Abstract
A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. This was confirmed histologically as adenocarcinoma. Radiological staging was consistent with a T3N2 rectal tumour. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease. She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. The perineal defect was reconstructed with Permacol (biological implant, Covidien) mesh. She had no clinical evidence of a perineal hernia at serial followup. Dynamic MRI images of the pelvic floor obtained during valsalva at 10 months revealed an intact pelvic floor. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was also imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision.
Highlights
National and international data on abdominoperineal excision (APER) reveal high-margin positivity rates and a high incidence of intraoperative perforation [1–3]
Marr and colleagues have described the tapering or “coning” of the specimen at the level of the pelvic floor that occurs with the conventional total mesorectal excision technique and can yield a positive circumferential resection margin (CRM) [6]
Holm and coworkers reported their initial experience in 2007 with the “cylindrical” or “extralevator” excision technique [7]. This results in the elimination of Morson’s waist and converts a coned specimen into a cylindrical specimen with consistent data demonstrating a reduction in intraoperative perforation and CRM positivity rates [8]
Summary
A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision
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