David Jayne

Antonio Longo


Stapled transanal rectal resection (STARR) was described in 2001 as a new technique for the treatment of obstructed defecation associated with distal rectal prolapse (rectocele, intussusception, mucohemorrhoidal prolapse). The original technique involved a double-stapling procedure using two PPH-01® staplers (Ethicon Endosurgery, Europe) to produce a circumferential, full-thickness rectal resection. This technique is referred to as PPH-STARR, or simply STARR. More recently, a reloadable-stapling device specifically designed for STARR has been introduced, the Contour30® Transtar (Ethicon Endosurgery), which allows a sequential full-thickness circumferential rectal resection to be performed. This procedure is referred to as Transtar to distinguish it from PPH-STARR and is described in a subsequent chapter.

Preoperative Planning

All patients presenting with ODS should have their symptoms quantified using a validated scoring system (4,5). Any history of transanal surgery or obstetric trauma should be documented, and a clinical examination should be performed to assess anal sphincter function, document the presence of rectocele and intussusception, and to exclude other anorectal pathology. Examination of the urogenital organs, preferably in conjunction with a urogynecologist, should be undertaken if relevant symptoms are present. The presence of rectal redundancy, with internal prolapse with or without rectocele, should be verified by dynamic pelvic floor imaging in the form of defecography or dynamic magnetic resonance imaging. If anal sphincter dysfunction is suspected, either on history or on examination, formal evaluation by anorectal manometry, anal electromyography, and endoanal ultrasound is recommended.


STARR can be performed under either spinal or general anesthesia. The lower bowel should be prepared by administration of a phosphate enema to ensure that the rectum
is empty. The patient is placed on the operating table in the supine position. The legs are supported in stirrups with the hips flexed to at least 90 degrees and the table tilted to 30 degree head-down for maximal exposure of the perineum. A single dose of broad-spectrum perioperative antibiotics is administered. An examination under anesthesia is performed to confirm the presence of internal prolapse with or without rectocele and to exclude coexistent pathology and other pelvic organ prolapse.

Figure 26.1 STARR: anterior prolapse. Three traction sutures are placed at the 10, 12, and 2 o’clock positions. The two ends of the 12 o’clock suture are tied separately to the 10 and 2 o’clock sutures. A spatula is inserted between the circular anal dilator (CAD) and the posterior anorectum to protect it during the anterior resection.

The following describes the steps involved in the double-stapled PPH-01 STARR procedure:

  • Four 1/0 silk sutures are placed at the anal verge in the 12, 3, 6, and 9 o’clock positions. Applying traction on the sutures, the anal canal is gently dilated with the anal dilator, following which the CAD33 is introduced and secured at the anal verge with the sutures.

  • The apex of the prolapse is identified with a dry swab inserted into the rectum and then withdrawn. Three 2/0 prolene traction sutures are placed at the 10, 12, and 2 o’clock positions. The two ends of the 12 o’clock suture are separated and one each tied with the 10 and 2 o’clock sutures such that in total two traction sutures are used to deliver the internal prolapse. A spatula is inserted into the anorectum at the 6 o’clock position between the posterior lip of the CAD33 and the anal canal to exclude the posterior anorectum (Fig. 26.1).

  • A fully opened PPH-01 stapler is inserted into the rectum such that its anvil lies beyond the area of prolapse. The two traction sutures are passed through the lateral channels in the stapler and are used to deliver the prolapse into the stapler housing. Keeping the stapler in line with the anal canal at all times, the stapler is closed. A digital vaginal examination is performed to ensure that the vaginal wall has not been inadvertently incorporated into the stapler. Thirty seconds is allowed for tissue compression before firing the stapler.

  • The stapler is opened by one half-turn of the opening mechanism and withdrawn. The resected specimen is retrieved from the stapler housing and should include a full-thickness resection of the anterior rectum (Fig. 26.2

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Jun 12, 2016 | Posted by in GENERAL | Comments Off on Starr
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