Three major problems and solutions in laparoscopic abdominoperineal resection for rectal carcinoma

Abstract

To investigate the three major problems and solutions in laparoscopic abdominoperineal resection(APR) for rectal carcinoma. A retrospective study of 60 low rectal carcinoma cases undergoing selective laparoscopic APR from September 2010 to May 2013 in our hospital was undertaken. A laparoscopic sigmoid stoma was performed through the extraperitoneal route at the left lower abdomen puncture point after lymphadenectomy and tumor excision during operation. Using the unique intracorporeal suture technique of transanal endoscopic microsurgery(TEM), the pelvic peritoneum was closed by continuous suture with TEM needle-forceps and absorbable suture. Those patients with the successful pelvic peritoneum closure received continuous irrigation of presacral space from the third postoperative day to prevent perineal incision infection. Only one patient (1.7%) was converted to laparotomy. Fifty-nine patients underwent laparoscopic APR and laparoscopic sigmoid stoma was successfully performed through the extraperitoneal route without abdominal incision, and the incidence of stoma complication was only 3.4%. Out of 59 patients undergoing laparoscopic APR, the pelvic peritoneum of 56 patients(94.9%) was closed successfully. The median time of closing the pelvic peritoneum was 15 min. Fifty-seven patients with pelvic peritoneum successfully closed by laparotomy or laparoscopic approach received continuous irrigation of presacral space and the median time of presacral drainage tube placement was 7.8 days. No patient developed postoperative intestinal obstruction. The rate of perineal wound healing in grade A, B and C was 87.7%, 8.8% and 3.5%, respectively. In the 3 patients whose pelvic peritoneum failed to be closed with simple drainage of presacral space, one developed postoperative intestinal obstruction and one had a grade C perineal wound healing. Laparoscopic sigmoid stoma through the extraperitoneal route during laparoscopic APR for rectal carcinoma is feasible and safe. It is convenient and effective to close pelvic peritoneum by using TEM intracorporeal suture technique. It is worth discussing the role of continuous irrigation of presacral space postoperatively to prevent perineal incision infection.