SCIENTIFIC PAPER

Laparoscopic Low Anterior Resection with Two

Planned Stapler Fires
Koki Otsuka, MD, Toshimoto Kimura, MD, Teppei Matsuo, MD,
Hitoshi Fujii, MD, Mizunori Yaegashi, MD, Kei Sato, MD, Suguru Kondo, MD, Akira Sasaki, MD

ABSTRACT dardize, and reduces the need for multiple linear fires and
the incidence of anastomotic leakage.
Background: Anastomotic leakage during laparoscopic
low anterior resection (Lap-LAR) for rectal cancer remains Key Words: Rectal cancer; Low anterior resection; Dou-
challenging for colorectal surgeons. Firing linear staplers ble stapling technique; Rectal transection.
multiple times has been reported as a risk factor for iatro-
genic anastomotic leakage. Our institute usually performs
rectal transection using 2 planned stapler fires followed by
anastomosis with the double-stapling technique. INTRODUCTION
Methods: Between November 2009 and September 2016, Anastomotic leakage is a major problem among patients
a total of 272 consecutive patients underwent Lap-LAR who undergo laparoscopic low anterior resection (Lap-LAR)
with double-stapling anastomosis for rectal cancer. We for rectal cancers. This complication is associated with not
inserted a linear 45-mm stapler cartridge from a port in the only short-term results, but also long-term results such as
lower right quadrant of the abdomen. The first transection local recurrence and patient survival.1–7 Reducing anasto-
was made up to three-quarters of the rectal wall, and the motic leakage has been recognized as a constant task for
remaining rectum was completely resected using a second colorectal surgeons. In 1980, Knight et al8 reported using a
stapler. During this procedure, the intersection of the 2 circular stapler to transect a linear staple line for LARs of the
staple lines, which might otherwise cause anastomotic rectum, and Cohen et al9 named this anastomosis method
leakage, was located in the center of the stump of the the “double staple technique” (DST). Since then, the DST has
distal rectum, so the intersection at the rectal stump was been accepted by many surgeons for use in LARs to treat
able to be easily removed using a circular stapler. rectal cancer. However, despite such technical improve-
ments and advances in equipment, recent studies have re-
Results: None of our patients were converted to open ported that the rate of anastomotic leakage after DST has
surgery. Among the 272 Lap-LAR procedures for which remained at around 6% to 18%.4,10 –14 In particular, causes of
use of 2 stapler fires was planned, 3 fires occurred in error anastomotic leakage after Lap-LAR may differ from those
only once (0.4%). Rectovaginal fistula and anastomotic after open surgery, due to the difficulty of the pelvic ap-
leakage occurred in 1 patient (0.4%) and 9 patients (3.3%), proach, the lack of tactile sense, and the inadequacy of
respectively, and 49 (18.0%) patients required protective cutting angles after transection. Several studies have reported
diverting stoma. that use of more than 3 cartridges for rectal transection
represents a risk factor for anastomotic leakage after Lap-
Conclusion: Rectal transection with 2 planned stapler
LAR.15–17 In our institute, we have performed Lap-LARs using
fires appears safe, practical, and straightforward to stan-
the DST method. As a feature of our DST anastomoses, 2
planned stapler fires were adopted to avoid needing 3 or
Department of Surgery, Iwate Medical University School of Medicine, Iwate Japan more rectal transections, which require multiple stapler fir-
(Drs Otsuka, Kimura, Matsuo, Fujii, Yaegashi, Sato, Kondo, and Sasaki). ings. This report describes a DST procedure using 2 planned
Disclosures: The authors have nothing to disclose. stapler fires in 272 patients with rectal cancer requiring Lap-
Conflicts of Interest: The authors do not cite any conflicts of interest. LARs. In addition, we describe the methods for our standard-
Informed consent: Dr. Otsuka, declares that written informed consent was obtained ized technical procedure.
from the patient/s for publication of this study/report and any accompanying images.
Address correspondence to: Koki Otsuka, MD, Department of Surgery, Iwate MATERIALS AND METHODS
Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate 020-8505,
Japan. Tel: ⫹81-19-651-5111; Fax: ⫹81-19-651-7166, E-mail: kokiotsu@iwate-
med.acjp Patients and Methods
DOI: 10.4293/JSLS.2018.00112
© 2019 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by The database at our institution for procedures performed
the Society of Laparoendoscopic Surgeons, Inc. between November 2009 and September 2016 showed

January–March 2019 Volume 23 Issue 1 e2018.00112 1 JSLS www.SLS.org

Laparoscopic Low Anterior Resection with Two Planned Stapler Fires, Otsuka K et al.

that 272 consecutive patients underwent Lap-LAR with the anastomotic site on computed tomography. All curative
DST method for rectal cancer. Among these 272 patients, operations were performed by 3 qualified surgeons
163 (59.9%) were male and 109 (40.1%) were female. (through the Endoscopic Surgical Skill Qualification Sys-
Median age was 63 years (range, 29 – 89 years). Mean tem in Japan) at our institution.
body mass index (BMI) was 23.6 kg/m2 (range, 17.4 – 40.3
kg/m2) (Table 1). The lower edges of the tumor were Surgical Techniques
within 10 cm from the anal verge in all cases. Either
tumor-specific mesorectal excision (TSME) or total meso- Port Placement and TME
rectal excision (TME) was adopted as the standard surgical The operation was performed under pneumoperitoneum
technique according to the location of the tumor. Tumors with the patient placed in a modified lithotomy, Tren-
located between the inferior margin of the second sacral delenburg position with the right side facing down. Port
vertebra and the peritoneal reflection were recorded as placements for Lap-LARs are shown in Figure 1. The
being in the upper rectum, while those located below the 12-mm port in the lower right quadrant was inserted as
peritoneal reflection were recorded as in the lower rec- caudally and medially as possible, paying attention to
tum.18 A total of 136 patients (50.0%) had upper rectal avoid damage to the inferior epigastric vessels under lapa-
cancer, and the remaining 136 patients (50.0%) had lower roscopic guidance. This facilitated adjustment of a linear
rectal cancer. Preoperative chemotherapy was performed stapler to be perpendicular to the rectum. For all patients,
in 17 patients (6.3%), and chemoradiotherapy was per- we adopted a medial-to-lateral approach, and low ligation
formed in 3 patients (1.1%) (Table 1). Neoadjuvant ther- of the inferior mesenteric artery was routinely performed
apy was indicated in cases receiving chemotherapy with to preserve the left colic artery. The splenic flexure was
FOLFOX or XELOX among patients with clinical T4 or not mobilized in most cases. For upper rectal cancer,
with a lateral lymph node showing a short-axis diameter TSME or TME was performed. For all lower rectal cancers,
of 5 mm or more, and neoadjuvant chemoradiotherapy TME was performed. These procedures were performed
was also performed for cases of progressive disease on to identify and preserve the hypogastric nerves and pelvic
neoadjuvant chemotherapy. The indications for protective plexus, without cancer invasion. The rectococcygeal liga-
diverting ileostomy or colostomy were neoadjuvant ther-
apy and obstruction by a bulky tumor. Clinical anasto-
motic leakage was investigated in the event of clinical
symptoms of sepsis, including abdominal pain, tender-
ness, and fever with shivering. Clinical anastomotic leak-
age was diagnosed by the presence of any of the follow-
ing: fecal discharge from the pelvic drain; abscess at the
level of the anastomosis; and fluid or air surrounding the

Table 1.
Characteristics of the Study Population
Variables Population (n ⫽ 272)

Age (years)* 63 (29–89)

Sex (male/female) 163/109
BMI (kg/m2)* 23.6 (17.4–40.3)
Site of rectal cancer, n (%)
Upper 136 (50)
Lower 136 (50)
Figure 1. Port placement for Lap-LAR. A 5-port technique is
Neoadjuvant chemotherapy, n (%) 17 (6.3)
employed in Lap-LAR, with a 10-mm port at the navel, a 12-mm
Neoadjuvant chemoradiotherapy, n (%) 3 (1.1) port in the lower right quadrant, and a 5-mm port in each of the
BMI, body mass index. other 3 quadrants. The 12-mm port in the lower right quadrant
should be inserted in a position as caudally and medially as
*, Median (range).
possible.

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ment was severed intra-abdominally in the cases with of the operator made fine adjustments to the rectum angle
TMEs, but was preserved in TSMEs. In both cases, rectal so as to avoid damaging the rectum with the linear stapler.
mobilization was made sufficiently distal from the ex-
For the second linear stapler fire, we approached the
pected transection line, as the most important target of a
remaining rectum with the linear stapler and then articu-
Lap-LAR with 2 planned stapler fires. Before transection,
lated the linear stapler with the rectum pulled in the right
the rectum below the tumor lesion was closed with a
cephalad direction (Figure 3). By articulating, the remain-
temporary intestinal clip using a clip applicator inserted
ing rectum could be covered by the stapler’s cartridge
from the right lower quadrant port, then the distal rectum
without the tip of the linear stapler hitting the pelvic floor.
was washed with saline.
While firing the second linear stapler, the operator’s left
grasper pulled the rectum up toward the right cephalad
DST Using 2 Planned Linear Stapler Fires
direction, and the assistant’s left grasper was applied to
The rectal transections were performed intracorporeally
support the portion of rectum distal to the linear stapler
with linear staplers through the 12-mm port in the right
(Figure 3). The assistant pulled up the seminal vesicle
lower quadrant. We usually used an ECHELON Flex
and vaginal wall using the right grasper, so that the
45-mm gold cartridge (Johnson & Johnson K.K., Ethicon
anterior aspect of the rectum was more visible. Firing
Endo-Surgery Inc., Tokyo, Japan), which is a linear stapler
was then performed after confirming that the rectum
with an articulation function. For patients who had re-
was included in the line displayed on the tip of the
ceived preoperative chemoradiotherapy or neoadjuvant
stapler. As a result of these procedures, the intersection
chemotherapy, a green cartridge was used because of
of the first and second linear staple lines was located
intestinal edema. To definitively complete the transections
approximately at the center of the stump of the distal
with the 2 linear staplers and to involve the intersection of
rectum (Figure 4A) and was therefore easily involved
the 2 linear staple lines with the circular stapler, the first
in the circular stapler (Figure 4B).
stapler needed to be inserted up to three-quarters of the
rectal wall, just below the intestinal clip. When the ports The specimen was extracted through a small incision in
were placed caudally and medially in the lower right the umbilical port. The anvil of the circular stapler was
quadrant, the first linear stapler could approach the rec- secured in place and the colon was returned intra-abdom-
tum at right angles to the long axis of the rectum. At that inally. The incision site was then temporarily closed. End-
time, the linear stapler was kept straight without flexing to-end anastomosis was performed intracorporeally using
and was fired in that state (Figure 2). While firing the first a DST with a circular stapler. We usually used a 25 CDH
linear stapler, an assistant held the mesocolon on the (Johnson & Johnson K.K., Ethicon Endo-Surgery Inc., To-
proximal side of the tumor with the right grasper and kyo, Japan) circular stapler. The rod of the circular stapler
pulled the rectum in the left cephalad direction and then was inserted transanally, piercing the rectal stump near
lifted the seminal vesicle or vaginal wall with the left the intersection of the 2 linear staple lines. With the DST
grasper to avoid involving these organs. The left grasper using 2 planned linear stapler fires, since the intersection

Figure 2. Rectal transection by first stapler fire. The first stapler Figure 3. Rectal transection by second stapler fire. For the second
reaches the upper quarter of the rectum along its long axis and linear stapler fire, the remaining rectum is included in the cartridge
is kept straight without articulating, then is fired in that state. At and the stapler is then articulated. At this time, the rectum is pulled
this time, the rectum is pulled in a left cephalad direction. in a right cephalad direction.

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Laparoscopic Low Anterior Resection with Two Planned Stapler Fires, Otsuka K et al.

RESULTS
The surgical outcomes are shown in Table 2. We per-
formed laparoscopic TSMEs for rectal cancer in 50 cases
and TMEs in 222 cases. Lateral lymph node dissections
were performed in 9 patients (3.3%). Splenic flexure mo-
bilization and high ligation of the inferior mesenteric ar-
tery were performed in 1 patient (0.4%) with sigmoid
colon cancer, but no complications were encountered. No
cases required blood transfusions and no hospital deaths
were encountered. Among the 272 Lap-LARs for which
only 2 stapler fires had been planned, 3 fires occurred in
error only once (0.4%), when an intestinal clip applicator
was mistakenly held by the first cartridge. Fortunately, no
anastomotic leakage occurred. In addition, for the 271
cases in which the transection was completed in 2 fires,
the intersection could be included within the circular
staple. Anastomotic leakage occurred in 9 cases (3.3%;
9/272 cases): 7 were male (4.2%; 7/163 cases), and 2 were
female (1.8%; 2/109 cases); 7 involved TMEs (3.2%; 7/222
cases), and 2 involved TSMEs (4.0%; 2/50 cases). Anasto-
motic leakages that required reoperation with a diverting
stoma occurred in 5 cases (1.8%; 5/272), whereas leakages
that required drainage only with no reoperation were seen
in 4 cases. For the case with vaginal fistula, we created a
diverting stoma the day after the event and closed the
stoma after 8 months. A protective diverting ileostomy or
Figure 4. End-to-end anastomosis by DST. (A) Rectal stump
from transection with 2 planned linear stapler fires. The inter-
colostomy was created in 49 cases (18.0%; 49/272), 3 of
section of the 2 linear staple lines is located approximately at the
center of the stump of the distal rectum ➟: Intersection. (B)
End-to-end anastomosis is performed using DST with a circular Table 2.
stapler. The rod of a circular stapler inserted transanally pierces Surgical Outcomes
the rectal stump near the intersection of the 2 linear staple lines.
Variables Population (n ⫽ 272)
The intersection is easily included in the circular stapler. ➟:
Intersection. Conversions (%), n (%) 0 (0)
Operative time (minutes)* 210 (128–447)
was located at the center of the rectal stump, the intersec- Blood loss (mL)* 10.5 (1–446)
tion at risk of anastomotic leakage was easily included. Surgical procedures, n (%)
The circular stapler was closed, paying attention to avoid TME 222 (81.6)
including any adjacent tissue (particularly the vaginal
TSME 50 (18.4)
wall), then fired. After completion of this procedure, the
Lateral lymph node dissection, n (%) 9 (3.3)
anastomosis was confirmed using an air-leak test. If an air
leakage was found, we checked and repaired the leak Number of staplers for rectal
transection, n (%)
point and then performed diverting ileostomy. Indications
that a covering ileostomy was needed were tumor with a 2 271 (99.6)
diameter ⱖ6 cm, chemoradiotherapy or neoadjuvant che- 3 1 (0.4)
motherapy patients, Intersphincteric resection (ISR) cases, Protective diverting ileostomy or 49 (18.0)
and air leak-positive cases. A surgical drain was placed in colostomy, n (%)
the pelvis from the left lower quadrant, and a transanal Anastomotic leakage, n (%) 9 (3.3)
drainage tube was inserted for 4 to 5 postoperative days in
*, Median (range).
all cases.

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which showed anastomotic leakage. In the 49 cases of than the 17.4% rate when the intersection remained. In
protective diverting stoma, contrast enema was routinely addition, they reported that the intersection was placed
performed before stoma closure, and no leakage or ste- near the edge of the lower rectal stump, so removal of
nosis of the anastomosis was encountered. No bleeding the intersection was technically difficult. Using our pro-
that required hemostatic treatment was seen in the anas- cedure, the transection was completed with 2 linear
tomotic region. stapler firings in 99.6% of cases (271/272 cases), and 3
linear staple lines was required in only one case. For all
DISCUSSION 271 cases completed with 2 linear stapler firings, the
intersection of the linear staple lines could be included
Anastomotic leakage after rectal cancer surgery has an within the circular staple. This fact was confirmed by
enormous influence not only on short-term results, such checking that the intersection was present in the donut-
as extending the hospitalization period, increasing the shaped structure within the circular stapler after the
treatment cost, and delaying administration of adjuvant DST.
chemotherapy, but also on local recurrence rate and
The rate of anastomotic leakage in this study was 3.3%,
long-term prognosis.1–7 Various risk factors, including
representing a good result, but the major limitation of this
sex, age, preoperative therapy, tumor location and size,
study was the difference in BMI between Japanese and
pelvis size, BMI, intra-operative bleeding, and the di-
Western populations. The surgical techniques that must
ameter of the circular stapler,15–17,19 –21 have been re-
be performed within the narrow pelvis and in cases of
ported to contribute to the occurrence of anastomotic
higher BMI are reportedly related to anastomotic leak-
leakage after rectal cancer surgery. Surgical technique,
age.20,23–25 Mean BMI for our patients was 23.6 kg/m2,
which must be performed within the narrow pelvic
much lower than generally seen in Western populations,
region and among complex anatomical structures, is
but we did in fact have 5 patients with BMI ⱖ 30 kg/m2 in
also related to anastomotic leakage. Making rectal tran-
this study. We still performed the 2 planned stapler fires
sections using a linear stapler in laparoscopic surgery is
with slight modifications for patients with BMI ⱖ 30 kg/
relatively difficult compared with open surgery. Several
m2. These technical modifications were to wrap gauze
studies have reported that use of more than 3 cartridges
around the thick rectum of obese patients and apply
for rectal transection was a risk factor for anastomotic
cephalad traction, and to always use a green stapler car-
leakage after Lap-LAR.15–17 These findings appear attrib-
tridge for rectal resection. With these technical modifica-
utable to an unduly long stapling line at an oblique
tions, we believe that this procedure, which involves 2
angle in the lower position. Another reason may be that
planned stapler fires with a linear 45-mm stapler cartridge,
the intersection of linear staples, which is considered a
is very effective for cases with a narrow pelvis and higher
risk factor for anastomotic leakage, will likely remain
BMI.
on the rectal stump. In contrast, a report by Kuroyanagi
et al22 showed that when the port in the lower right
quadrant of the abdomen was placed more caudally CONCLUSION
and medially, a laparoscopic stapler could be inserted We demonstrated that rectal transection with 2 planned
perpendicular to the long axis of the rectum through stapler fires to prevent excessive linear stapler fires ap-
cooperation between the surgeon and assistant. Fur- pears to be safe and feasible. We believe this procedure
thermore, when the techniques of the operator and offers a useful standard in Lap-LAR for lower rectal cancer,
assistant were well choreographed, transection was which is considered a technically difficult cancer to treat
able to be completed with 2 cartridges in 84.6% of cases surgically, resulting in further reductions to the risk of
(66/78 cases), while 3 firings were required in 15.4% anastomotic leakage.
(12/78 cases). As a result, the rate of anastomotic leak-
age was a phenomenal 2.6% (2/78 cases). Another
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