STARR — Stapled TransAnal Rectal Resection - general and visceral surgery
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Verifying the indication and dilating the anal sphincter
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
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
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.
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
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.
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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