Stapler access and visibility in the deep pelvis: A comparative human cadaver study between a computerized right angle linear cutter versus a curved cutting stapler

Twelve male cadavers underwent pelvic dissection by 4 surgeons. After rectal mobilization as in a total mesorectal excision, the staplers were applied to the rectum as deep as possible in both the coronal and sagittal positions. The distance from the pelvic floor was measured for each application. A questionnaire rated the visibility and access of the stapling devices. Measurements were taken between pelvic landmarks to see what anatomic factors hinder the placement of a distal rectal stapler.The median (range) distance of the stapler from the pelvic floor in the coronal position for the RALC was 1.0 cm (0-4.0) vs. 2.0 cm (0-5.0) for the CC, p = 0.003. In the sagittal position, the median distance was 1.6 cm (0-3.5) for the RALC and 3.3 cm (0-5.0) for the CC, p < 0.0001. The RALC scored better than the CC in respect to: 1. interference by the symphysis pubis, 2. number of stapler readjustments, 3. ease of placement in the pelvis, 4. impediment of visibility, 5. ability to hold and retain tissue, 6. visibility rating, and 7. access in the pelvis. A shorter distance between the tip of the coccyx and the pubic symphysis correlated with a longer distance of the stapler from the pelvic floor (p = 0.002).The RALC is superior to the CC in terms of access, visibility, and ease of placement in the deep pelvis. This could provide important clinical benefit to both patient and surgeon during difficult rectal surgery.Oncologic outcomes after surgical treatment of rectal cancer have been improved by techniques such as the total mesorectal excision (TME) [1,2]. The division of the distal rectum with adequate tumor clearance is a critical step in a successful TME, and this is most commonly achieved using a stapling device. The ability to place a stapling device deep in the pelvis with good visualization could determine whether a sphincter-preserving operation is performed, or whether an abdominoperineal resection would be necessary. A distal resection margin of 2 cm has been gener