VM71 - Laparoscopic Rectal Resection with fully Intracorporeal Anastomosis for Traumatic Rectal Perforation

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Purpose/Background: During conventional laparoscopic left-sided colorectal resection the proximal bowel is usually exteriorized through a mini-laparotomy or Pfannenstiel incision to secure the anvil of the circular stapler. This then requires an additional abdominal incision. We described a fully intracorporeal method of proximal bowel preparation by securing the circular stapler anvil through the antimesenteric border of the colon using an attached ancillary trocar. We term this approach intracorporeal antimesenteric ancillary trocar application for double-stapling (IAAT-DST). This is especially useful in natural orifice specimen extraction surgery to remove the need for additional abdominal incision. In this case we show how we employ this technique for rectal resection following traumatic rectal perforation.

Methods/Interventions:

Case: The patient is a 38 year old male who presented at the emergency room with rectal bleeding and generalized abdominal pain. History reveals transanal foreign body insertion 24 hours prior to presentation. Abdominal CT scan showed extensive pneumoperitoneum in the upper abdomen and perirectal free air and fluid collection. Diagnostic laparoscopy was performed confirming a large rectal perforation with a length of 5cm with friable wound edges. Rectal resection with primary anastomosis and defunctioning stoma was performed. The sigmoid and rectum was mobilized and segmental resection of the involved rectum was performed. The circular stapler anvil with its ancillary trocar is inserted transanally and the proximal bowel is prepared for colorectal anastomosis intracorporeally. Following insertion of the trocar through the antimesenteric border, the cut end of the colon is closed with a linear stapler reload. The ancillary trocar is then removed, followed by further anchoring of the anvil in position using a Prolene 2-0 suture. Side-to-end colorectal anastomosis was completed using a circular stapler and air leak test was negative. The specimen was extracted via the stoma site and a defunctioning ileostomy was fashioned.

Results/Outcomes: The patient had an unremarkable postoperative recovery with good cosmetic outcome. Patient was discharged on the 5th postoperative day. The defunctioning stoma was reversed after 2 months with normal function and good quality of life on follow up.

Conclusion/Discussion: Intracorporeal antimesenteric ancillary trocar (IAAT) application for preparation of the proximal bowel following left-sided colorectal resection is a viable option in selected patients with rectal perforation, reducing the need for an additional abdominal incision.