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Anastomotic Techniques for TaTME
Posted in Videos on 14 November 2019
Antonio M. Lacy (Director of Department of Gastrointestinal Surgery)
Marta Jiménez Toscano (Gastrointestinal Surgery Specialist)
Hospital Clínic, Barcelona – Spain

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TaTME is not only a surgical technique: it is a new way to provide rectal cancer or rectal non-oncological treatment.

TaTME involves different situations, which require different surgical steps and instruments.

Each procedure needs a different type of anastomosis. In this video we will review most of them.

Hand sewn colo-anal anastomosis

This anastomosis is indicated in very low rectal cancer or when a partial or total intersphincteric resection is required. To perform it correctly, a long star device will improve anal exposure and we will use single vicryl stitches for a side to end or end-to-end anastomosis.

First of all, the long star is placed and we make four cardinal vicryl stitches in the distal rectum. Then the rectum is exteriorized and cut with an endoGIA.

Two sutures are positioned on each side to control the anastomosis from the abdominal side.

In this case, we introduce the colon again to open it laterally so as to perform a side to end anastomosis.

The previous sutures made are completed with four stitches in the proximal colon after opening the colonic wall.

We can check that we have a correct colonic lumen during the procedure.

The anastomosis is completed with single vicryl stitches between the previous cardinal sutures.

End to end mechanical anastomosis

The end to end mechanical anastomosis can be used if we have enough distal margin to use a stapler. For TaTME we prefer a Covidien EEA Haemorrhoidal Stapler due to its longer spike, thicker donuts and the possibility of introducing the non dissected distal rectal stump in the anastomosis.

As a first step we should make a prolene purse string in the distal rectum.

At the same time the abdominal team has exteriorized the specimen through a Pfannenstiel incision and has introduced the anvil of a 33 haemorrhoidal stapler in the proximal colon with a silicon tube connected to it. This will help us to exteriorize the anvil through the anus so as to knot the prolene over it and connect with the stapler. We can see the final view of the mechanical anastomosis.

Side to end anastomosis

A side to end anastomosis is indicated when we have enough proximal colon to exteriorize the specimen through a Pfannenstiel incision or through the anus. With this kind of anastomosis we are looking for better functional outcomes.

In this case the specimen was exteriorized through the anus.

The anterior side of the colon is opened in a well vascularised area. The edges are held with three babcocks.

The long spike of the anvil is introduced and exteriorized 4-5 centimetres proximally.

The whole anvil is carefully introduced into the colonic lumen bearing in mind potential damage to the colonic wall.

The distal colon is cut with a 60mm endoGIA and two stitches are made in the stapler line for better abdominal control of the anastomosis..

The colon is introduced in the pelvis.

The prolene purse string that was previously made as a first step is closed over the spike.

The stapler is connected and closed with abdominal control. We should always check the vagina to avoid accidentally  introducing it into the anastomosis.

Ulcerative colitis can also be dealt with using a combined approach. In this case, a J pouch is made through the ileostomy wound, and, thanks to a 33 haemorrhoidal stapler, is joined to the distal rectum.

J pouch coloanal mechanical anastomosis

The combined transanal–transabdominal approach can also be used to complete a proctectomy. In these situations, a J–pouch places the rectum again in the pelvis.

The J pouch is made through the previous ileostomy wound and the anvil of a 33 EEA haemorrhoidal stapler is fixed in the apex of the stapler with a prolene purse string.

Again, the longer spike helps us to exteriorize the anvil through the anus and to perform the anastomosis

A silicon tube is connected to the spike to improve traction through the anus.

After the transection of the rectum to complete the proctectomy,  a prolene purse string is made over the distal rectum.

When the circumferential suture is finished, the gelpoint is extracted and the long star is placed to improve visualization

By means of a grasp introduced through the anus, the silicon tube is retracted and exteriorized, with abdominal control of the correct position of the pouch.

Good retraction of the surrounding tissue from the abdominal side is important, so as to allow the pouch to descend correctly, avoiding taking any kind of tissue into the anastomosis.

The distal purse string is closed over the spike, which is connected posteriorly to the stapler, so as to carefully complete the procedure.

Mechanical anastomosis in the high rectum

We are still looking for the best and most effective stapler for each situation. For this reason, we have used the Ethicon 33 EEA (Ethicon Endo-Surgery Intraluminal Stapler (ILS)) for the high rectum to avoid some drawbacks of the 33 hemorrhoidal stapler. To use it, some of the main steps of the anastomotic procedure must be changed.

After the transection of the high rectal wall, the prolene purse string is made. This step could be especially challenging due to the parallel position of the instruments.

As you can see, a full thickness continuous suture is made.

Once the rectal resection is finished, the stapler is introduced through the anus. In this case, the silicon tube is connected to the stapler to help knotting the suture over it, and to better visualize and retract it when it is introduced into the abdomen

The plastic tube is withdrawn and anvil and stapler are connected.

The anastomosis is completed under abdominal control

An indicator on the handle will tell us when the stapler is correctly closed so we can cut and complete the procedure.

The complete donuts are checked.

A complete anastomosis with no bleeding is visualized.

Other anastomoses

There are other possibilities to perform the anastomosis using the TaTME procedure, such as the introduction of the anvil into the abdominal cavity, so as to place it directly into the J pouch or the proximal colon. The anvil is fixed with  a prolene suture.

Any of the staplers previously discussed can be used here.

A coloanal hand-sewn end to end anastomosis after transanal extraction of the rectum is also feasible and safe.  The intersphincteric resection is made as a first step, and the rectal lumen is closed at the beginning of the procedure. At the end, the anastomosis is made with single vicryl stitches, first anteriorly with 3 cardinal stitches and the last fourth stitch at twelve after finishing the rectal resection. The rest of the circumferential area is finished with single stitches posteriorly.