Retrograde single stapling technique for laparoscopic ultralow anterior resection

A highly effective surgical technique is required for laparoscopic low rectal transection without sufficient distal margins when ultralow anterior resection (ULAR) with a stapler is a technical challenge for laparoscopic surgery. We report a retrograde single stapling technique (RSST) for laparoscopic ULAR. Total mesorectal excision is performed laparoscopically. After the anal side of the tumor has been closed transanally, the distal line in the right lateral wall of the rectum is partially transected with laparoscopic coagulation shears (LCS). The distal line in the rectum is transected circularly with LCS after detecting the cutting part in the right lateral wall of the rectum laparoscopically. The end of the distal rectum is closed by a purse-string suture using 2-0 prolene transanally. Intestinal resection is performed extracorporeally through a suprapubic incision. After an anvil is placed in the proximal end of the colon over a purse-string suture, it is introduced to the anal canal transabdominally. The purse-string suture is tied to the anvil shaft before connecting it to the center shaft of the circular stapler; the instrument is then fired to create end-to-end anastomosis. For the prevention of anastomotic leakage, a 24-french balloon catheter which decompresses the anastomosis is inserted through the anus.