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



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.

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Correspondence to Chi Chung Foo.

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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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Foo, C.C., Hung, H.T., Ho, Y.C. et al. Predicting the level of difficulty of the double-stapling technique in laparoscopic total mesorectal excision. Surg Endosc 34, 3382–3387 (2020).

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  • Total mesorectal excision
  • Double-stapling technique
  • MRI pelvimetry