Starr

Stapled transanal rectal resection (STARR) is a relatively new procedure for the treatment of obstructed defecation syndrome (ODS). It aims to achieve a full-thickness, circumferential resection of the distal rectum, together with accompanying internal prolapse (intussusception) and/or rectocele, resulting in a neorectum, which is devoid of any mechanical impediment to evacuation. In the absence of a dedicated device to perform STARR, the original technique employed separate firings of two 33 mm circular staplers (PPH-01™; Ethicon Endo-surgery, Cincinnati, OH, USA); one stapler to perform each of the anterior and posterior semi-circumferential resections. Subsequently, the Contour Transtar™ (STR5G; Ethicon Endo-surgery) stapler was developed specifically for STARR, with the ability to perform a continuous circumferential transanal rectal resection. For the purpose of this chapter, the PPH-STARR procedure will be considered, as it is the simpler of the two techniques and, as yet, no clinical advantage has been demonstrated for the Transtar procedure, although it is accepted that this may only become apparent on long-term follow-up. It should be noted that both techniques, PPH-STARR and Transtar, produce the same anatomical outcome, namely a full-thickness distal rectal resection. The difference between the two techniques is the device and method used to achieve the full-thickness resection. For further information on Transtar the reader is referred to Jayne and Stuto.¹