The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery

Abstract

Purpose: Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery.

Materials and methods: In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups.

Results: Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis.

Conclusions: The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.

FIGURE 1

Exclusion criteria of patients.

FIGURE 2

A, Group A had no intersection of staple lines (arrows). B, Group B had 1 point of intersection (arrow). C, Group C had 2 points of intersection, either 1 at left side (arrow).

FIGURE 3

The circular endostapler was introduced through the anus. “Dog-ear” (arrows) and either one or both edges of linear staple line (arrowheads) were located out of the rim of circular stapler head.

FIGURE 4

A, Either one or both edges of linear staple line were folded or pierced by the integrated trocar of circular endostapler. B, Linear staple line hid inside the rim of the circular stapler head.

FIGURE 5

If the rectal remnant could not be mobilized distally enough to invaginate both edges of linear staple lines, left edge (arrows) was pierced by integrated trocar of circular endostapler and right edge (arrowheads) was abandoned avoiding 2 intersections of staple lines and for ease of reinforcement suture.

FIGURE 6

A, Inversion or invagination technique was performed perfectly. B, Right edge was abandoned avoiding 2 intersections of staple lines.