The Extraperitoneal Approach to Left-Sided Colorectal Rectal Resections: EXPERTS Procedure.

Abstract

Current transperitoneal approaches to colorectal resections can be technically challenging, especially in obese patients. The head-down position can lead to rare but serious complications, e.g. compartment syndrome and brachial plexus injuries. The aim of this study was to assess the safety and feasibility of a novel extraperitoneal approach in patients requiring anterior resection. The extraperitoneal left-sided approach was performed in the supine position. A 5cm LIF incision was created into which a Gelpoint port was inserted. The full video of the procedure is embedded in the QR code below. The procedure was performed by three surgeons with experience in minimally invasive surgery. Patients requiring left colonic resections were prospectively selected over a 2-year period. Forty-one patients were prospectively assessed between March 2020 and April 2022; 26 were males, with a median age of 67 (55-88)years. The average body mass index (BMI) was 30 (22-40). 38/41 cases were cancers and three were diverticular diseases; 31 cases had anterior resection and 11 had sigmoid colectomies. Peak airway pressures were significantly less (10 cmH20) in the supine position compared with the head-down position (p<0.0001). Median time to identify the ureter and gonadal vessels was 23 (3-55)min, and median time to return of bowel function and length of stay was 2 (0-13) and 5 (IQR 3-7) days, respectively. No intraoperative complications or postoperative mortality occurred within 90 days of discharge. Three patients had anastomotic complications, and an R0 resection was achieved in all 38 cancer patients. The median lymph node count was 16. Extraperitoneal surgery for left colonic resections is safe and clinically feasible, and allows for early identification of important retroperitoneal structures.