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Laparoscopic Low Anterior Resection with Distal Rectal Washout Using the New Device of Gut-clamper

TABLE 1: Advantages of gut-clamper and characteristics Different from ringed manner, as it were, this linear manner
of the patients of clipping using gut-clamper makes possible to reduce the
number of times using laparoscopic staplers as shown in our
With gut-clamper Without
gut-clamper results. As the laparoscopic staplers are easy for the liberalized
gut tract, this gut-clamper is very suitable to use in laparoscopic
Number of the cases 30 10 surgery.
Age range 66-87 65-92
Mean 71.4 70.2 Moreover, when tightening the gut tract in a ringed manner,
Sex male: female 13:17 5:5 the tightened portion is constricted like a banded bundle. When
Rate of complete washout 100 60 observing the gut tract from the interior of the gut tract through
The number of 1.9±1.0 3.4±1.1 a scope, it becomes difficult to accurately identify the resection
times using stapler line due to the constricted portion, therefore, extra portions
Complication none leakage (one case)
may be resected in the gut tract resection. However, in the case
of the gut-clamper, especially in laparoscopic low anterior
resection, the gut tract is clipped by the steel sticks and the
DISCUSSION
width of the gut tract is pressed and widened, and the constricted
Studies have shown that viable tumor cells exist in the lumen of portion is reduced, so that rational resection of the gut tract
the colon and rectum. Therefore, it is believed that rectal could be made after the rectal washout.
washout might have value. Nevertheless, no data conclusively Distal rectal washout has been recommended to prevent
demonstrate reduction of local recurrence or anastomotic implantation of exfoliated malignant cells in the after anterior
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implantation with rectal washout. There are reported that resection for rectal cancer. Maeda et al have been reported
exfoliated malignant cells have been found in the effluent of that the irrigation volume determined the efficacy of rectal
resection margins in the rectal stumps and on circular stapling washout were 1.5 liters of saline irrigation appears to clear
devices. 10-12 In addition, the viability and metastatic potential contents from cancer cells in patients with tumors below the
of exfoliated malignant colorectal cells have been implicated. 11,12 peritoneal reflection whereas at least 2 liters is recommended
As the evidence for potential anastomotic implantation, with for patients with tumor above the peritoneal reflection. As for
no risk and minimal cost, it might have some utility in the laparoscopic low anterior resection, we have used much more
management of rectal cancer, where the proximity of the anasto- volume for irrigation (3 liters of water). Nevertheless, only 60%
motic site and the cancer is close. Beside, it might reduce the were completed in the cases underwent colorectal washout
microbial concentration that is associated to the leakage of without using gut-clamper, but 100% were possible to perform
anastomotic site. distal rectal washout using gut-clamper. Our data of the reduced
In laparoscopic surgery, it is sometimes difficult to apply rate of complete washout also support the benefit of gut-clamper
the same technique as the open surgery. After the first laparos- for the proper sealing the gut tract.
copic colectomy, a lot of laparoscopic surgical innovations for Furthermore, the gut-clamper wherein lengths of the two
colorectal cancer have been made. 13-17 Nevertheless, there was steel sticks are made different from each other and the position
no established method for perioperative rectal washout before of a hole made in a belt connected to the shorter steel stick, is
the resection of the rectum in laparoscopic low anterior resec- set to match with the end of the longer steel stick when the two
sticks are put together by using the joint as a pivot. This
tion. mechanism is easy and safe as well as reasonable physically
Here, we have introduced gut-clamper including, two hard and economically. This device of gut-clamper enables to shed
steel stick having belts with flexibility on their one ends, a joint novel lights on the new standard method for rectal cancer.
at which the steel sticks are joined, and one through hole made
in one of the belts. As the belts with flexibility are made of a soft REFERENCES
resin, it can be safely wound around the gut tract like a band.
The gut-clamper clips the gut tract by using the two hard steel 1. Terzi C, Unek T, Sagol O, Yilmaz T, Fuzun M, Sokmen S, Ergor
sticks by using the joint as a pivot. Different from the case where G, Kupelioglu A. Is rectal washout necessary in anterior resection
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2006;30:233-41.
thread, this clipping method has the following advantages. 2. Agaba EA. Does rectal washout during anterior resection prevent
When clipping, the side surfaces of the steel stick clip the local tumor recurrence? Dis Colon Rectum 2004; 47:291-6.
gut tract, therefore, the gut tract can be clipped while the width 3. Sayfan J, Averbuch F, Koltun L, Benyamin N. Effect of rectal
of the gut tract is pressed and widened, so that tearing of the stump washout on the presence of free malignant cells in the
gut due to excessive tightening as in the case of tightening in a rectum during anterior resection for rectal cancer. Dis Colon
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