TECHNICAL REPORT
Laparoscopic Sigmoidectomy Using a Hemi–Double-stapling Technique Eiki Ojima, MD, Tetsuya Ikeda, MD, Tomofumi Noguchi, MD, Hideki Watanabe, MD, Takeshi Yokoe, MD, Hideki Ito, MD, Naomi Konishi, MD, and Hitoshi Tonouchi, MD
Background: The double-stapling technique (DST) is frequently used in laparoscopic sigmoidectomy. Unfortunately, anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with DST is seen with some frequency. Methods: We performed DST on 40 patients (June 2007 to August 2008) and hemi-DST on 50 patients (September 2008 to December 2011) undergoing laparoscopic sigmoidectomy. Results: There were no occurrences of anastomotic leakage in the hemi-DST group, and 2 instances of anastomotic leakage in the DST group were observed. In these patients, the leakage appeared at the lateral intersecting anastomotic margins. Conclusions: Using the hemi-DST for laparoscopic intracorporeal colorectal anastomosis will make laparoscopic sigmoidectomy a safer procedure. Key Words: laparoscopic sigmoidectomy, hemi–double-stapling technique, colorectal anastomosis
(Surg Laparosc Endosc Percutan Tech 2014;24:e41–e42)
n 1980, Knight and Griffen1 developed the “double-staple” technique (DST), using a circular stapler to transect a linear staple line for low anterior resection of the rectum. Since then, the DST has been adopted worldwide for low anterior resection to treat rectal carcinomas, and many surgeons have confirmed its advantages.2 In our practice, we frequently used the DST technique for laparoscopic sigmoidectomy. Unfortunately, anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with DST is fairly common.3–5 In this series, we recorded anastomotic leakage in 2 of 40 (5%) laparoscopic sigmoidectomies. Since the conversion of DST into hemi-DST, we have not experienced any anastomotic leakage. In this report, we show the successful use of the hemi-DST in 50 patients with sigmoid colon cancer requiring laparoscopic sigmoidectomy. We also introduce several technical procedural points.
I
MATERIALS AND METHODS Patients The institutional database of procedures performed between June 2007 and December 2011 showed that 90 Received for publication September 1, 2013; accepted November 12, 2013. From the Department of Surgery, Mie Prefectural General Medical Center, Yokkaichi, Mie, Japan. The authors declare no conflicts of interest. Reprints: Eiki Ojima, MD, Department of Surgery, Mie Prefectural General Medical Center, 5450-132 Hinaga, Yokkaichi, Mie 5100885, Japan (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
patients with sigmoid colon cancer underwent laparoscopic sigmoidectomy. We performed DST on 40 patients (June 2007 to August 2008), and hemi-DST was performed on 50 patients (September 2008 to December 2011).
Anastomosis Devices The linear stapling device used to transect the colon or rectum on the anal side of the tumor was the Echelon 60 Endopath Stapler (Johnson & Johnson K.K., Ethicon Endo-Surgery Inc., Tokyo, Japan). For the circular stapler device, we used the Proximate ILS curved intraluminal stapler with a 29 mm curve (CDH 29) (Ethicon Endo-Surgery Inc.).
Operative Procedure Vessel Division and Lymph Node Dissection Lymph node dissection was performed either at the roof of the inferior mesenteric artery (dissection level 3) or at the root of the superior rectal artery (dissection level 2).
Rectal Transection After mobilizing the sigmoid colon, rectum, and mesorectum, the rectum was transected at a distance of 10 cm or more from the tumor. Before transection, a temporary intestinal clip was introduced with a clip applicator and placed across the rectum below the lesion. The distal rectum was then irrigated with saline. The Echelon 60 Endopath Stapler, usually with a gold cartridge, was used for the rectal transection. Normally, one cartridge is adequate for complete transection; however, in some cases, 2 cartridges were required. In such cases, we transected the rectum as much as possible with the first cartridge, then used the second cartridge for the remaining portion.
Hemi-DST: Conversion From DST We used a CDH 29 circular stapler to perform end-toend anastomosis. The anvil was positioned in the proximal colon, then the circular stapler was inserted through the rectum and an end-to-end anastomosis was created. With standard DST anastomosis, the rod of the circular stapler was inserted transanally and pierced the rectal wall in the center of the staple line. With a hemi-DST anastomosis, the rod of the circular stapler was similarly inserted but in contrast with DST, it pierced the rectal wall at the left edge of the staple line (Fig. 1). When the anvil was applied to the rod, the edge of the mesentery of the proximal colon should be positioned anteriorly so that the proximal colon is positioned in front of the sacrum, without tension. The stapler was closed, paying attention not to include any adjacent tissue and then fired, completing the anastomosis.
Volume 24, Number 2, April 2014
www.surgical-laparoscopy.com |
e41
Surg Laparosc Endosc Percutan Tech
Ojima et al
Volume 24, Number 2, April 2014
the left side edge of the staple line
staple line
DST
FIGURE 1. The rod of a circular stapler inserted transanally pieces the rectal wall, the left side edge of the staple line, with hemi-DST anastomosis. DST indicates double-stapling technique.
RESULTS All patients started food intake by postoperative day 3. There were no anastomotic leakages detected in the hemi-DST group. In the DST group, however, 2 patients experienced anastomotic leakage (Table 1). On radiographic studies, these leakages appeared at the lateral intersecting margins of the anastomosis (so-called dog ears).
DISCUSSION Since its introduction to sigmoid colon cancer treatment, laparoscopic surgery for low anterior resection has been rapidly popularized. In our practice, we often use the laparoscopic DST anastomosis for sigmoid colon cancer surgery. Anastomotic leakage is fairly common after laparoscopic DST anastomosis, occurring in 2.8% to 6.8% of cases.3,6,7 In this series, 2 of 40 (5%) sigmoidectomies performed with DST experienced anastomotic leakage. In these cases, the leakages appeared at the “dog ears” of the anastomoses. Cutting a staple line causes traction on nearby tissues and just before the staple line itself is split, the corner is disrupted, creating a dog ear. At the corner of this dog ear, too many staples come together in such a way that the gut tissue is crushed, making it prone to show disruption at low pressure. Roumen et al8 found the double-stapled anastomoses to be inferior, as it was able to resist a lower pressure than the nicely organized staple line created by a circularstapled anastomosis. There has been some concern that the lateral intersecting margins that result from the doublestapling procedure might increase the risk of anastomotic leakage. Therefore, it is important to reduce the number of lateral intersecting margins at the anastomotic site. There are 2 lateral intersecting margins resulting from DST but just 1 from hemi-DST, as it is a technique of one-sided circular stapling across a linear staple line (Fig. 2). This TABLE 1. Anastomotic Leakage
DST (n = 40) [n (%)]
Hemi-DST (n = 50) [n (%)]
2 (5)
0 (0)
DST indicates double-stapling technique.
e42 | www.surgical-laparoscopy.com
hemi-DST
FIGURE 2. There are 2 lateral intersecting margins resulting from DST but just 1 from hemi-DST, as it is a technique of 1-sided circular stapling across a linear staple line. DST indicates doublestapling technique.
should reduce the opportunity for anastomotic leakage. Furthermore, the lateral positioning point used in hemiDST to pierce the staple line is intended to avoid creating an ischemic area between the linear and circular staple lines. In this series, no patients had anastomotic leakage after we converted our practice from DST to hemi-DST. The unique feature of this technique is that we transect the rectum with a linear stapler using 1 cartridge. If 2 cartridges are required for complete resection, we transect the rectum as much as possible with the first cartridge and transect the remaining portion with the second cartridge. In addition, the rod of the circular stapler pierces the rectal wall at the left edge of the staple line. It is not absolutely necessary to insert the rod of the circular stapler at the edge of the transection staple line, but it is important to fire the circular stapler to include the “left side dog-ear.” In conclusion, the hemi-DST method described in this study will make laparoscopic sigmoidectomy with anastomosis much safer. Lowering the incidence of anastomotic leaks is the most important benefit of this operative procedure. REFERENCES 1. Knight CD, Griffen FD. An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery. 1980;88:710–714. 2. Griffen FD, Knight CD Sr, Whitaker JM, et al. The double stapling technique for low anterior resection. Results, modifications, and observations. Ann Surg. 1990;211:745–751. 3. Feinberg SM, Parker F, Cohen Z, et al. The double stapling technique for low anterior resection of rectal carcinoma. Dis Colon Rectum. 1986;29:885–890. 4. Varma JS, Chan AC, Li MK, et al. Low anterior resection of the rectum using a double stapling technique. Br J Surg. 1990; 77:888–890. 5. Baran JJ, Goldstein SD, Resnik AM. The double-staple technique in colorectal anastomoses: a critical review. Am Surg. 1992;58:270–272. 6. Fu CG, Muto T, Masaki T. Results of the double stapling procedure in colorectal surgery. Surg Today. 1997;27:706–709. 7. Kim JS, Cho SY, Min BS, et al. Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg. 2009;209: 694–701. 8. Roumen RM, Rahusen FT, Wijnen MH, et al. “Dog ear” formation after double-stapled low anterior resection as a risk factor for anastomotic disruption. Dis Colon Rectum. 2000; 43:522–525.
r
2014 Lippincott Williams & Wilkins
Laparoscopic Sigmoidectomy Using a Hemi–Double-stapling Technique Eiki Ojima, MD, Tetsuya Ikeda, MD, Tomofumi Noguchi, MD, Hideki Watanabe, MD, Takeshi Yokoe, MD, Hideki Ito, MD, Naomi Konishi, MD, and Hitoshi Tonouchi, MD
Background: The double-stapling technique (DST) is frequently used in laparoscopic sigmoidectomy. Unfortunately, anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with DST is seen with some frequency. Methods: We performed DST on 40 patients (June 2007 to August 2008) and hemi-DST on 50 patients (September 2008 to December 2011) undergoing laparoscopic sigmoidectomy. Results: There were no occurrences of anastomotic leakage in the hemi-DST group, and 2 instances of anastomotic leakage in the DST group were observed. In these patients, the leakage appeared at the lateral intersecting anastomotic margins. Conclusions: Using the hemi-DST for laparoscopic intracorporeal colorectal anastomosis will make laparoscopic sigmoidectomy a safer procedure. Key Words: laparoscopic sigmoidectomy, hemi–double-stapling technique, colorectal anastomosis
(Surg Laparosc Endosc Percutan Tech 2014;24:e41–e42)
n 1980, Knight and Griffen1 developed the “double-staple” technique (DST), using a circular stapler to transect a linear staple line for low anterior resection of the rectum. Since then, the DST has been adopted worldwide for low anterior resection to treat rectal carcinomas, and many surgeons have confirmed its advantages.2 In our practice, we frequently used the DST technique for laparoscopic sigmoidectomy. Unfortunately, anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with DST is fairly common.3–5 In this series, we recorded anastomotic leakage in 2 of 40 (5%) laparoscopic sigmoidectomies. Since the conversion of DST into hemi-DST, we have not experienced any anastomotic leakage. In this report, we show the successful use of the hemi-DST in 50 patients with sigmoid colon cancer requiring laparoscopic sigmoidectomy. We also introduce several technical procedural points.
I
MATERIALS AND METHODS Patients The institutional database of procedures performed between June 2007 and December 2011 showed that 90 Received for publication September 1, 2013; accepted November 12, 2013. From the Department of Surgery, Mie Prefectural General Medical Center, Yokkaichi, Mie, Japan. The authors declare no conflicts of interest. Reprints: Eiki Ojima, MD, Department of Surgery, Mie Prefectural General Medical Center, 5450-132 Hinaga, Yokkaichi, Mie 5100885, Japan (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
patients with sigmoid colon cancer underwent laparoscopic sigmoidectomy. We performed DST on 40 patients (June 2007 to August 2008), and hemi-DST was performed on 50 patients (September 2008 to December 2011).
Anastomosis Devices The linear stapling device used to transect the colon or rectum on the anal side of the tumor was the Echelon 60 Endopath Stapler (Johnson & Johnson K.K., Ethicon Endo-Surgery Inc., Tokyo, Japan). For the circular stapler device, we used the Proximate ILS curved intraluminal stapler with a 29 mm curve (CDH 29) (Ethicon Endo-Surgery Inc.).
Operative Procedure Vessel Division and Lymph Node Dissection Lymph node dissection was performed either at the roof of the inferior mesenteric artery (dissection level 3) or at the root of the superior rectal artery (dissection level 2).
Rectal Transection After mobilizing the sigmoid colon, rectum, and mesorectum, the rectum was transected at a distance of 10 cm or more from the tumor. Before transection, a temporary intestinal clip was introduced with a clip applicator and placed across the rectum below the lesion. The distal rectum was then irrigated with saline. The Echelon 60 Endopath Stapler, usually with a gold cartridge, was used for the rectal transection. Normally, one cartridge is adequate for complete transection; however, in some cases, 2 cartridges were required. In such cases, we transected the rectum as much as possible with the first cartridge, then used the second cartridge for the remaining portion.
Hemi-DST: Conversion From DST We used a CDH 29 circular stapler to perform end-toend anastomosis. The anvil was positioned in the proximal colon, then the circular stapler was inserted through the rectum and an end-to-end anastomosis was created. With standard DST anastomosis, the rod of the circular stapler was inserted transanally and pierced the rectal wall in the center of the staple line. With a hemi-DST anastomosis, the rod of the circular stapler was similarly inserted but in contrast with DST, it pierced the rectal wall at the left edge of the staple line (Fig. 1). When the anvil was applied to the rod, the edge of the mesentery of the proximal colon should be positioned anteriorly so that the proximal colon is positioned in front of the sacrum, without tension. The stapler was closed, paying attention not to include any adjacent tissue and then fired, completing the anastomosis.
Volume 24, Number 2, April 2014
www.surgical-laparoscopy.com |
e41
Surg Laparosc Endosc Percutan Tech
Ojima et al
Volume 24, Number 2, April 2014
the left side edge of the staple line
staple line
DST
FIGURE 1. The rod of a circular stapler inserted transanally pieces the rectal wall, the left side edge of the staple line, with hemi-DST anastomosis. DST indicates double-stapling technique.
RESULTS All patients started food intake by postoperative day 3. There were no anastomotic leakages detected in the hemi-DST group. In the DST group, however, 2 patients experienced anastomotic leakage (Table 1). On radiographic studies, these leakages appeared at the lateral intersecting margins of the anastomosis (so-called dog ears).
DISCUSSION Since its introduction to sigmoid colon cancer treatment, laparoscopic surgery for low anterior resection has been rapidly popularized. In our practice, we often use the laparoscopic DST anastomosis for sigmoid colon cancer surgery. Anastomotic leakage is fairly common after laparoscopic DST anastomosis, occurring in 2.8% to 6.8% of cases.3,6,7 In this series, 2 of 40 (5%) sigmoidectomies performed with DST experienced anastomotic leakage. In these cases, the leakages appeared at the “dog ears” of the anastomoses. Cutting a staple line causes traction on nearby tissues and just before the staple line itself is split, the corner is disrupted, creating a dog ear. At the corner of this dog ear, too many staples come together in such a way that the gut tissue is crushed, making it prone to show disruption at low pressure. Roumen et al8 found the double-stapled anastomoses to be inferior, as it was able to resist a lower pressure than the nicely organized staple line created by a circularstapled anastomosis. There has been some concern that the lateral intersecting margins that result from the doublestapling procedure might increase the risk of anastomotic leakage. Therefore, it is important to reduce the number of lateral intersecting margins at the anastomotic site. There are 2 lateral intersecting margins resulting from DST but just 1 from hemi-DST, as it is a technique of one-sided circular stapling across a linear staple line (Fig. 2). This TABLE 1. Anastomotic Leakage
DST (n = 40) [n (%)]
Hemi-DST (n = 50) [n (%)]
2 (5)
0 (0)
DST indicates double-stapling technique.
e42 | www.surgical-laparoscopy.com
hemi-DST
FIGURE 2. There are 2 lateral intersecting margins resulting from DST but just 1 from hemi-DST, as it is a technique of 1-sided circular stapling across a linear staple line. DST indicates doublestapling technique.
should reduce the opportunity for anastomotic leakage. Furthermore, the lateral positioning point used in hemiDST to pierce the staple line is intended to avoid creating an ischemic area between the linear and circular staple lines. In this series, no patients had anastomotic leakage after we converted our practice from DST to hemi-DST. The unique feature of this technique is that we transect the rectum with a linear stapler using 1 cartridge. If 2 cartridges are required for complete resection, we transect the rectum as much as possible with the first cartridge and transect the remaining portion with the second cartridge. In addition, the rod of the circular stapler pierces the rectal wall at the left edge of the staple line. It is not absolutely necessary to insert the rod of the circular stapler at the edge of the transection staple line, but it is important to fire the circular stapler to include the “left side dog-ear.” In conclusion, the hemi-DST method described in this study will make laparoscopic sigmoidectomy with anastomosis much safer. Lowering the incidence of anastomotic leaks is the most important benefit of this operative procedure. REFERENCES 1. Knight CD, Griffen FD. An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery. 1980;88:710–714. 2. Griffen FD, Knight CD Sr, Whitaker JM, et al. The double stapling technique for low anterior resection. Results, modifications, and observations. Ann Surg. 1990;211:745–751. 3. Feinberg SM, Parker F, Cohen Z, et al. The double stapling technique for low anterior resection of rectal carcinoma. Dis Colon Rectum. 1986;29:885–890. 4. Varma JS, Chan AC, Li MK, et al. Low anterior resection of the rectum using a double stapling technique. Br J Surg. 1990; 77:888–890. 5. Baran JJ, Goldstein SD, Resnik AM. The double-staple technique in colorectal anastomoses: a critical review. Am Surg. 1992;58:270–272. 6. Fu CG, Muto T, Masaki T. Results of the double stapling procedure in colorectal surgery. Surg Today. 1997;27:706–709. 7. Kim JS, Cho SY, Min BS, et al. Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg. 2009;209: 694–701. 8. Roumen RM, Rahusen FT, Wijnen MH, et al. “Dog ear” formation after double-stapled low anterior resection as a risk factor for anastomotic disruption. Dis Colon Rectum. 2000; 43:522–525.
r
2014 Lippincott Williams & Wilkins
