Overview
Definition:
Stapled Transanal Rectal Resection (STARR) is a minimally invasive surgical procedure designed to treat obstructed defecation syndrome (ODS) by correcting rectal intussusception and rectocele
It involves the transanal excision of a circumferential full-thickness segment of the rectal wall using a circular stapling device, aiming to reduce rectal prolapse and improve anorectal function.
Epidemiology:
Obstructed defecation syndrome affects a significant proportion of the population, with estimates suggesting it impacts up to 20% of women and a smaller percentage of men, particularly those who have undergone multiple childbirths or experienced chronic straining
STARR is a relatively newer technique, but its adoption is growing for carefully selected patients.
Clinical Significance:
ODS is a debilitating condition leading to reduced quality of life, chronic pain, and significant healthcare utilization
STARR offers a less invasive alternative to traditional abdominal or perineal proctectomy for specific types of ODS, providing relief for patients refractory to conservative management and potentially avoiding more complex surgeries
Understanding STARR is crucial for surgical residents preparing for DNB and NEET SS examinations in colorectal and general surgery.
Indications
Patient Selection:
STARR is indicated for patients with confirmed obstructed defecation syndrome due to specific anatomical abnormalities, including symptomatic rectal intussusception and rectocele, who have failed conservative management (e.g., dietary changes, laxatives, biofeedback).
Diagnostic Confirmation:
Diagnosis and patient selection require comprehensive evaluation including detailed history, physical examination, anorectal manometry, defecography, and potentially dynamic MRI of the pelvic floor to confirm the presence and severity of rectal intussusception and/or rectocele.
Contraindications:
Absolute contraindications include anal stenosis, severe anal sphincter dysfunction, significant inflammatory bowel disease, active anal fissures or fistulas, and patients with a rectocele or intussusception that is not the primary cause of their ODS
Poor patient compliance or unrealistic expectations are relative contraindications.
Preoperative Preparation
Patient Counseling:
Thorough counseling regarding the procedure, potential benefits, risks, expected recovery, and the need for continued lifestyle modifications is essential
Patients must understand that STARR is not a cure-all and may require ongoing management.
Bowel Preparation:
Standard bowel preparation, including a clear liquid diet and laxatives, is typically performed the day before surgery to ensure a clean operative field and facilitate the stapling procedure.
Anesthesia Considerations:
The procedure can be performed under general anesthesia or spinal anesthesia, depending on patient factors and surgeon preference
Adequate analgesia and muscle relaxation are important for patient comfort and surgical access.
Procedure Steps
Patient Positioning:
The patient is placed in the lithotomy position, allowing for adequate perineal exposure and access to the anus and distal rectum.
Stapler Insertion:
A specialized circular stapling device (e.g., Transanal Decompaction System - T.D.S.) is introduced into the anal canal
The instrument is designed to excise a circumferential cuff of rectal mucosa and submucosa.
Rectal Wall Excision:
The stapler is advanced to encircle the diseased rectal wall segment, typically involving the rectocele and/or intussuscepted segment
The stapler is then fired, excising the tissue and simultaneously creating two rows of staples, forming an anastomosis.
Anastomosis Check:
Following stapler firing, the staple line is carefully inspected for hemostasis and integrity
Any bleeding points are managed with sutures or electrocautery
The excised rectal tissue is removed for pathological examination.
Postoperative Care
Pain Management:
Postoperative pain is typically managed with oral analgesics, and sometimes with topical anesthetic creams
Epidural or spinal anesthesia can provide prolonged pain relief.
Bowel Management:
Early mobilization and a gradual return to a normal diet are encouraged
Stool softeners are usually prescribed to facilitate bowel movements and prevent straining, which could compromise the staple line
Laxatives may be used judiciously.
Wound Care And Monitoring:
The staple line is usually not dressed
Patients are advised to maintain good perianal hygiene
Monitoring for signs of infection, bleeding, or anastomotic leak is crucial
Patients are usually discharged within 24-48 hours.
Complications
Early Complications:
Bleeding from the staple line is the most common complication, usually manageable conservatively
Rectal pain and tenesmus are frequent but transient
Less common early complications include fecal incontinence (often temporary), wound infection, and, rarely, anastomotic leak.
Late Complications:
Late complications can include persistent or recurrent ODS symptoms, anal stricture formation at the staple line, and chronic fecal incontinence
Development of a rectovaginal fistula or abscess is rare but possible.
Prevention Strategies:
Meticulous surgical technique, careful patient selection, appropriate stapler choice, and vigilant postoperative management including stool softeners and avoidance of straining are key to preventing complications
Early recognition and prompt management of any complications are vital.
Prognosis
Factors Affecting Prognosis:
Prognosis is generally good for carefully selected patients with specific anatomical defects
Factors influencing outcomes include the severity and type of ODS, patient adherence to postoperative care, and the presence of coexisting pelvic floor dysfunction
Success rates vary in literature, often ranging from 60-85% symptom improvement.
Outcomes:
Successful STARR can lead to significant improvement in bowel frequency, reduced straining, decreased sensation of incomplete evacuation, and enhanced quality of life
However, some patients may still require ongoing medical management for residual symptoms.
Follow Up:
Regular follow-up is essential, typically with clinic visits at 2 weeks, 2 months, and 6 months postoperatively, and then annually
This allows for assessment of symptom resolution, functional improvement, and early detection of any complications or recurrence
Biofeedback may be recommended as part of long-term management.
Key Points
Exam Focus:
Understand the indications for STARR, differentiate it from other ODS treatments, and recall potential complications like bleeding and stricture
Be prepared to discuss patient selection criteria based on defecography findings.
Clinical Pearls:
STARR is best suited for significant rectocele and/or intussusception causing outlet obstruction
Remember the importance of stool softeners postoperatively and the need to counsel patients on realistic expectations and continued lifestyle management.
Common Mistakes:
Overlooking other causes of ODS, performing STARR in patients with significant sphincter dysfunction, or failing to adequately counsel patients preoperatively are common pitfalls
Underestimating the importance of postoperative bowel management can lead to staple line complications.