STARR (Stapled Transanal Rectal Resection)

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Indications include:

  • Persistent rectal or vaginal symptoms – pain, urgency, bleeding, mucus, soiling
  • Incomplete, prolonged, difficult evacuation unresponsive to enemas/laxatives
  • Rectal and/or vaginal digitation to facilitate rectal emptying
  • Failure of medical Rx (2 litres water/day, movicol)
  • Sigmoidoscopic finding of rectal anal intussusception and traumatised mucosa

Defecography is only necessary when there is obstructed defecation or you suspect an enterocele.  Indications for STARR include:

  • Recto-anal intussusception > 1cm or Grade III/IV RI
  • Rectocele deeper than 3 cm on straining

Anorectal physiology; Anal Resting Pres. > 30 mmHg, Max Contraction > 95 mmHg.

Exclusion criteria;
Paradoxical contraction of pubo-rectalis, faecal incontinence with sphincter defect and slow transit constipation.

As in PPH we always use antibiotics, general anaesthesia (full paralysis) and lithotomy using hydraulic boots (allows you to check vagina and sphincters and the small bowel to fall away).  Most patients will have associated rectal mucosal prolapse and a rectocele (see below).  We always give our patients a phosphate enema 30 minutes before surgery.  Not only does this purge the left colon but it allows the surgeon to view the prolpase at its worst!

 visible mucosal prolapse

Gently dilate the anal verge and insert the CAD obturator. Pull the prolapsed rectum through the anal dilator using a swab and/or Rampley’s forceps.

If it prolapses more than halfway into the anal obturator continue with STARR.  If it is more, stop and consider a laparoscopic ventral rectopexy. 

We have used two approaches to STARR over the last 5 years. 

The first (similar to Longos) is to insert a single purse string stay suture into the Anterior muscle wall at the apex of the intussusception and retract caudaly.  This aids further anterior placement of 2-3 further purse string sutures (2/0 prolene 8977) 1-2cm apart along the anterior rectal wall.  Include the top of any rectocele in the suture line.  Place the first purse string 2– 3cm. above the base of the haemorrhoids. The second and third are placed at 2- 2.5 cms intervals above. Knot the sutures.  (Early on in our experience we tryed placing longitudinal sutures but abandoned it after running into a few problems).

Introduce a 10mm Davis Brain Spatula (Codman & Shurtleff, ref., 075308) through the posterior opening of the CAD to prevent stapling of the posterior wall.  A cheap alternative is a wooden tongue depressor.  

Pull the ends of the threads caudally and insert the open PPH01 circular stapler so that its head is positioned above the semicircular purse-strings. Finally pull out the ends of the threads through the lateral hole of the stapler. Slowly close the stapler and gently pull on the purse strings pushing the stapler into the rectum. In Females ensure that the stapler casing is above the levators and that the vagina is freely mobile. Tighten completely and fire. Check the staple line for haemostasis.

If necessary, rpt the procedure on the posterior wall. Infiltrate around the sphincter and pudendal nerve  with local anaesthetic. Prescribe oral morphine for take home analgesia.

We quickly learnt that it was much easier to place a series of full thickness sutures (2/0 vicryl) at 10, 12 and 2 o'clock approx 4cm above the dentate line at the apex of the intussusception.   Start with a loose suture, or us a Babcock retractor, at the 12 o,clock position to pull down the intussusception (see below).

Occasionally a fourth suture is needed.


Tie the two 10 o'clock and one of the 12 o'clock threads together (rpt with the 2 o'clock ties). 

Introduce the spatula posteriorly behind the CAD as seen above.  We use a woden tongue depressor (if it gets caught in the anvil the gun will still fire the staples; a metal spatula will lead to a misfire of staples whilst the blade will partially excise the bowel!).

Introduce the opened PPH01 and pull the knotted threads through staple gun.  Apply countertraction on the threads, close and fire the gun checking free mobility of the vagina first.  Once the gun has been removed look and see if you have created a mucosal bridge.  Whilst it is not advocated by Ethicon EndoSurgery, PPH03 (as above) is perfectly adequate for the anterior resection, in fact it is our preference.


If you have divide it between clamps.  Place a stay suture through either 'dog end' along with a suture at 6 o'clock.  Tie the right and left sutures as above and pull the  respective ties into a further PPH01 (protect the anterior wall with a spatula). 

Divide any bridge, close the ends and burry the dog ends.  Check for any bleeding.  If you get your sutures right, you wont get a bridge.  NB always look and make sure that there is no break in the staple line, or worse a split in the rectum above the staple line. 

Although not recommended by Ethicon Endo-Surgery, we have found that a PPH03 works fine, particularly in elderly patients with thin tissues.  It is also more haemostatic.  Occassionaly it is necessary to use three staple guns. 

We are always surprised by the size of the resected specimen and how much fat there is!

Internal view post STARR

What to look out for

  • Bleeding (underrun with a suture)
  • Staple line failure - do not panic.  Close the defect with interrupted sutures.
  • Slit in rectal wall - close with interrupted sutures.
  • Closure of rectum - ciut out the staple line and rectify
  • Massive mesenteric haematoma - incise the haematoma and evacuate it.  Pack the cavity from below.  Remove tha pack a few hrs later and repair the defect.  defunction with a loop colostomy.
  • Complete anterior dehiscence - close with interrupted sutures.
  • Postoperative pain - augment ORAL opiates with 25mg amitriptyline. If that does not work go for a Ketamine infusion.
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