Surgical Technique and Difficult Situations from Neil Mortensen (Laparoscopic)

Abstract

The prognosis of rectal cancer has significantly improved over the last decades since the introduction of the total mesorectal excision (TME) surgery. However, the outcome of lower rectal cancer has not improved to the same degree despite the increased use of neoadjuvant treatment. Large multicentre studies have shown that abdominoperineal resection (APR) for low rectal cancer is associated with increased intraoperative perforation and circumferential resection margin (CRM) involvement and subsequent worse prognosis compared to similar stage of rectal cancer resected with a low anterior restorative procedure [1–3]. For this reason, the surgical technique of the standard APR is under debate. Because of anatomical coning of the mesorectum at the level of the pelvic floor, there is less margin for error resulting in increased rates of R1 or incomplete resections (Fig. 45.1a). A more extensive resection by extralevator dissection with a cylindrical specimen is associated with decreased intraoperative perforation rates, CRM involvement and subsequently less recurrence and better survival in several studies [4]. Although forms of bias in these publications are present and other reports have shown good outcome after standard APR, the extralevator abdominoperineal resection (ELAPR) has clear advantages for treatment of more advanced lower rectal cancers [5].