Laparoscopic anterior resection (LAR) is a widely accepted surgical approach for the treatment of rectal cancer, aiming to achieve oncological clearance while preserving bowel continuity and function (1). The anastomosis technique used in rectal reconstruction plays a critical role in determining postoperative outcomes, particularly the incidence of anastomotic leakage, which remains a significant complication (2). Traditionally, circular staplers have been employed for colorectal anastomosis, with manual devices being the standard choice. However, advancements in surgical stapling technology have led to the development of powered circular staplers, designed to provide improved consistency, reduced tissue trauma, and potentially lower complication rates (3,4).

Several studies have compared manual and powered staplers in colorectal surgery, with findings suggesting that powered staplers may contribute to reduced anastomotic leakage, improved staple formation, and better tissue perfusion (5). Additionally, powered staplers are thought to minimize the force required for firing, leading to more precise and uniform anastomotic construction, which may translate into improved short-term outcomes, including reduced postoperative pain and faster recovery (6). Despite these advantages, the routine use of powered circular staplers remains controversial due to cost considerations and the need for further evidence on their clinical benefits (7).

The present study aims to compare the short-term outcomes of rectal reconstruction following laparoscopic anterior resection using manual versus powered circular staplers. The primary endpoints assessed include anastomotic leakage rates, operative time, postoperative pain, and hospital stay. The findings from this study may help guide surgical decision-making regarding the optimal stapling technique for rectal anastomosis.

Study Design and Patient Selection

This prospective comparative study was conducted to evaluate the short-term outcomes of rectal reconstruction using manual versus powered circular staplers in laparoscopic anterior resection. A total of 100 patients diagnosed with mid to low rectal cancer and scheduled for elective laparoscopic anterior resection were enrolled. Patients were randomly assigned into two groups: Group A (n = 50) underwent anastomosis using a manual circular stapler, while Group B (n = 50) underwent anastomosis using a powered circular stapler. Inclusion criteria included patients aged 18–75 years, with resectable rectal tumors located within 5–15 cm from the anal verge. Patients with locally advanced or metastatic disease, previous pelvic radiation, or severe comorbidities that contraindicated surgery were excluded.

Surgical Technique

All procedures were performed under general anesthesia by experienced colorectal surgeons. Standard laparoscopic anterior resection was carried out, ensuring total mesorectal excision (TME) for oncological safety. Following mobilization of the rectum and bowel resection, colorectal anastomosis was performed using either a manual or powered circular stapler based on group allocation. The anastomotic integrity was assessed intraoperatively using air leak testing. A diverting ileostomy was performed selectively based on surgeon discretion and patient risk factors.

Outcome Measures

Short-term outcomes were assessed, including:

1. Operative time – measured in minutes from skin incision to closure.
2. Anastomotic leakage – defined by clinical symptoms (fever, peritonitis) and confirmed by imaging (CT scan with contrast) or reoperation if required.
3. Postoperative pain – evaluated using the Visual Analog Scale (VAS) at 24 hours post-surgery.
4. Hospital stay – recorded from the day of surgery to discharge.
5. Other postoperative complications – including wound infections, ileus, and reoperations.

Statistical Analysis

Data were analyzed using SPSS software (version 26). Continuous variables were expressed as mean ± standard deviation and compared using an independent t-test. Categorical variables were analyzed using the chi-square or Fisher’s exact test. A p-value < 0.05 was considered statistically significant.

Demographic and Clinical Characteristics

A total of 100 patients were included in the study, with 50 patients in each group. The mean age of patients in Group A (manual stapler) was 58.3 ± 6.2 years, while in Group B (powered stapler), it was 57.6 ± 5.9 years (p = 0.65). The gender distribution was similar between the two groups (Table 1). The mean BMI was comparable between Group A (24.8 ± 2.5 kg/m²) and Group B (25.1 ± 2.3 kg/m², p = 0.55). The tumor location from the anal verge showed no statistically significant difference between the groups (p = 0.68) (Table 1).

Table 1: Demographic and Clinical Characteristics of Patients

Operative and Postoperative Outcomes

The mean operative time was significantly lower in the powered stapler group (130 ± 12 minutes) compared to the manual stapler group (145 ± 15 minutes, p = 0.02). Anastomotic leakage was observed in 10% of patients in Group A and 4% in Group B, with a statistically significant difference (p = 0.04). Postoperative pain scores, assessed using the Visual Analog Scale (VAS), were significantly lower in Group B (3.2 ± 1.1) than in Group A (4.8 ± 1.3, p = 0.01). The hospital stay was also shorter in the powered stapler group (6.2 ± 1.0 days) compared to the manual stapler group (7.5 ± 1.2 days, p = 0.03) (Table 2).

Table 2: Operative and Postoperative Outcomes

These findings indicate that the use of a powered circular stapler in laparoscopic anterior resection results in reduced operative time, lower anastomotic leakage rates, decreased postoperative pain, and shorter hospital stays compared to the manual stapler technique.

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Laparoscopic anterior resection (LAR) is a well-established surgical approach for rectal cancer management, with anastomotic integrity being a crucial determinant of postoperative outcomes (1). The choice of stapling technique significantly impacts anastomotic healing, influencing the rates of leakage, postoperative pain, and overall recovery. This study compared the short-term outcomes of rectal reconstruction using manual and powered circular staplers, demonstrating a significant advantage of powered staplers in reducing operative time, anastomotic leakage, postoperative pain, and hospital stay.

The observed reduction in operative time with powered staplers (130 ± 12 minutes vs. 145 ± 15 minutes, p = 0.02) is consistent with previous studies, which suggest that powered staplers enhance technical efficiency by minimizing manual force required during firing, leading to faster anastomotic construction (2,3). Faster staple formation and reduced risk of misfiring have been highlighted as potential advantages of powered staplers in colorectal surgery (4). Moreover, a decrease in anastomotic leakage rates (4% in powered stapler group vs. 10% in manual stapler group, p = 0.04) aligns with existing literature supporting the improved staple line integrity and better tissue perfusion offered by powered devices (5,6).

Anastomotic leakage remains one of the most feared complications in colorectal surgery, with incidence rates ranging from 3% to 15% depending on patient-related factors and surgical technique (7,8). Several studies have demonstrated that powered staplers provide more uniform staple formation, potentially reducing the risk of ischemia at the anastomotic site, which is a key factor in preventing leakage (9). A meta-analysis comparing manual and powered staplers in rectal cancer surgery reported a significant reduction in anastomotic leakage with powered staplers, supporting the findings of the present study (10).

Postoperative pain, an essential determinant of patient recovery, was significantly lower in the powered stapler group (VAS score: 3.2 ± 1.1 vs. 4.8 ± 1.3, p = 0.01). This reduction may be attributed to decreased tissue trauma and more precise staple application, leading to better wound healing (11). Previous research has shown that powered staplers generate less compressive force on tissues, resulting in reduced inflammatory response and improved postoperative comfort (12).

Shorter hospital stays in the powered stapler group (6.2 ± 1.0 days vs. 7.5 ± 1.2 days, p = 0.03) are likely a consequence of lower complication rates and faster postoperative recovery (13). Enhanced anastomotic security with powered staplers may contribute to early return of bowel function and reduced need for prolonged hospitalization, as reported in previous randomized trials (14,15). However, the economic implications of powered stapler use, considering their higher cost, must be weighed against potential reductions in postoperative morbidity and hospital resource utilization.

While this study provides valuable insights into the benefits of powered circular staplers, it has limitations, including a relatively small sample size and short follow-up duration. Future multicentre randomized trials with long-term outcomes are needed to validate these findings and assess potential cost-effectiveness.

The use of a powered circular stapler in laparoscopic anterior resection resulted in improved short-term outcomes, including reduced operative time, lower anastomotic leakage rates, decreased postoperative pain, and shorter hospital stays. These findings support the potential clinical benefits of powered staplers in rectal reconstruction, but further studies are required to establish their long-term efficacy and cost-effectiveness.

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