Single versus double stapled anastomosis in natural orifice specimen extraction (NOSE) laparoscopic anterior resection

Background: Laparoscopic anterior resection (LAR) with Natural Orifice Specimen Extraction (NOSE) has shown benefits such as reduced pain, fewer wound complications, and improved cosmesis. In colorectal anastomosis during NOSE, double staple anastomosis (DSA) and triple stapled technique (TSA) are common. However, a novel single stapled anastomosis (SSA) technique, utilising two laparoscopically placed purse strings and only four 5 mm ports, has emerged. This study aims to compare the complications between single and double stapled anastomoses in NOSE LAR.

Methods: A retrospective analysis of NOSE LAR data from 2011 to 2022 included patients. All patients received mechanical bowel preparation, colonoscopic instillation of betadine or chlorhexidine, and antibiotics. DSA was performed conventionally, while the SSA technique involved an additional rectal laparoscopic purse string. Fisher's exact test assessed anastomotic leak rates and the need for intraoperative revisions.

Results: Analysis of 179 patients revealed 40 with SSA and 139 with DSA. Patient age ranged from 20 to 88 years, with a BMI between 22 and 46 kg/m². Diverticulitis and malignant polyps, the most common indications. Operation duration was similar between groups (238 min in SSA, 234 min in DSA; P = 0.69). Intraoperative laparoscopic anastomotic redo was significantly higher in the SSA group (six patients) than the DSA group (five patients; P = <0.05). No anastomotic leaks occurred in the SSA group, while six occurred in the DSA group (P = 0.34). There was no significant difference in Length of Stay (LOS), (5 days in SSA versus 6 days in DSA group, P = 0.29).

Conclusions: Single stapled anastomosis in NOSE LAR appears safe for benign conditions but is more likely to necessitate intraoperative redo compared to double stapled anastomosis.