STARR — Stapled TransAnal Rectal Resection

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Pelvic floor

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    (1) Rectogenital septum, (2) Rectal stalks (paraproctium), (3) Mesorectal fascia

    Acting as a "functional unit" the muscular pelvic floor closes off the inferior abdominal cavity and prevents the prolapse of intestines and pelvic organs. The structures of the pelvic floor support the intestinal and urogenital outlet system, with the muscular parts playing an essential functional role in retention and continence. Muscular overstretching and denervation may result in pelvic floor descent or the various forms of lesser pelvis organ prolapse. Women are affected far more frequently than men (ratio 9: 1).

    Usually, the development of pelvic floor deficiency is a multifactorial process. The number of vaginal deliveries, excessive pressing during defecation, obesity, and previous pelvic surgery are some of the most common causes of pelvic floor disorders.

  • Rectum

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    Rectum
    From a functional point of view, the rectum is a storage reservoir for feces preventing its continuous discharge. The rectum directly adjoins the sigmoid colon and resembles it in that it has an S-shaped anteroposterior and lateral curvature (sacral, anorectal and sacral flexure). Typically, the rectum is divided into three segments:

    1. Rectal ampulla (main reservoir, anterior to the sacrum)
    2. Anal canal (see below, sealing zone between the anorectal flexure and the cutaneous orifice)

    Between 1. and 2. an unspecified section which emerges perpendicularly from 1. and joins 2., also at right angles. Here, the mucosa presents with typical folds (Kohlrausch's folds).

    Posteriorly the rectum is related to the sacrum and coccyx, laterally to the internal iliac arteries and veins, regional lymph nodes, sacral plexus and parts of the autonomic nervous system, as well as both ureters and uterine adnexa. In the female, the uterus and vagina lie anteriorly, while in men this is true for the bladder and prostate/seminal vesicles. Inferiorly the rectum is related to the pelvic floor.

    Blood supply
    Three main arteries supply the rectum with blood:

    • Superior rectal artery (from the inferior mesenteric artery) via the sigmoid mesocolon (Caution: Transection of this artery at the level of the sigmoid colon results in ischemia of the upper rectum!)
    • Medial rectal artery (from the internal iliac artery), coursing craniad of the levator ani
    • Inferior rectal artery (from the internal pudendal artery) inferior to the levator ani.

    Venous drainage is via the venous rectal plexus underneath the mucosa of the rectum. The superior rectal vein drains the blood of the upper rectum via the inferior mesenteric vein into the liver, while the medial and inferior rectal veins drain the blood of the middle and lower rectum via the internal iliac vein into the lower vena cava (portocaval anastomosis). Medications administered as suppositories therefore only enter the body without being metabolized, if they are not advanced up into the region drained by the superior rectal vein.

    Lymphatic drainage of the rectum parallels the rectal blood vessels: The large cluster of inferior mesenteric lymph nodes forms a separate group at the upper rectum (superior rectal lymph nodes); the internal iliac lymph nodes filter lymph from the middle rectum (from the pararectal lymph nodes) and the superficial inguinal lymph nodes from the lower anal region, anus and perineal skin.

  • Anal canal

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    (1) Tunica muscularis, longitudinal sublayer, (2) Tunica muscularis, circular sublayer, (3) levator ani, (4) puborectalis, (5) external anal sphincter, deep part, (6) anal columns, (7) external anal sphincter, superficial part, (8) external anal sphincter, subcutaneous part, (9) Kohlrausch’s fold, (10) internal anal sphincter, (11) proctodeal gland, (12) corrugator cutis ani
    Anal canal

    The interaction of three muscles in the lower rectum creates a sphincter mechanism:

    1. The internal anal sphincter represents a thickening of the last annular fibers of the smooth colon muscles and is innervated by the sympathetic nervous system.

    2. The levator ani, however, has voluntary innervation (sacral plexus) and includes the puborectalis arising from the symphysis pubis. Since the course of the puborectalis creates a sling (deficient anteriorly) around the rectum, the latter becomes angulated.

    3. The external anal sphincter is also a striated muscle and extends from the center of the perineum (centrum perinei, perineal body) to the coccyx. Its somatic innervation is supplied by the pudendal nerve. With its contraction it completely seals off the anal canal.

    The different innervation of the three muscles involved in the sphincter mechanism provides additional protection against failure and resulting incontinence.

    The mucosa of the anal canal is plicated into numerous longitudinal folds (anal columns) displaying a dense arterial (!) plexus with venous drainage. When the sphincter muscles contract, these plexuses fill up quickly distending the mucosa and pushing the folds against each other, thereby ensuring a gas-tight seal. Hemorrhoids and venous thromboses are well known vascular complications in this region.
    Defecation involves not only relaxation of the sphincter mechanisms (initiated by voluntary muscle action, drainage of the cavernous bodies) but also active abdominal press and intestinal peristalsis.

  • Perineum

    The perineum includes the region inferior to the pelvic diaphragm (genitourinary and anal region) and is delimited:
    Craniad by the fascia of the inferior pelvic diaphragm
    Anterior to the pubic symphysis: Laterad by the ischium and posteriad by the greatest gluteal muscle

    The posterior perineum corresponds to the anal region and is known in the nomenclature as ischioanal fossa, while the anterior perineum corresponds to the pubic region and can itself be divided into three segments lying on top of each other: At the most superficial level a subcutaneous perineal pouch (Colles space) (between the stratum membranosum telae subcutaneae perinei = Colles fascia and the perineal fascia), a superficial perineal pouch between the perineal fascia and perineal membrane (Buck), and a deep perineal pouch superior to the perineal membrane.

    Below the skin the posterior ischioanal fossa consists mainly of fatty tissue and numerous vessels/nerves (branches of the inferior rectal and internal pudendal artery and the pudendal nerve to the anal region). At the transition to the sacral region, a space lined with epithelium may develop in the gluteal fold and form a sinus between the tip of the coccyx and the anal verge. It may be encapsulated like a cyst (dermoid cyst) or have an external orifice (pilonidal sinus).

    The anterior superficial perineal space comprises the superficial muscles of the perineum and the blood vessels and nerves to the external genitals (perineal artery and artery of bulb of vestibule, as well as branches of the pudendal nerve to the labia/clitoris and scrotum respectively).

    The deep anterior perineal space is less clearly delimited, merges with the ischioanal fossa posteriorly and comprises the deep perineal muscles and other deep vessels/nerves.

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 06.07.2014

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  • Verifying the indication and dilating the anal sphincter

    133-6

    Perform a digital rectal examination to verify the findings and carefully dilate the anus digitally. During the digital rectal examination, the rectocele can be palpated anteriad, while the posterior wall of the vagina bulges into the rectum. The extent of rectoanal intussusception is assessed with dressing forceps and/or an Allis clamp. Now carefully dilate the anal sphincter with fingers before inserting the anal dilator. Introduce the transparent proctoscope into the anal canal as an anal port and for protection of the anoderm.

    Note: The transparent proctoscope (anal port) may be temporarily anchored to the perianal skin with four stitches.

  • Anterior purse string suture

    133-7

    After insertion of the 3/4 anoscope, place the semicircular purse string suture (nonabsorbable monofilament suture 0/0 or 2/0). Depending on the extent of the prolapse, it may require placement of 2-3 semicircular purse string sutures. Place the semicircular suture is placed at least 2cm craniad of the hemorrhoidal zone from about 9 o'clock to 3 o'clock. Unlike in stapler hemorrhoidectomy, the bite goes not only through the mucosa but the full wall of the rectum. Follow this with the first digital examination of the posterior vaginal wall.

    Note: Alternatively, take a full bite of the rectal wall with one lock-stitch suture each, at 2-3 o'clock, 12 o'clock and 9 o'clock, which is then tied.

  • Inserting the stapler

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    Protect the posterior wall of the rectum with a pediatric spatula at 6 o'clock when closing the stapler. With the circular stapler in its maximum open position, now introduce it into the rectum until the anvil is craniad of the purse string suture. With the suture threader pull the ends of the thread through the stapler housing.

    Note: In the alternative technique depicted in the illustration, the ends of the placed suture(s) are pulled through the slots provided for this purpose and the two ends of the fixation suture(s) are separated at 12 o'clock: One thread is added to the fixation stitch at 10 o'clock, the other thread to the fixation stitch at 2 o'clock. This ensures that the central part of the rectal wall is best drawn into the stapler.

  • Anterior resection

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    Gather the ends in a clamp or tie them. Close the stapler step by step and push it forward into the rectum while keeping the clamp/suture ends under slight tension. Check the posterior vaginal wall before closing the stapler and firing it.

    Note: Checking the posterior vaginal wall ensures on the one hand that the edge of the stapler housing is positioned just above the levator muscle and on the other hand that no parts of the posterior vaginal wall are caught.

    Firing the stapler resects a cuff of the anterior rectal wall by placing a semicircular stapled suture line.

    Now extract the resectate from the stapler housing, check it for completeness and measure it. Resectates comprise all the layers of the rectal wall. And then inspect the stapled suture line.

    Note: Usually, two "mucous membrane ears" are seen in the rectum after the resection, which are connected to a bridge of mucosa by the stapled suture line. This bridge of mucous membrane must be severed with scissors.
    Tip: Control any bleeding at the stapled suture line by suture ligation. An absorbable multifilament suture 2/0 is recommended.

  • Posterior purse string suture

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    Analogous technique for the posterior wall. Starting at the base of the "mucosal ears" (result of the anterior anastomosis), place the semicircular purse string suture from 3-4 o'clock to 8-9 o'clock.

    Note: As an alternative to the purse string suture, anchor the segment to be resected with a stitch. To this end, include the projecting lateral ends of the stapled suture line in in the suture. Place a third suture at 6 o'clock.

  • Posterior resection

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    First, in order to protect the anterior stapled suture line, reposition the pediatric spatula from its position at 12 o'clock. Now insert the second stapler and, after the ends of the suture have been pulled through the housing again, slowly close and then fire the stapler while keeping constant tension on these ends. As in step 3, extract the all-layer resectate from the stapler housing. Here, too, there may be a mucosal bridge that must be transected.

    Note: The figure illustrates an alternative to the purse string suture - fixation of the posterior rectal wall with three seams at 4 o'clock, 6 o'clock and 8 o'clock.

  • Inspecting the stapled suture lines; ending the operation

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    As a final step, check all stapled suture lines again and control any arterial bleeding by suture ligation. Insert an anal tamponade made of dressings soaked in epinephrine (1:100,000) and xylocaine.

    Tip: Troublesome mucous membrane ears at 3 and 9 o'clock can be inverted by one suture each.

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  • Intraoperative complications

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  • Postoperative complications

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  • Städtisches Klinikum München Schwabing

    Dr. Anne Heiss

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  • Literature summary

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  • References on this topic

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  • Current trials

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    Literature search under: http://www.pubmed.com