Conversion of double stapling to single stapling using reverse smile or satay technique for colorectal anastomosis: surgical technique

Introduction

Traditionally double-stapling technique (DST) is used for restoration of colorectal anastomosis. However, this will result in dog ears at corners with increase chance of anastomotic leak, from 6% to 15% (1,2). The leak from dog ears was reported due to structural weak points and tissue ischemia (2). There are many ways to improve DST to single stapling line (3). The presented video demonstrates modification of the DST into single stapling line using the reverse smile technique, also described by Spinelli (https://www.youtube.com/watch?v=cTaAKuyaMu0&rco=1). We newly introduced a simpler and quicker version called as satay technique—a novel approach developed by the surgical team. This method simplifies the procedure by converting it into a single-stapled anastomosis while maintaining safety and efficacy. The video highlights the key steps of this new technique. We present this article in accordance with the SUPER reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-56/rc).

Preoperative preparations and requirements

The patient should ideally undergo bowel preparation using either oral agents or a fleet enema. For the stapler size, we routinely use 28- or 29-mm circular staplers; however, a larger size that accommodates the anal canal or colorectal anastomosis is recommended when available. All other preparations follow standard anterior resection protocols.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Step by step description

The reconstruction of the colorectal anastomosis proceeds as standard until anvil preparation with the proximal colon end. The circular stapler is then introduced transanally (see Video 1 and Figures 1,2).

Figure 1 Distal donuts with dog ears and proximal donut within the anvil.

Figure 2 Additional rectal tissue dog ears are incorporated into stapler barrel housing. The piercing (satay) can be done one side or both sides.

The stapler spike pierces the center of the rectal stump’s staple line to incorporate both dog ears. However, if the staple line is excessively long and full inclusion is impractical, the spike may alternatively engage only one dog ear (see Figure 2: unilateral satay). In such cases, eliminating even a single dog ear may reduce leak risk by addressing its structural weakness.

Technical note: retracting the stapler cartridge during spike advancement facilitates easier piercing of dog ears (demonstrated clearly in the video). After piercing, the anvil is joined to the spike, gradually closed, and compressed for 15 seconds. The stapler is then removed, and donuts are inspected (Figure 1). The distal donut will exhibit two concentric rings due to incorporated rectal tissue with dog ears. Endoscopic verification of the anastomosis is routinely performed to exclude bleeding or leakage.

Discussion

The modified single stapling technique are solutions to simplify anastomosis while reducing potential issues associated with double stapling, such as anastomotic leak or bleeding. The elimination of the dog ears from single stapling without sutures may reduce the risk of anastomotic leak (4). However, the reverse smile technique may have issue of possibility of not included dog ears. In our case, we modified this technique by suturing the dog ears. Alternatively, we postulate that piercing the dog ears with the circular stapler’s spike allows for a swift and effective single stapling anastomosis, which we called in as “satay technique”. The name is derived from satay, a Malaysian dish of skewered meat, as our technique involves piercing the dog ears onto the spike in a similar fashion. The time consumed is about 5 min for satay technique compared to reverse smile technique with suturing which is about 15 min. Nonetheless, the reverse smile technique without suturing as described by Antonino is about 5 min which is similar duration with satay technique as our novel technique (1). However, we identify reverse smile technique may have higher chances of not including the dog ears if no suturing of the dog ear is performed as shown in the video. Both the cases shown in the video, patient had uneventful recovery with no leak.

For surgeons performing low anterior resections, this method could offer a more efficient alternative without taking much effort and time compared to prior technique. The video briefly discusses the technical tips and issues that could happened. While the technique is promising, it would benefit from a prospective comparison study with conventional DST in terms of leak rates, operative time, or short-term outcomes.

With regards of risk of bleeding or anastomotic leak, the use of the circular stapler ensures even distribution (equilibration) of the rectal tissue seated on the stapler cartridge ring. The rectal wall stapled is even due to this stapling mechanism. The additional rectal tissue dog ears are incorporated in stapler barrel housing as in the Figures 1,2.

We have performed this stapling technique in at least five cases, with no instances of anastomotic bleeding or leakage. Additionally, we routinely verify the anastomosis endoscopically. This double-check confirms the absence of bleeding, as the circular stapler provides adequate compression for at least 15 seconds.

Conclusions

This surgical report describes and demonstrates the satay technique as a novel modification to single-stapled colorectal anastomosis. The approach appears practical and could be a valuable addition to colorectal surgery. However, further clinical studies would strengthen its validation.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-56/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-56/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-56/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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