Colorectal Anastomotic Leakage in Laparoscopic Low Anterior Resection: Aspects of Prevention and Technical Tips

Toshimasa Yatsuoka1, Junichi Tanaka1, Takahiro Umemoto1, Sumito Sato1, Yoji Nishimura2, Yoshiyuki Kawashima2, Hirohiko Sakamoto2. 1Showa University Fujigaoka Hospital, 2Saitama Cancer Center

Aims: Low rectal anastomosis with the double-stapling technique (DST) was reported by Knight and Griffen in 1980. Despite of the recent advances of stapling devices, anastomotic leak is one of the most dangerous and feared surgical complications after low anterior resection (LAR). The development of a leak is known to be associated with local recurrence and worse prognosis after a curative resection for rectal cancer. The aim of this study is to address technical tips for preventing anastomotic leakage after laparoscopic low anterior resection (Lap LAR) and review the clinical outcome of our experiences.

Methods: We completely mobilize the rectum to the pelvic bottom due to perform a safe transection of the lower rectum. The lower rectal segment is transected and closed horizontally using a single-fire cartridge with a flexible linear stapler. Performing the DST, the center rod of circular stapler is pierced through one third of the left end of the rectum stapler line to eliminate the dog-ear on the left side (eliminating the left lateral intersection). We make the additional sutures to eliminate rigt-sided dog-ear in DST anastomosis. We use the routine intra-operative colonoscopy (IOC) to visualize anastomotic bleeding and anastomotic leakage. A transanal drainage tube is placed through the anastomosis. 

Results: Between January 2007 and March 2015,1446 patients undergoing anterior resection for rectal cancer was done. Conventionl open low anterior resection (Open LAR) was performed in 250 patients and Lap LAR was done in 28 patients. In Open LAR group anastomotic leakage occurred in 18 patients (6.9%) and in Lap LAR group anastomotic leakage occurred in one patients (3.5%). 

Conclusion: Our techniques may be safe and effective means of reducing the occurrence of anastomotic leakage in laparoscopic low anterior resection. Making further risk reduction in colorectal anastomosis, a larger-scale prospective randomized study is necessary for further clarification of this issue in laparoscopic surgery.

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