Low anterior resection (LAR) is commonly performed as part of the surgical treatment of rectal cancer. The operation removes the affected portion of the rectum while preserving the anus and reconnecting the remaining bowel.
Rectal cancer surgery today considers not only appropriate cancer resection, but also the impact of treatment on function and quality of life. Where oncologically appropriate, preserving the anal sphincter and bowel continuity can help maintain these aspects of care.
For cancers located lower in the rectum, achieving these objectives may require the surgeon to work deep within the pelvis. At this level, the space available for surgical devices becomes more restricted, making the positioning of a stapler particularly important when the rectum is divided.
What Is Low Anterior Resection?
During LAR, the part of the rectum affected by cancer is removed together with the tissue required for appropriate oncological resection. The remaining colon is then reconnected to the rectum to restore bowel continuity.
The location and extent of the tumour influence the planned resection. For lower rectal cancers, surgeons need to consider whether the tumour can be removed with appropriate oncological clearance while preserving the anal sphincter and an acceptable level of postoperative function.
The operation may be performed using an open, laparoscopic or robotic-assisted approach, depending on the patient, disease characteristics, planned procedure and surgical expertise.
Why Does the Level of Rectal Transection Matter?
As part of the operation, the rectum needs to be divided below the section being removed. Where this division takes place is determined by the requirements of the cancer resection, including tumour location and the planned surgical margin.
When the rectum needs to be divided at a lower level, the surgeon must work deeper within the pelvis.
The lower rectum is surrounded by the bony pelvis and lies close to urinary, reproductive, vascular and neural structures. The space available to manoeuvre and position surgical devices can therefore become increasingly limited further down the pelvis.
Pelvic anatomy also differs between patients. A narrow and deep pelvis, which is more commonly encountered in male anatomy, may further restrict the space available for positioning a stapler across the rectum.
Why Does Stapler Positioning Matter?
During LAR, a stapler may be placed across the rectum to close and divide it at the planned level before the affected section is removed and the bowel is reconnected.
When working low in the pelvis, the stapler needs to reach the intended transection level and be positioned appropriately across the rectum within the available space. Restricted positioning can affect how the transection is completed.
In some procedures, more than one stapler firing may be required to divide the rectum. The reasons can vary and may include the level of transection, pelvic anatomy and the position from which the stapler can be applied.
The number of firings has been examined in clinical studies. Braunschmid et al. reported an association between the use of three or more stapler cartridges for rectal division and anastomotic leakage. A systematic review and meta-analysis by Balciscueta et al. subsequently reported an association between two stapler firings and a higher rate of anastomotic leakage compared with a single firing.
These studies do not establish that multiple firings themselves cause anastomotic leakage. The need for additional firings may also reflect procedures that are more difficult because of factors such as anatomy or a low level of rectal transection.
How Does Articulation Support Stapler Positioning?
Articulation gives surgeons more options for positioning a stapler when space is limited. Instead of being restricted to a relatively straight approach, the stapler can be adjusted to reach the rectum from different positions within the available operating space.
This can be relevant during low rectal surgery, where the depth and confined dimensions of the pelvis may limit how the stapler can be placed across the rectum.
The Ultraflex 90 reload provides up to 90° articulation, offering a wider range of positioning options when placing the stapler in confined spaces such as the deep pelvis.
Greater articulation does not mean that a transection will necessarily be completed with a single firing. The number of firings required depends on multiple factors, including individual anatomy, the level of transection and the circumstances of the procedure.
Why Access and Stapler Positioning Matter in Low Anterior Resection
Low anterior resection reflects the broader objectives of modern rectal cancer surgery: achieving appropriate cancer resection while considering preservation of function and quality of life where possible.
When surgery extends lower into the pelvis, the available working space can make stapler positioning an important consideration. Features such as articulation provide additional positioning options when working within these confined anatomical spaces.
References:
- You YN, Hardiman KM, Bafford A, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Diseases of the Colon & Rectum. 2020;63(9):1191–1222.
- Langenfeld SJ, Davis BR, Vogel JD, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement. Diseases of the Colon & Rectum. 2024;67(1):18–31.
- Braunschmid T, Hartig N, Baumann L, Dauser B, Herbst F. Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate. Surgical Endoscopy. 2017;31(12):5318–5326.
- Balciscueta Z, Uribe N, Caubet L, et al. Impact of the number of stapler firings on anastomotic leakage in laparoscopic rectal surgery: a systematic review and meta-analysis. Techniques in Coloproctology. 2020.
This article is intended for general educational purposes and does not replace individual medical advice, diagnosis or treatment from a qualified healthcare professional.