THE BAD MOVE: GOING THROUGH THE STAPLE LINE IN THE RECTAL STUMP
One of the most devastating intraoperative complications from circular stapler use is going through the rectal stump. This occurs when the operator loses control while inserting the circular stapler and goes through the transverse staple line. This is most likely to happen when the rectal stump is very short. Usually during insertion of the circular stapler, there is a “give” just as the operator traverses the sphincter muscles. If one is not careful to introduce the stapler in a controlled fashion through the sphincters, they can tear right through the transverse staple line in the lower rectum.
Obviously at that point in surgery, the surgical team is tired and exhausted. Take a deep breath, and keep in mind that it will take patience and time to fix the problem.
In case there is enough length of the rectal stump:
Dissect the rectal stump circumferentially, and then staple again below that area.
If that is not an option due to any reason, then perform a purse string suture around the spike of the circular stapler. If you are not able to sew laparoscopically, then convert to open to do this.
If the rectal stump is very short:
Handsewn coloanal anastomosis can be done.
Place a purse string on the rectal stump—either laparoscopically or open—and pass the pin of the circular stapler through it and then tie the purse string snug onto it. This is quite challenging in morbidly obese and in male patients. Robotic surgery facilitates this step as sewing is easier. If technically not feasible, then one can do a handsewn anastomosis.
If adequate length of the proximal colon is available, then one can perform the Turnbull-Cutait procedure (Figure 19-1) where the colon is pulled through the anal canal without anastomosis as a first stage. It followed later by a second operation, and handsewn coloanal anastomosis is performed.
Immediate post operative appearance after a Tunbull-Cutait procedure. (Reproduced with permission from Dr. Sherief Shawki.)
Salvage options if performing an anastomosis is deemed technically impossible:
Leave the stump open, place an omental pedicle on it, and place a rectal drain and pelvic drain with end colostomy.
Convert the operation to an intersphincteric abdominoperineal resection (APR). In most cases where ultralow rectal anastomosis is anticipated, the patient should have been counseled for possibility of an intersphincteric APR. However, if that is not the case, then the surgeon should scrub out and talk to the family before proceeding. If they are not in agreement to proceed with an intersphincteric proctectomy then the option described above (end colostomy + drains) should be used.
THE CIRCULAR STAPLER THAT WON’T COME OUT