INTERNATIONAL JOURNAL OF SURGICAL PROCEDURES (ISSN:2517-7354)

Background: Recently, several studies have demonstrated the feasibility and effectiveness of totally laparoscopic colectomy with intracorporeal anastomosis. In this study, we describe our novel technique for intracorporeal end-to-end anastomosis, which we have named the modified book-binding technique (MBBT), in totally laparoscopic colectomy, and present our preliminary experience in clinical practice.

Patients and Methods: MBBT is performed as follows: (1) the 45-mm endoscopic linear stapler is inserted parallel into each hole at the mesenteric side of the proximal and distal ends of the bowel; (2) before stapling, the ends of the bowel are repositioned such that the oral side of the stapler tip is pushed toward the oral bowel, and the anal side is pushed toward the anal bowel, with the root side of the stapler remaining as a pivot point. Then, the stapler is inserted deeply; (3) the anterior wall of the bowel is excised according to ischemia; (4) the anterior wall of the bowel is stapled again in 2 parts using the 60-mm endoscopic linear stapler.

Results: A total of 7 patients underwent totally laparoscopic colectomy using this technique. One patient experienced postoperative ileus. There were no other postoperative complications, including anastomotic leakage or intraperitoneal abscess. All patients have survived without any recurrence or late-phase complications.

Conclusion: This novel technique has a feasibility for end-to-end anastomosis in totally laparoscopic colectomy, ensuring a sufficient anastomotic area. MBBT could be an alternative method of intracorporeal anastomosis.

• We introduce our novel technique for intracorporeal end-to-end anastomosis, which we have named the modified book-binding technique (MBBT), in totally laparoscopic colectomy.
• This novel technique has a feasiblity for end-to-end anastomosis in totally laparoscopic colectomy, ensuring a sufficient anastomotic area.MBBT could be an alternative method of intracorporeal anastomosis compared with FEEA and overlap.
  

Laparoscopic Colectomy; Intracorporeal Anastomosis; End-to-end Anastomosis

LAC-EA: laparoscopy-Assisted Colectomy with Extracorporeal Anastomosis

TLC-IA: Totally Laparoscopic Colectomy with Intracorporeal Anastomosis

FEEA: Functional End-to-End Anastomosis

MBBT: Modified Book-Binding Technique

Laparoscopic colectomy as a minimally invasive surgery has gained wide acceptance because of its feasibility and lower rates of complications and morbidity compared with open colectomy [1-3]. In addition, several studies have demonstrated comparable oncologic outcomes between laparoscopic and open approaches against colon cancer [4-6]. In most countries, when a laparoscopic approach for colectomy is decided, surgeons often select laparoscopy-assisted colectomy with extracorporeal anastomosis (LAC-EA) as the standard procedure.

Recently, several studies have demonstrated the feasibility and effectiveness of totally laparoscopic colectomy with intracorporeal anastomosis (TLC-IA) [7-9]. Possible advantages in TLC-IA compared with LAC-EAare as follows;

1. Good visualization demonstrated by a similar anastomotic leak rate;
2. Less traction on the mesentery with a decreased rate of prolonged postoperative ileus;
3. Smaller incision with less postoperative pain;
4. Possibility of performing a suprapubic incision in all cases with less postoperative pain, decreased rate of pulmonary complications and incisional hernias, especially in obese patients. In fact, several systematic reviews and meta-analyses have demonstrated the usefulness of TLC-IA compared with LACEA in terms of perioperative morbidity, length of hospital stay, and surgical site infection, showing comparable incidences of anastomotic leakage and intra-abdominal abscess [7,9].

There are 2 well-known techniques for intracorporal anastomosis in TLC-IA: functional end-to-end anastomosis (FEEA) and overlap anastomosis [10-12]. Both are truly side-to-side anastomosis, and theserarely cause abnormal dilation around the anastomotic lesion, such as blind loop syndrome, due to incising the circular muscle of the bowel [13-15]. On the other hand, end-to-end anastomosis is typically preferred from the point of view of less mobilization and not cutting a circular muscle of the colon. Ikeda and Oki reported a technique for end-to-end anastomosis between the remnant stomach and duodenum in totally laparoscopic distal gastrectomy, which they named the “book-binding technique” [16,17]. Although we applied this technique to colonic anastomosis in experimental animals, we were afraid of the area of anastomosis. Therefore, we have modified this technique to ensure a sufficient anastomotic area.

In this study we describe our novel technique for intracorporeal end-to-end anastomosis, which we have named the modified bookbinding technique (MBBT), in totally laparoscopic colectomy, and present our preliminary experience in clinical practice.

Before anastomosis, the oral and anal bowels are tentatively overlapped to confirm whether anastomosis is achieved without tension. First, the 45-mm or 60-mm endoscopic linear stapler is inserted parallel into each hole at the mesenteric side of the proximal and distal ends of the bowel (Figure 2a). Second, each end of the bowel is repositioned such that the oral side of the stapler tip is pushed toward the oral bowel, and the anal side is pushed toward the anal bowel, with the root side of the stapler remaining as a pivot point (Figure 2b). Third, the anterior wall of the bowel is excised (Figure 2c). Since it is easy to identify the ischemic area, this area is excised adequately, thereby preserving several millimeters of anterior staple line from the tip (Figure 2d) Fourth, the anterior wall of the bowel is stapled again in 2 parts using the 60-mm endoscopic linear stapler (Figure3a-c). In the second part, the 60-mm endoscopic linear stapler or hand-sewn sutures are selected according to the surgeon’s preference. Theoretically, the shape of the anastomosis becomes quadrangular, sufficiently expanding the anastomotic area [Figure3d].In this study, all these procedures were performed by a single surgeon (EH)

Postoperative wounds of this surgery are shown in (Figure 4).

The patient characteristics and surgical outcomes is shown in (Table 1). Seven men and 1 woman underwent TLC-IA using MBBT. Mean age was 73.6 years (range, 64-90 years), and mean body mass index was 22.3 kg/m² (range, 16.8-26.0 kg/m² ). Tumor locations were as follows: 4 in the transverse colon, and 1 in the cecum, descending colon, and sigmoid colon, respectively. The following operations were performed: one ileocecalectomy, 1 sigmoidectomy, 2 transversectomies, and 3 left colectomies. Mean operating time was 286 min (range, 245-340 min), and mean estimated blood loss was 20.7 mL (range, 5-50 mL). There was no conversion to laparoscopyassisted or open surgery, and no intraoperative complications were observed. One patient experienced postoperative ileus, which did not require bowel drainage. There were no other postoperative complications, including anastomotic leakage or intraperitoneal abscess. Mean length of hospital stay was 16.3 days (range, 10-36 days).

Oncologic results are shown in (Table 2). Mean tumor size was 3.6 cm (range, 0.9-5.8 cm), and mean length of resected specimen was 24.1 cm (range, 17-31 cm). Mean number of retrieved lymph nodes was 14.9 (range, 7-25). TNM classifications according to the Union for International Cancer Control, 8th edition, were as follows: 5stage A and 2stage.

TLC-IA has gained widespread acceptance because of its high feasibility and low rate of postoperative complications [7-9].However, to our knowledge, the methods of intracorporeal anastomosis in TLC-IA are side-to-side techniques, such as FEEA and overlap, and no study has described intracorporeal end-to-end anastomosis. In the present study, we demonstrated that our novel technique, which we have named MBBT, is a safe and feasible alternative in TLC-IA.

The book-binding technique was originally reported for endto-end anastomosis between the remnant stomach and duodenum in totally laparoscopic distal gastrectomy [16,17]. The steps of this technique are as follows: First, the posterior intestinal wall is stapled. Next, the anterior intestinal wall is excised because the area surrounding the staples becomes ischemic. Then, the anterior intestinal wall is stapled again. We applied this technique to colonic anastomosis in an experimental animal model. However, the 45 mm endoscopic linear stapler could not be inserted up to the root of its cartridge. Then, the shape of the completed anastomosis looked slightly narrow, and we were concerned about an insufficient anastomotic area. Therefore, we decided that before stapling, both tip sides are repositioned like a double-door opening, with the root side remaining as a pivot point. This modification enables insertion of the stapler up to the root of its cartridge. Moreover, when excising the anterior intestinal wall, several millimeters of anterior staple line from the tip are preserved. Thus, the shape of the anastomosis becomes quadrangular, ensuring a sufficient anastomotic area. After we experienced this procedure several times on an experimental animal model, we applied to the patients who were diagnosed colon cancer.

Side-to-side anastomosis can cause abnormal dilation around the anastomotic lesion, such as blind loop syndrome, due to incising the circular muscle of the bowel [13-15]. This issue is less worrisome in end-to-end anastomosis. However, it is unclear whether this procedure leads to significantly less invasion than side-to-side anastomosis in terms of surgical stress response, and makes a significant clinical difference compared with side-to-side anastomosis. Moreover, in ileocolostomy, such as ileocecalectomy and right hemicolectomy, this procedure would not be meaningful because the ileum can easily reach the right upper quadrant of the abdomen. On the other hand, in colocolostomy, such as transversectomy, left colectomy, and sigmoidectomy, this procedure might be useful.

In TLC-IA, intra-abdominal abscess and cancer celldissemination are a possibility. Recently, several systematic reviews and metaanalyses have demonstrated that rate of intra-abdominal abscess in TLC-IA is the same as that in LAC-EA [7,9]. In our study, although only 7 cases were included, no intra-abdominal abscess occurred. On the other hand, regarding the possibility of cancer cell dissemination, only a few studies have reported comparable long-term survival between TLC-IA and LAC-EA, with no increase in rate of intraperitoneal recurrence [18-19]. However, it is difficult to draw a conclusion based on the lack of evidence. The possibility of cancer cell dissemination is still unclear and should be assessed in the future.

This study has several limitations. First, although we demonstrated the feasibility in MBBT anastomosis, we did not show the clinical benefit of MBBT anastomosis compared with that in FEEA or overlap anastomosis. Second limitation is a feasibility, a safety and a reproducibility. This study was a small sample size including some different surgical procedures; right colectomy, transversectomy, and left colectomy. Moreover, all procedures were performed by a single surgeon. Therefore, the true feasibility, safety and reproducibility is still unclear. Third limitation is cost effectiveness. The number of the usage of stapling device in MBBT anastomosis is one or two more than that in FEEA or overlap anastomosis. We have to demonstrate that MBBT anastomosis is worth the cost, comparing with other intracorporeal anastomosis. To overcome these limitations, we have to conduct a prospective clinical trial to clarify the clinical benefit and superiority of MBBT anastomosis. 

This novel technique, which we have named MBBT, has a feasiblity for end-to-end anastomosis in totally laparoscopic colectomy, ensuring a sufficient anastomotic area. MBBT could be an alternative method of intracorporeal anastomosis compared with FEEA and overlap.

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