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Anastomotic leakage after colorectal surgery is a serious complication leading to increased morbidity and mortality. Multiple studies have found the following risk factors for anastomotic leakage: male gender, obesity, preoperative steroid and non-steroidal anti-inflammatory drug use, longer duration of the operation, surgical experience and preoperative blood transfusion. The laparoscopic approach is not inferior to open surgery in terms of rate of anastomotic fistula.
Several studies have also shown the ASA score and tumor distance from the anal verge as predictors for increased operative time and morbidity after laparoscopic total mesorectal excision. There is strong evidence that preoperative radiochemotherapy for rectal cancer increases the risk of anastomotic leakage. Preoperative bowel preparation does not reduce the incidence of postoperative leaks. The use of a diversion stoma has not been shown to reduce leak rate, but it mitigates the clinical effects of fistula.
This video shows the way to perform an end to end colorectal anastomosis after a sigmoidectomy. This is the technique commonly used in our center, with good results.
After the oncological dissection we perform the section of the distal colon by intracorporeal EndoGIA™. In this case we used two mechanical staplers (60mm + 45mm) to complete the section of the colon. After this, the specimen was exteriorized through a small incision (Pfannenstiel incision) in the hypogastrium. The wound is protected with a 3M bag during this maneuver.
Then the pursestring instrument were used for proximal section. It places a circumferential strand of 2-0 nonabsorbable braided polyester surgical suture, held in place by stainless steel staples. We cut the proximal colon, completing the sigmoidectomy.
The usual technique then involves securing the EEA stapler anvil at the distal end of the proximal colon within the pursestring suture. At this point it is important to ensure that the colon mucosa does not invaginate when closing the bag snuff. The EEA instrument is introduced transanally until it reaches the tip of the rectal stump.
A rectotomy is made above or below the staple line to allow easy advancement of the central shaft.
We must make sure that the mesocolon is not twisted when performing the anastomosis and we must to check that the anastomosis is tension-free.
The anvil shaft was then attached to the central shaft and the EEA stapler was closed, activated, and fired. And end-to-end colorectal anastomosis was performed after firing the EEA stapler. The EEA instrument was removed through the anus and we checked the doughnuts’ integrity.
Occasionally we make two stitches on each end to strengthen the anastomosis, ending the procedure.