grasped with laparoscopic forceps and inserted to the proximal colon transanally (Figure 2). The proximal site was then transected with the linear stapler. The proximal colonic wall was penetrated by the trocar of the anvil about 3–5 cm away from the transection site for side-to-end anastomosis. Then the trocar was detached from the anvil and retrieved through the 12-mm port (Figure 3). The staple line of the distal stump, which was extracted by forceps inserted transanally, was grasped, and the
Figure 2 The scar from the previous endoscopic resection (former T1 cancer site) was marked with a combination of clipping and tattooing. The anvil head was grasped by laparoscopic forceps and transanally inserted into the proximal colon, beyond the proximal transection line.
colon–rectum was pulled out transanally while it was being everted. At this time, eversion can be facilitated if two points of the colonic wall are grasped near the stapler line. The skeletonized distal transection line, where the mesentery was resected beforehand, was palpated, and it was then transected with the linear stapler to extract the specimen (Figure 4). The distal stump was pushed back into the abdominal cavity while the circular stapler was inserted transanally, and reconstruction by DST was performed. The procedure from the anvil insertion to the distal transection is demonstrated in supporting information (Video S1).
Discussion Extraction of surgical specimen via natural orifices has been proposed as a bridging technique to NOTES (4). The vagina has been established as a specimen extraction route (5). For the left side colon and rectum, specimen extraction through the anus is reasonable and is also applicable to men. The rectal-prolapsing technique would be an appropriate method for resection and extraction of the specimen to obtain a natural orifice access. COLC has been performed in 17 patients to date. All cases were bowel resection with lymph node dissection after endoscopic resection. The procedure was completed in 13 of 17 patients. The procedure was not completed in the remaining four patients because a narrow lumen prevented the anvil head from being inserted into the
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
339
Complete laparoscopic colorectal surgery
S Endo et al.
Figure 3 The anvil shaft was grasped, and the colonic wall was penetrated about 3–5 cm away from the transection line. The trocar was detached from the anvil and retrieved through the 12-mm port. The proximal transection line was transected with the endoscopic linear stapler. The anvil of the circular stapler was secured with a silk braid through the hole of the tip and retrieved through the port.
Figure 4 The staple line of the distal stump was grasped and pulled outside the anus by an forceps inserted transanally. The proximal stump was opened, and the dissected vessel and mesentery were pulled out to prevent entanglement. The distal transection line was transected by the linear stapler to extract the specimen.
proximal colon (n = 3) and excessive mesenteric fat prevented the distal stump from being everted (n = 1). Because the lumen of sigmoid colon is not very large, use of a 25-mm circular stapler is required in some cases. In these patients, surgery could be safely completed a through a 3–6-cm small incision in a conventional laparoscopic procedure. Even when it was determined intraoperatively that CLOC was not possible, conversion to conventional laparoscopic-assisted surgery was possible without any problems. The median operative time
340
of CLOC was 199 min (range, 152–278 min) and median blood loss was 77 mL (range, 5–100 mL), which are similar to figures for standard laparoscopic surgery. The median number of lymph node harvested was 14 (range, 4–22), a number comparable to the harvest during standard laparoscopic surgery. For totally laparoscopic surgery, there are some issues regarding the anvil insertion into the proximal colon. As previously reported, the method used for totally laparoscopic colectomy involves the anvil being inserted transanally into the abdominal cavity, the proximal colon being opened in the peritoneal cavity, and the anvil being inserted into the colon (1,6). With these methods, both the proximal colon and the distal colon are opened in the peritoneum. Therefore, there are concerns about peritoneal contamination by enteric bacteria and peritoneal dissemination caused by intraluminal exfoliated cancer cells (7,8). To avoid opening the intestine in the peritoneal cavity during anastomosis creation, reconstruction by transanal anastomosis has been reported (9), but its indications are limited to lower rectal cancer. CLOC is premised on reconstruction by DST using the rectal prolapsing technique (3,10); the anvil is inserted transanally into the proximal colon, and bowel resection and excision are performed extracorporeally after the colon– rectumis pulled out transanally. Moreover, the CLOC method resolves issues of peritoneal contamination and dissemination. Proximal limitations depend on the reach of the forceps. For instance, if standard forceps are used to grasp the anvil, the level of the distal descending colon would be the
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Complete laparoscopic colorectal surgery
S Endo et al.
most proximal transection line. As for the distal limitation, to enable reliable closure of the everted intestine with the linear stapler, a distance between the anal verge and the tumor site should be approximately 4 cm (3). This procedure was limited to early sigmoid colon and rectal cancer after endoscopic resection, and it may be impossible in patients with thick mesentery or anal stenosis. There were no complications such as anastomotic leakage, and outcomes were good. However, a new protection method for implantation of exfoliated cancer cells needs to be established, so that complete laparoscopic surgery can be employed in patients with small cancers.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References 1. Akamatsu H, Omori T, Oyama T et al. Totally laparoscopic sigmoid colectomy: A simple and safe technique for intracorporeal anastomosis. Surg Endosc 2009; 23: 2605– 2609. 2. Cheung HYS, Leung ALH, Chung CC et al. Endolaparoscopic colectomy without mini-laparotomy for leftsided colonic tumors. World J Surg 2009; 33: 1287–1291. 3. Fukunaga M, Kidokoro A, Iba T et al. Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer. Surg Today 2005; 35: 598–602. 4. Palanivelu C, Rangarajan M, Jategaonker PA et al. An innovative technique for colorectal specimen retrieval: A new era of “natural orifice specimen extraction” (N.O.S.E). Dis Colon Rectum 2008; 51: 1120–1124. 5. Franklin ME Jr, Kelly H, Kelly M et al. Transvaginal extraction of the specimen after total laparoscopic right
6.
7.
8.
9.
10.
hemicolectomy with intracorporeal anastomosis. Surg Laparosc Endosc Percutan Tech 2008; 18: 294–298. Nishimura A, Kawahara M, Suda K et al. Totally laparoscopic sigmoid colectomy with transanal specimen extraction. Surg Endosc 2011; 25: 3459–3463. Tsunoda A, Shibusawa M, Tsunoda Y et al. Implantation on the suture material and efficacy of povidone-iodine solution. Eur Surg Res 1997; 29: 473–480. Umpleby HC, Fermor B, Symes MO et al. Viability of exfoliated colorectal carcinoma cells. Br J Surg 1984; 71: 659– 663. Person B, Vivas DA, Wexner SD. Totally laparoscopic low anterior resection with transperineal handsewn colonic J-pouch anal anastomosis for low rectal cancer. Surg Endosc 2006; 20: 700–702. Akamatsu H, Omori T, Oyama T et al. Totally laparoscopic low anterior resection for lower rectal cancer: Combination of a new technique for intracorporeal anastomosis with prolapsing technique. Dig Surg 2009; 26: 446–450.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Video S1 The procedure from the anvil insertion to the distal transection is demonstrated. The anvil attached to a trocar was grasped by laparoscopic forceps and inserted to proximal colon. Then, the proximal site was transected with the linear stapler. The proximal colonic wall was penetrated by the anvil trocar, and the trocar was detached from the anvil and retrieved through the 12-mm port. The penetrated colonic wall was sutured around the anvil shaft to prevent bacterial contamination. Next, the colon–rectum was inverted and pulled out transanally, and then distal site was transected the linear stapler.
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
341
Asian J Endosc Surg ISSN 1758-5902
SURGICAL TECHNIQUE
Complete laparoscopic surgery for early colorectal cancer after endoscopic resection Shungo Endo, Yusuke Takehara, Jun-ichi Tanaka, Eiji Hidaka, Shumpei Mukai, Tomokatsu Omoto, Fumio Ishida & Shin-ei Kudo Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
Keywords Laparoscopic colorectal surgery; rectal-prolapsing technique; totally laparoscopic surgery Correspondence Shungo Endo, 21-2 Yazawa aza Maeda, Kawahigashi-machi, Aizu-wakamatsu, Fukushima 969-3492, Japan. Tel: +81 242 75 2100 Fax: +81 242 75 2150 Email: [email protected] Received: 14 April 2013; revised 2 May 2013; accepted 12 May 2013 DOI:10.1111/ases.12045
Abstract Introduction: Laparoscopic-assisted colorectal surgery requires a minilaparotomy to extract the specimen and insert the anvil head of the circular stapler into the proximal colon. However, such a mini-laparotomy occasionally causes local pain and surgical-site infection. To avoid mini-laparotomy, we invented a new laparoscopic technique, complete laparoscopic surgery for colorectal cancer. Materials and Surgical Technique: Sigmoid colon or rectal cancer patients who had undergone colonoscopic excision for T1 cancer and subsequently required bowel resection due to unfavorable histology were recruited. This new procedure used both the double stapling technique and the rectal-prolapsing technique, where the anvil was transanally inserted into the proximal colon and bowel resection was extracorporeally performed after pulling out the colon–rectum via the anus. Discussion: This procedure was attempted in 17 patients and successfully achieved in 13 patients. Total laparoscopic colorectal surgery has some problems such as bacterial contamination or infection, as well as dissemination caused by intraluminal exfoliated cancer cells. This procedure is limited to post-endoscopic resection patients who are suited for reconstruction by double stapling technique, and it may be impossible in patients with thick mesentery or anal stenosis. Moreover, this method resolves issues of peritoneal contamination and dissemination. However, a new protection method for implantation of exfoliated cancer cells needs to be established, so that complete laparoscopic surgery can be employed in patients with small cancers.
Introduction Laparoscopic surgery for colorectal disease has become a standardized procedure. This procedure requires an abdominal incision for extraction of the specimen, and although the incision is smaller than that used in conventional open surgery, the wound occasionally causes postoperative pain, surgical-site infection and incisional hernia, reducing the advantages of laparoscopic surgery. Several reports have described a technique for totally laparoscopic resection and reconstruction in rectal cancer (1,2). To realize reconstruction using a double stapling technique (DST), the intestine is opened intraperitoneally because the anvil head of the circular stapler is introduced into the proximal colon. However, there are concerns
338
about intraperitoneal contamination or infection, as well as dissemination of exfoliated malignant cells. Therefore, we invented complete laparoscopic operation for colorectal cancer (CLOC) that comprises the anvil insertion into the proximal colon, the rectal-prolapsing technique for bowel resection and reconstruction by DST (3). In this paper, details of this new technique are described.
Materials and Surgical Technique Patients This study includes patients with T1 sigmoid colon or rectal cancer who required bowel resection with nodal resection due to unfavorable histology after endoscopic
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Complete laparoscopic colorectal surgery
S Endo et al.
Figure 1 A 12-mm port was placed in the right lower abdomen. Four or five 5-mm ports were placed in the right supraumbilical, right lateral abdominal, left lateral abdominal, and left lower abdominal regions. The supraumbilical port was used as the camera port with a 5-mm laparoscope.
resection. All patients were treated at Showa University Northern Yokohama Hospital (Yokohama, Japan) between August 2009 and March 2012. Surgical procedure Port sites are shown in Figure 1. A 12-mm port was placed in the right lower abdomen by the open method. Then, four or five 5-mm ports were placed. The sigmoid colon and rectum were mobilized up to the peritoneal reflection, even if the tumor was in the sigmoid colon. The CLOC procedure makes it easier to pull the distal transection line extracorporeally through the anus. The hypogastric nerves must be confirmed and preserved dorsally beforehand, because traction for these nerves may occur with eversion. After mesenteric lymph node and vessel dissection, the proximal and distal transection lines were determined, and transection of the mesentery was performed. A trocar was attached to the anvil head of a 28- or 29-mm circular stapler, and the anvil shaft was grasped with laparoscopic forceps and inserted to the proximal colon transanally (Figure 2). The proximal site was then transected with the linear stapler. The proximal colonic wall was penetrated by the trocar of the anvil about 3–5 cm away from the transection site for side-to-end anastomosis. Then the trocar was detached from the anvil and retrieved through the 12-mm port (Figure 3). The staple line of the distal stump, which was extracted by forceps inserted transanally, was grasped, and the
Figure 2 The scar from the previous endoscopic resection (former T1 cancer site) was marked with a combination of clipping and tattooing. The anvil head was grasped by laparoscopic forceps and transanally inserted into the proximal colon, beyond the proximal transection line.
colon–rectum was pulled out transanally while it was being everted. At this time, eversion can be facilitated if two points of the colonic wall are grasped near the stapler line. The skeletonized distal transection line, where the mesentery was resected beforehand, was palpated, and it was then transected with the linear stapler to extract the specimen (Figure 4). The distal stump was pushed back into the abdominal cavity while the circular stapler was inserted transanally, and reconstruction by DST was performed. The procedure from the anvil insertion to the distal transection is demonstrated in supporting information (Video S1).
Discussion Extraction of surgical specimen via natural orifices has been proposed as a bridging technique to NOTES (4). The vagina has been established as a specimen extraction route (5). For the left side colon and rectum, specimen extraction through the anus is reasonable and is also applicable to men. The rectal-prolapsing technique would be an appropriate method for resection and extraction of the specimen to obtain a natural orifice access. COLC has been performed in 17 patients to date. All cases were bowel resection with lymph node dissection after endoscopic resection. The procedure was completed in 13 of 17 patients. The procedure was not completed in the remaining four patients because a narrow lumen prevented the anvil head from being inserted into the
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
339
Complete laparoscopic colorectal surgery
S Endo et al.
Figure 3 The anvil shaft was grasped, and the colonic wall was penetrated about 3–5 cm away from the transection line. The trocar was detached from the anvil and retrieved through the 12-mm port. The proximal transection line was transected with the endoscopic linear stapler. The anvil of the circular stapler was secured with a silk braid through the hole of the tip and retrieved through the port.
Figure 4 The staple line of the distal stump was grasped and pulled outside the anus by an forceps inserted transanally. The proximal stump was opened, and the dissected vessel and mesentery were pulled out to prevent entanglement. The distal transection line was transected by the linear stapler to extract the specimen.
proximal colon (n = 3) and excessive mesenteric fat prevented the distal stump from being everted (n = 1). Because the lumen of sigmoid colon is not very large, use of a 25-mm circular stapler is required in some cases. In these patients, surgery could be safely completed a through a 3–6-cm small incision in a conventional laparoscopic procedure. Even when it was determined intraoperatively that CLOC was not possible, conversion to conventional laparoscopic-assisted surgery was possible without any problems. The median operative time
340
of CLOC was 199 min (range, 152–278 min) and median blood loss was 77 mL (range, 5–100 mL), which are similar to figures for standard laparoscopic surgery. The median number of lymph node harvested was 14 (range, 4–22), a number comparable to the harvest during standard laparoscopic surgery. For totally laparoscopic surgery, there are some issues regarding the anvil insertion into the proximal colon. As previously reported, the method used for totally laparoscopic colectomy involves the anvil being inserted transanally into the abdominal cavity, the proximal colon being opened in the peritoneal cavity, and the anvil being inserted into the colon (1,6). With these methods, both the proximal colon and the distal colon are opened in the peritoneum. Therefore, there are concerns about peritoneal contamination by enteric bacteria and peritoneal dissemination caused by intraluminal exfoliated cancer cells (7,8). To avoid opening the intestine in the peritoneal cavity during anastomosis creation, reconstruction by transanal anastomosis has been reported (9), but its indications are limited to lower rectal cancer. CLOC is premised on reconstruction by DST using the rectal prolapsing technique (3,10); the anvil is inserted transanally into the proximal colon, and bowel resection and excision are performed extracorporeally after the colon– rectumis pulled out transanally. Moreover, the CLOC method resolves issues of peritoneal contamination and dissemination. Proximal limitations depend on the reach of the forceps. For instance, if standard forceps are used to grasp the anvil, the level of the distal descending colon would be the
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Complete laparoscopic colorectal surgery
S Endo et al.
most proximal transection line. As for the distal limitation, to enable reliable closure of the everted intestine with the linear stapler, a distance between the anal verge and the tumor site should be approximately 4 cm (3). This procedure was limited to early sigmoid colon and rectal cancer after endoscopic resection, and it may be impossible in patients with thick mesentery or anal stenosis. There were no complications such as anastomotic leakage, and outcomes were good. However, a new protection method for implantation of exfoliated cancer cells needs to be established, so that complete laparoscopic surgery can be employed in patients with small cancers.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References 1. Akamatsu H, Omori T, Oyama T et al. Totally laparoscopic sigmoid colectomy: A simple and safe technique for intracorporeal anastomosis. Surg Endosc 2009; 23: 2605– 2609. 2. Cheung HYS, Leung ALH, Chung CC et al. Endolaparoscopic colectomy without mini-laparotomy for leftsided colonic tumors. World J Surg 2009; 33: 1287–1291. 3. Fukunaga M, Kidokoro A, Iba T et al. Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer. Surg Today 2005; 35: 598–602. 4. Palanivelu C, Rangarajan M, Jategaonker PA et al. An innovative technique for colorectal specimen retrieval: A new era of “natural orifice specimen extraction” (N.O.S.E). Dis Colon Rectum 2008; 51: 1120–1124. 5. Franklin ME Jr, Kelly H, Kelly M et al. Transvaginal extraction of the specimen after total laparoscopic right
6.
7.
8.
9.
10.
hemicolectomy with intracorporeal anastomosis. Surg Laparosc Endosc Percutan Tech 2008; 18: 294–298. Nishimura A, Kawahara M, Suda K et al. Totally laparoscopic sigmoid colectomy with transanal specimen extraction. Surg Endosc 2011; 25: 3459–3463. Tsunoda A, Shibusawa M, Tsunoda Y et al. Implantation on the suture material and efficacy of povidone-iodine solution. Eur Surg Res 1997; 29: 473–480. Umpleby HC, Fermor B, Symes MO et al. Viability of exfoliated colorectal carcinoma cells. Br J Surg 1984; 71: 659– 663. Person B, Vivas DA, Wexner SD. Totally laparoscopic low anterior resection with transperineal handsewn colonic J-pouch anal anastomosis for low rectal cancer. Surg Endosc 2006; 20: 700–702. Akamatsu H, Omori T, Oyama T et al. Totally laparoscopic low anterior resection for lower rectal cancer: Combination of a new technique for intracorporeal anastomosis with prolapsing technique. Dig Surg 2009; 26: 446–450.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Video S1 The procedure from the anvil insertion to the distal transection is demonstrated. The anvil attached to a trocar was grasped by laparoscopic forceps and inserted to proximal colon. Then, the proximal site was transected with the linear stapler. The proximal colonic wall was penetrated by the anvil trocar, and the trocar was detached from the anvil and retrieved through the 12-mm port. The penetrated colonic wall was sutured around the anvil shaft to prevent bacterial contamination. Next, the colon–rectum was inverted and pulled out transanally, and then distal site was transected the linear stapler.
Asian J Endosc Surg 6 (2013) 338–341 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
341
