Predicting the level of difficulty of the double-stapling technique in laparoscopic total mesorectal excision

The transection of rectum and fashioning of anastomosis is a crucial step in laparoscopic total mesorectal excision (TME) and the double-stapling technique (DST) is often employed. This study aimed to evaluate the factors that were associated with difficult DST.

Cases of laparoscopic TME were retrospectively reviewed. The clinico-anatomical parameters were retrieved from a prospectively maintained database. In addition, pelvic dimensions were taken by reviewing the magnetic resonance imaging scan. The number of stapler cartridges used for intracorporeal transection of rectum was used as a surrogate for the level of difficulty of DST and its relationship with various parameters were evaluated.

There were a total of 121 consecutive cases analyzed. The mean number of stapler cartridges used was 2.1 ± 0.7. Pelvic inlet (p = 0.002) and tumor height (p = 0.015) were predictors of the number of cartridges used, R² = 0.366. A model was developed to predict the likelihood of transecting the rectum with two or less stapler cartridges, which included the following parameters: gender, pelvic inlet, interspinous distance, intertuberous distance, and tumor height. The predicted probability also correlated with overall operation time (p = 0.009) and anastomotic leakage (p = 0.023).

The difficulty of DST was associated with patient's clinico-anatomical factors. Surgeons can consider other feasible alternatives, like transanal anastomosis, when a technically challenging DST is anticipated.