Table 1.

Comparison of hand-sewn and stapling techniques for coloanal and colorectal anastomoses post-transanal total mesorectal excision

Anastomotic technique	Advantages	Disadvantages
Hand-sewn coloanal	Suitable for coloanal and low colorectal anastomoses Suture placement and depth of suture controlled by surgeon under direct vision Avoids the difficult step of placing a rectal pursestring	Difficult anastomosis if a long rectal stump due to: Inadequate visual exposure Too far to reach with ‘open’ instruments Potentially worse functional outcomes compared to colorectal anastomoses
Stapled—EEA™ Haemorrhoid Stapler 33 mm	Long central rod allows passage through the anal canal and attachment to the spindle prior to pursestring closure Good for long rectal stumps	Large 33-mm stapler diameter posing a risk to adjacent structures, such as anal sphincters and vagina Needs sufficient rectal stump length to form the rectal pursestring
Abdominal double pursestring stapled—28- or 31-mm CEEA™ stapler	Smaller stapler diameter posing less risk to adjacent structures Precise placement of the anvil through the centre of the pursestring under direct vision Abdominal conventional anvil-stapling device attachment	Needs sufficient rectal stump length to form the rectal pursestring May be difficult to connect the anvil to the spindle laparoscopically in an obese narrow pelvis with poor visualisation
Transanal double pursestring stapled—28- or 31-mm CEEA™ stapler	Smaller stapler diameter posing less risk to adjacent structures Precise placement of the anvil through the centre of the pursestring under direct vision Transanal stapling technique for low anastomoses	Can be used only for low anastomoses. Good transanal exposure is essential and therefore not suitable for heights above 4 cm. For higher anastomoses, the two other techniques are preferred