Transanal Minimally Invasive Surgery: An Effective Approach for Patients Who Require Redo Pelvic Surgery for Anastomotic Failure

Abstract

Background: Anastomotic leaks cause significant patient morbidity that may require redo pelvic surgery. Transanal minimally invasive surgery facilitates direct access to the pelvis with increased visualization and maneuverability for technically difficult redo surgery.

Objective: This study aimed to assess the feasibility and outcomes of transanal minimally invasive surgery in redo proctectomy for anastomotic complications.

Design: This was a retrospective cohort study.

Settings: This study was conducted at a single tertiary-care institution.

Patients: Consecutive patients undergoing transanal minimally invasive redo proctectomy were included.

Interventions: Transanal minimally invasive redo proctectomy was performed.

Main outcome measures: The primary end point was intraoperative feasibility. The secondary end points were safety, perioperative morbidity, and symptom resolution.

Results: Seven patients underwent redo proctectomy via transanal minimally invasive surgery for anastomotic defect (n = 6) or stricture (n = 1). Median time from initial to redo operation was 27 months (range, 13-67). Redo proctectomy included redo low anterior resection with coloanal anastomosis and diverting loop ileostomy (n = 4), completion proctectomy with end colostomy (n = 2), and pouch resection with end ileostomy (n = 1). Six patients had an open abdominal approach. There were no conversions for the anal approach. Median operative time was 6.4 hours (range, 4.0-7.1). All 4 planned redo coloanal anastomoses were successfully created. Hospital length of stay was a median of 8 days (interquartile range, 6-9). Intraoperative complications included 2 patients with carbon dioxide emboli, which resolved with supportive care; there was no adjacent organ injury. Three patients were readmitted within 30 days. There were no postoperative anastomotic leaks, and all 4 patients with diverted ileostomies underwent reversal at a median of 4 months (interquartile range, 4-6). All symptoms prompting redo surgery remain resolved at a median follow-up of 20 months.

Limitations: This study was limited by its small sample size and its single-institution focus.

Conclusion: For those with expertise in transanal surgery, transanal minimally invasive surgery is a safe and effective option for patients with anastomotic failure requiring redo proctectomy because it provides direct access to and visualization of the pelvis.