Predicting the level of difficulty of the double-stapling technique in laparoscopic total mesorectal excision

  • Chi Chung FooEmail author
  • Hing Tsun Hung
  • Yuen Chi Ho
  • Wendy Wai Man Lam
  • Wai Lun Law



The transection of rectum and fashioning of anastomosis is a crucial step in laparoscopic total mesorectal excision (TME) and the double-stapling technique (DST) is often employed. This study aimed to evaluate the factors that were associated with difficult DST.


Cases of laparoscopic TME were retrospectively reviewed. The clinico-anatomical parameters were retrieved from a prospectively maintained database. In addition, pelvic dimensions were taken by reviewing the magnetic resonance imaging scan. The number of stapler cartridges used for intracorporeal transection of rectum was used as a surrogate for the level of difficulty of DST and its relationship with various parameters were evaluated.


There were a total of 121 consecutive cases analyzed. The mean number of stapler cartridges used was 2.1 ± 0.7. Pelvic inlet (p = 0.002) and tumor height (p = 0.015) were predictors of the number of cartridges used, R2 = 0.366. A model was developed to predict the likelihood of transecting the rectum with two or less stapler cartridges, which included the following parameters: gender, pelvic inlet, interspinous distance, intertuberous distance, and tumor height. The predicted probability also correlated with overall operation time (p = 0.009) and anastomotic leakage (p = 0.023).


The difficulty of DST was associated with patient’s clinico-anatomical factors. Surgeons can consider other feasible alternatives, like transanal anastomosis, when a technically challenging DST is anticipated.


Total mesorectal excision Double-stapling technique MRI pelvimetry 



The authors report no external funding for this study.

Compliance with ethical standards


Dr. Chi Chung Foo, Hing Tsun Hung, Yuen Chi Ho, Wendy Wai Man Lam, and Professor Wai Lun Law have no conflicts of interest or financial ties to disclose.


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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryThe University of Hong KongHong KongChina
  2. 2.Department of RadiologyQueen Mary HospitalHong KongChina
  3. 3.Department of SurgeryThe University of Hong Kong, Queen Mary HospitalHong KongChina

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