nevertheless , completely laparoscopic colorectal procedures have been adopted in clinical practice by a limited number of surgeons .
this is possibly due to increased operating time and costs , to the fact that their relative benefit is as yet unclear , and that these procedures are technically demanding .
the latter reason prompted this experimental study , which was carried out to evaluate whether a previously described intracorporeal approach to sigmoid resection could be facilitated and applied to the rectum in a porcine model .
ten domestic pigs with a median weight of 40.7 kg ( range 38.5 - 43 kg ) were anesthetized with intubation and ventilation with halothane . prior to surgery
, the animals were fasted for 48 hours and kept on fluids ad libitum and received a 2-liter enema .
pneumoperitoneum was induced using carbon dioxide insufflated to a pressure of 10 mm hg by placement of a trocar in the infraumbilical skin using a cut - down technique .
two 12 mm ports were then inserted in the left hypocondrium and in the midline cephalad to the umbilicus . due to porcine anatomy ,
a 33 mm cannula ( endopath , ethicon endosurgery , cincinnati , oh ) was inserted in the right iliac fossa rather than suprapubically .
all subjects were turned into a steep head - down position in addition to a right lateral tilt until no small bowel was seen in the field . a surgical technique previously described for laparoscopic sigmoid resection with intracorporeal colorectal anastomosis and specimen removal via a suprapubic incision
once the proximal site of bowel division was identified , a laparoscopic pursestring clamp ( ethicon endosurgery , cincinnati , oh ) ( figure 1 ) was applied to the colon , and two straight needles ( placed at opposite ends of a monofilament suture and held in position against the clamp by an endoloop ) were passed through the clamp and retrieved through a port , as previously described .
the colon was divided with scissors against the pursestring clamp after having been ligated with an intracorporeally knotted suture .
the lower third of the rectum was transected with an articulating endoscopic stapler ( ets flex 35 , ethicon endosurgery , cincinnati , oh ) . a plastic bag allowed temporary intra - abdominal storage of the specimen .
the rectal stump was irrigated by 1uminal wash - out in order to verify that the linear staple row was tight .
the anvil of a circular stapler ( ecs 25 ethicon endosurgery , cincinnati , oh ) held by a modified allis - clamp was inserted through the 33 mm port into the colon and the pursestring was tied intracorporeally around the anvil notch . the same circular gun with a spike fixed to its shaft was introduced per anum ( figure 2 ) , and a doublestapled colorectal anastomosis was performed according to a previously - described technique .
the integrity of the anastomosis was checked by irrigation with methylene blue after the application of a noncrushing intestinal clamp just proximal to the circular staple line .
the specimen , in a plastic bag , was delivered through the 33 mm port .
circular stapler with spike fixed to its shaft is advanced behind the staple line of the rectal stump .
complete proximal and distal doughnuts were obtained in all cases and anastomoses were all methylene blue tight .
the mean anastomotic level from the anal verge was 5.2 cm ( range 4 - 6 cm ) .
all porcine subjects had an uneventful 5-week postoperative course at the end of which both laparoscopy and rigid proctoscopy were carried out . at celioscopy
there were no adhesions or other abnormalities at the anastomotic site , while endoscopy revealed normal suture lines .
histology of colorectal anastomoses revealed healing mucosa with neither foreign body reactions nor thickening of bowel wall at anastomotic site .
transection of the rectum at a lower level can be achieved inserting an open - surgery articulating stapler through a suprapubic incision . however
, this approach requires a third stapler ( in addition to endoscopic linear and circular staplers ) , re - establishing pneumoperitoneum twice , and manipulation of an open - surgery stapling device with laparoscopic graspers .
the results of the present experimental study show that the use of a laparoscopic articulating stapling device helps to overcome these downsides and allows secure division of the low rectum .
intracorporeally hand - sewn pursestring sutures are usually fashioned with curved or ski - shaped needles on the proximal colon , but this is a time - consuming procedure .
the introduction of the t - needle technique ( endo - stitch , ussc , norwalk , ct ) failed to facilitate this procedure .
in fact , since the t - needle should not be detached from the instrument 's jaws ( unless for reloading ) , the anvil shaft must , at a certain point , be loosened from the allis - clamp to allow 360 suturing and tying around the pursestring notch of the anvil .
, that the use of a laparoscopic pursestring suture clamp seems to facilitate the construction of intracorporeal pursestring sutures and results in a safe colorectal anastomosis . according to previously described techniques ,
once the circular stapling gun 's central spike ( auto suture , pceeatm , ussc , norwalk , connecticut ) is advanced behind the staple line of the rectal stump , the spike must be disconnected and removed through a port ( figure 3 ) .
the use of a gun adapted for laparoscopy ( with a spike fixed to its shaft ) ( figure 2 ) eliminates the need for retrieval of the spike .
the present study shows that a previously described intracorporeal approach to sigmoid resection can be facilitated and applied safely to the rectum in a porcine model .
however , further experimental and clinical comparative studies are needed with regard to safety , time - frame and costs of the construction of intracorporeal pursestring sutures .
 background and objectives : an experimental study was undertaken to evaluate whether a previously described technique for laparoscopic sigmoid resection with intracorporeal resection - anastomosis and specimen removal via a suprapubic incision could be facilitated and applied to the rectum.methods:ten domestic pigs ( median weight 41 kg ) underwent low anterior resection of the rectum , which was transected with an articulating endoscopic stapler . 
 pursestring sutures were fashioned intracorporeally with a laparoscopic pursestring clamp . 
 the anvil of a circular stapler was inserted through a 33 mm port into the colon and pursestring tied intracorporeally . 
 a circular gun with a spike fixed to its shaft was introduced per anum and a double - stapled anastomosis performed.results:complete doughnuts were obtained in all cases and anastomoses were all methylene blue tight . 
 all porcine subjects had an uneventful 5-week postoperative course . 
 the median anastomotic level from the anal verge was 5.2 cm . 
 histology of colorectal anastomoses revealed healing mucosa.conclusions:the use of articulating endoscopic stapler , laparoscopic pursestring clamp , and circular stapler with a spike fixed to its shaft seems to facilitate a previously described intracorporeal approach to sigmoid resection which was safely applied to the rectum in a porcine model . 