Multiple robotic stapler firings to transect the rectum are not associated with anastomotic leakage.

Aim: The relationship between the number of stapler firings (SFs) during robotic rectal transection and the risk of colorectal/coloanal anastomotic leakage (AL) is controversial. This study investigates whether the number of robotic SFs is associated with an increased risk of AL.

Method: Retrospective review of adult patients who underwent robotic total mesorectal excision (TME) and partial mesorectal excision (PME) with double-stapled colorectal or coloanal anastomosis for both benign and malignant colorectal diseases between 2015 and 2023 across three enterprise-wide hospitals.

Primary Outcome: the effect of multiple SFs on postoperative AL rate among patients who underwent one, two, or three or more SFs.

Secondary Outcome: the effects of other potential risk factors on postoperative AL.

Results: Of 503 patients who underwent robotic colorectal resection with a double-stapled anastomosis, 56 (11%) developed a postoperative AL. The number of SFs was not associated with the AL rate (p = 0.51): the univariable and multivariate analyses found no correlation between the AL rate and the increasing number of SFs required, compared with one SF as the reference (adjusted two SFs, OR = 1.1, 95% CI: 0.6-2.2, p = 0.77 vs. adjusted three or more SFs, OR = 0.98, 95% CI: 0.4-2.3, p = 0.96). On multivariate analysis, AL was strongly associated with male gender (OR = 2.5, 95% CI: 1.3-4.9, p = 0.005) and with TME versus PME (OR = 2.8, 95% CI: 1.5-5.5, p = 0.002).

Conclusion: The number of robotic SFs for rectal transection is not correlated with postoperative AL.