Surgeons often encounter difficulty when constructing a colorectal anastomosis in the “hostile pelvis.” Examples include performing low anterior resection or colostomy takedown in the setting of prior radiation, severe inflammation, or a narrow pelvis. Circular staplers have made low anastomosis a viable alternative to permanent colostomy in these situations. However, the surgeon may occasionally be faced with the difficult decision of how to manage a gross disruption of a stapled anastomosis in a pelvis that will not permit anastomotic redo. The traditional approach to this would be creating a permanent colostomy. We describe an alternate approach: endoscopic suturing with protecting ileostomy. We have successfully applied this technique to 4 patients with gross anastomotic disruption in a hostile pelvis. All patients tolerated the procedure well and have maintained normal bowel function without the need for a permanent colostomy.
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Technique of transanal endoscopic repair. A laparoscopic needle driver is placed through a 10-cm proctoscope to the site of anastomotic disruption. A, The suture is passed from inside to outside through the inferior portion of the disrupted anastomosis. B, The suture is passed from outside to inside through the superior portion of the disrupted anastomosis. C, The suture is tied, and several other similar sutures are placed. Note that there is no attempt to perform an airtight repair.
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