Mohammed K Al Sibani, MDFRCSC1, Kin F Chin, MD, FRCS2, POk E Hong2. 1Armed Forces Hospital, 2University of Malaya
Background: Anastomotic leak after anterior resection is a common complication which arises in up to 20% of cases. Preoperative general condition of the patient, level of the anastomosis and duration of operation are considered important contributory factors. Transanal endoscopic microsurgery (TEMS) has emerged as a safe and effective method to treat many early rectal lesions.
Objective : In this article we describe a minimally invasive approach in three patients with early rectal anastomotic leak after low anterior resection LAR for rectal cancer. With this technique it was possible to visualize and repair the defect without the need for defunctioning colostomy after controlling the contamination and allowing the inflammation to subside.
Cases history : Three patients underwent LAR for rectal cancer sustained early anastomotic leak were managed initially with percutaneous drain, intravenous antibiotics and defuntioning ileostomy for 2 weeks and then they were taken for transanal laparoscopic repair.
Intervention : Single port device and conventional laparoscopic instruments were used to repair the anastomotic defect. The defect was repaired using intracorporeal interrupted absorbable suturing. Full thickness of the rectal wall was approximated. The defect was well approximated and there was no residual gaping.
Result : Post-operative course was uneventful and gastrografin enema showed no evidence of anastomotic leak. All patient return back to normal activity within two weeks. No long term complication after 2 years of follow up.
Limitation: The technique is demanding due to narrow working field and instrument crowding. Laparoscopic suturing of distensible colon was a major challenging.
Conclusion: Transanal minimally invasive surgery is an excellent approach to treat anastomotic leak after LAR for rectal cancer in selected patients. It provides an alternate to major pelvic surgery, which carries the risk of intra-operative and postoperative complication. In addition, it obviates the need for colostomy and a second intervention. Surgeon experience as well as careful patient selection is required before embarking in such task. The learning curve is steep because the number of cases are rather small for surgeons to acquire technical expertise.