Extralevator Abdominoperineal Resection Research Articles

Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel.

To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer. This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system. A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months. For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

Effect of differing flap reconstruction strategies in perineal closure following advanced pelvic oncological resection: a retrospective cohort study.

Advancing approaches to locally invasive pelvic malignancy creates a large tissue defect resulting in perineal wound complications, dehiscence, and perineal hernia. Use of reconstructive flaps such as vertical rectus abdominus myocutaneous (VRAM) flap, gracilis, anterolateral thigh and gluteal flaps have been utilised in our institution to address perineal closure. The authors compared outcomes using different flap techniques along with primary perineal closure in advanced pelvic oncological resection. A prospectively maintained database of patients undergoing advanced pelvic oncological resection in a single tertiary hospital was retrospectively analysed. This study included consecutive patients between 2014 and 2021 according to the Strengthening The Reporting of Cohort Studies in Surgery (STROCSS) criteria. Primary outcome measures were the frequency of postoperative perineal complications between primary closure, VRAM, gluteal and thigh (anterolateral thigh and gracilis) reconstruction. One hundred twenty-two patients underwent advanced pelvic resection with perineal closure. Of these, 40 patients underwent extra-levator abdominoperineal resection, and 70 patients underwent pelvic exenteration. Sixty-four patients received reconstructive flap closure, which included VRAM (22), gluteal (21) and thigh flaps (19). Perineal infection and dehiscence rates were low. Infection rates were lower in the flap group despite a higher rate of radiotherapy ( P <0.050). Reoperation rates were infrequent (<10%) but specific for each flap, such as donor-site hernia following VRAM and flap dehiscence after thigh flap reconstruction. In patients who are at high risk of postoperative perineal infections, reconstructive flap closure offers acceptable outcomes. VRAM, gluteal and thigh flaps offer comparable outcomes and can be tailored to the individual patient.

Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience.

Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh. We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021. 49 patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of21 (± 7). Overall survival during the follow-up period was 91%. Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.

Closure of pelvic peritoneum with bladder peritoneum flap reconstruction after laparoscopic extralevator abdominoperineal excision: A prospective stage II study.

Extralevator abdominoperineal resection (ELAPE) has increased perineal wound complications due to the extended resection area. Closure of the pelvic peritoneum (CPP) may exclude the abdominal content from descending into the pelvic cavity and reduce the incidence of perineal complications after ELAPE. We have previously introduced bladder peritoneum flap reconstruction (BLAPER) as a novel method for patients in whom traditional CPP is not possible. The aim of the present study was to report the development and preliminary outcomes of BLAPER. This is a prospective single-arm study at the development and exploration phase and fulfills the IDEAL framework stage II. Ultralow rectal cancer patients with rigid pelvis who underwent ELAPE with BLAPER were enrolled. Primary outcomes were intraoperative complications and postoperative complications within 1 month after surgery. Among 27 patients included, the overall success rate of BLAPER was 96.3% (26/27). Indocyanine green fluorescence imaging and antiadhesive barrier placement were introduced to improve the BLAPER technique. The incidence of major pelvic wound complications was 7.7%. No patient who underwent BLAPER has suffered small bowel obstruction (SBO), presence of small bowel in the retrourogenital space, or perineal hernia (PH). BLAPER is safe and may prevent the small bowel from descending into the retrourogenital space and subsequently developing PH and SBO without increasing the intraoperative and postoperative complications. BLAPER may serve as an option when the primary suture of the pelvic peritoneum is not feasible.

Mucinous adenocarcinoma arising from a chronic perianal fistula: A case report and literature review

Perianal fistula is a common disease affecting the general population but development of mucinous adenocarcinoma (MA) in a chronic perianal fistula is a rare entity. Due to the rare nature of the disease, there are no established guidelines regarding the diagnosis and management of the condition. The aim of this article is to report a case of MA perianal region that we managed surgically with an extra levator abdominoperineal resection and flap reconstruction.

Malignant Melanoma of Anorectum: A Report of Five Cases

BACKGROUND: Anorectal melanoma (ARM) is an extremely rare, highly aggressive form of a tumor with the worst prognosis. ARM contributes 0.5% of all melanoma cases. Its presentation is similar to that of adenocarcinoma of the rectum, hemorrhoids, or solitary rectal ulcer, the incorrect clinical diagnosis or delayed diagnosis is often made. The definite diagnosis is only made through histopathology in which immunohistochemical stains positive to S-100, Melan A, and HMB-45 which differentiates it from adenocarcinoma of the rectum. Because of the limited number of patients and retrospective design of studies to date, there is no proven efficacy of abdominoperineal resection (APR) over local excision (LE) in terms of survival. Furthermore, this neoplasm is quite resistant to chemoradiotherapy. It has a median survival of 18 months and a 5-year survival rate of only 6%. PRESENTATION OF OUR CASES: Here, we report 5 rare cases of anorectal malignant melanoma presented to our institute between 2018 to 2022, who were treated with APR and diversion colostomy. The first case is a 27-years old young female with typical complaints, she was diagnosed ARM with locoregional metastasis. Only a diversion colostomy was performed and referred to an oncologist for palliation. Our second case is a 68-years old male with a similar complaint who presented relatively early and was diagnosed with localized disease. Conventional APR was performed and referred for adjuvant chemoradiotherapy, but the patient refused. However, the lump recurred after 6 months of tumor excision. The third case is a 29 years old male again early presentation with a similar complaint labeled as localized diseased. The conventional APR was performed followed by adjuvant chemoradiation; patient presented with metastatic disease after 6 months. The fourth case is a 60-years old male with typical history and diagnosed with localized disease. Conventional Extra-levator APR was performed followed by adjuvant therapy, but patient developed recurrence of disease with mets after 4 months. The fifth case is a 39-years old female diagnosed as ARM, had advance disease and metastatic deposits at the time of presentation, refused any palliative treatment. The study aims to evaluate our experience in treating this neoplasm. CONCLUSION: Because of the rarity of this neoplasm, no proper trial has been conducted so far. The role of chemoradiotherapy is questionable and the surgical approach varies from radical APR to conservative LE. No surgical approach has been standardized in terms of survival.

Laparoscopic extralevator abdominoperineal excision in distal rectal cancer patients: a retrospective comparative study

At present, abdominoperineal excision with neoadjuvant chemoradiotherapy (nCRT) is one of the treatment modalities of distal rectal cancer. Our study analyzed the effects of laparoscopic extralevator abdominoperineal resection (ELAPE) compared with laparoscopic conventional abdominoperineal resection(cAPR) in the treatment of distal rectal cancer. Retrospective analysis was conducted on the clinicopathological data of 177 distal rectal cancer patients treated with a laparoscopic abdominoperineal resection between 2011 and 2018. The patients were divided into four groups as follows: ELAPE without nCRT (group A), cAPR without nCRT (group B), ELAPE with long-course nCRT (group C) and cAPR with long-course nCRT (group D). Positive circumferential resection margin (CRM), local recurrence rate, 3-year disease-free survival (DFS) and 3-year overall survival (OS) did not differ between group A and group B. The rate of positive CRM in group C was lower than group D (4.4% vs. 11.9%, respectively), although the difference was not significant (P = 0.377). The 3-year local recurrence rate in group C was lower compared with group D (6.6% vs. 16.7%, respectively), although the difference was not significant (P = 0.135). Three-year DFS and 3-year OS were not different between groups C and D. This study showed that the effect of laparoscopic ELAPE in patients with low-risk rectal cancer is similar to laparoscopic cAPR, revealing that laparoscopic cAPR can be routinely selected for patients with low-risk rectal cancer. Furthermore, laparoscopic ELAPE has a tendency to reduce the rate of positive CRM and local recurrence in patients with high-risk rectal cancer. Laparoscopic ELAPE can be routinely considered for patients with high-risk rectal cancer.

Transperineal pelvic drainage combined with lateral position to promote perineal wound healing after abdominoperineal resection: A prospective cohort trial.

Background:For the rectal cancer <5 cm from anal margin, extralevator abdominoperineal resection (eAPR) has been accepted widely by surgeons. However, the rate of perineal infection following up eAPR is approximately 70%. We did the study with the aim of evaluating the effect and safety of transperineal pelvic drainage combined with lateral position (TPDLP) on perineal wound in patients undergoing eAPR.Methods:Patients were randomly assigned to N-TPDLP group (standard arm) or TPDLP group (intervention arm). In the standard arm, surgery was completed after abdominal drainage tube was placed in pelvic. Comparatively, an additional transperineal wound drainage tube was applied in the experimental arm. Postoperatively, patients of both 2 groups were informed not to sit to reduce perineal compression until the perineal wound healed. But lateral position was demanded in the intervention arm. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of <2 at 30 days postoperatively. Patients were followed for 6 months.Results:In total, 60 patients were randomly assigned to standard arm (n = 31) and intervention arm (n = 29). The mean perineal wound healing time was 34.2 (standard deviation [SD] 10.9) days in TPDLP arm, which significantly differ from 56.4 (SD 34.1) in N-TPDLP arm (P = .001). At 30 days postoperatively, 3 (10%) of 29 patients undergoing TPDLP were classified into grade 4 according to Southampton wound score, however, 16 (52%) of 31 patients were classified into grade 4 in control arm, and significantly difference was observed between randomization groups (P = .001). What's more, perineal wound pain was assessed at 30 days postoperatively, and it is discovered that the pain degree of patients in control arm was significantly more severe than the interventive arm (P = .015).Conclusion:In the present study, we found that TPDLP generated a favorable prognosis for perineal wounds with acceptable side-effects.

Is it worthwhile to perform closure of the pelvic peritoneum in laparoscopic extralevator abdominoperineal resection?

There is no uniformity in the use of closure of the pelvic peritoneum (CPP) after laparoscopic extralevator abdominoperineal excision (ELAPE). This study aimed to evaluate the short-term outcomes of CPP after ELAPE and provide supporting evidence for the performance of CPP in laparoscopic ELAPE. Patients with rectal cancer who underwent ELAPE from January 2014 to April 2019 were retrospectively investigated. CPP was routinely performed unless it was not feasible. The main outcome was the difference in the occurrence of perineal hernia (PH), small bowel obstruction (SBO) and perineal wound complications between laparoscopic and open ELAPE, which were compared using Kaplan-Meier curves. Of the 244 patients included, 104 received laparoscopic ELAPE, and 140 received open ELAPE. Patients in the laparoscopic group suffered a higher incidence of PH (11.5% (12/104) vs. 5.0% (7/140), p = 0.049), SBO (10.6% (11/104) vs. 7.9% (11/140), p = 0.433) and major perineal wound complications (12.5% (13/104) vs. 7.9% (11/140), p = 0.228) than those in the open group. Multivariate analysis showed that no-CPP was an independent risk factor for the occurrence of PH (p = 0.022, OR 3.436, 95% CI 1.199-9.848) and major perineal wound complications (p = 0.012, OR 3.683, 95% CI 1.337-10.146). In this comparative cohort study with a risk of allocation bias, CPP was associated with a lower incidence of radiological PH and major perineal wound complications regardless of the surgical approach. Thus, we believe CPP could serve as an option L-ELAPE for the prevention of perineal complications. To further determine the impact of CPP on postoperative complications after ELAPE, a prospective multicentre study is needed.

Surgical Treatment of Low-Lying Rectal Cancer: Updates.

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.

Laparoscopic extralevator abdominoperineal resection with perineal reconstruction with gluteal flap (clinical case)

AIM: to demonstrate the first experience of extralevator abdominoperineal resection (ELAPR) with gluteoplasty.PATIENTS AND METHODS: patient K., aged 71 years old, with a low rectal cancer cT3aN0M1a CRM– EMVI+ (IV st) after neoadjuvant chemoradiation therapy, underwent surgery. Laparoscopic extralevator abdominoperineal resection with gluteoplasty was performed.RESULTS: the patient was mobilized on the next day after surgery, the drain tubes were removed on the 5th day. On the 7th day, the seroma of the perineal wound without signs of suppuration was drained. No discomfort or movement disorders were noted. The patient was discharged in satisfactory condition on the 17th day.CONCLUSION: the presented clinical case allows us to consider gluteoplasty as a promising method for reconstruction of the pelvic floor defect after ELAPR.

Laparoscopic extralevator abdominoperineal resection with perineal reconstruction with gluteal flap (clinical case)

AIM: to demonstrate the first experience of extralevator abdominoperineal resection (ELAPR) with gluteoplasty.PATIENTS AND METHODS: patient K., aged 71 years old, with a low rectal cancer cT3aN0M1a CRM– EMVI+ (IV st) after neoadjuvant chemoradiation therapy, underwent surgery. Laparoscopic extralevator abdominoperineal resection with gluteoplasty was performed.RESULTS: the patient was mobilized on the next day after surgery, the drain tubes were removed on the 5th day. On the 7th day, the seroma of the perineal wound without signs of suppuration was drained. No discomfort or movement disorders were noted. The patient was discharged in satisfactory condition on the 17th day.CONCLUSION: the presented clinical case allows us to consider gluteoplasty as a promising method for reconstruction of the pelvic floor defect after ELAPR.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level.

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded. Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed. Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3±11.9 and 10.7±5.3, respectively, at 1year after closure. PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches

BackgroundPerineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap. MethodsThis is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates. ResultsFifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients’ age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach. ConclusionOpen and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods.

The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

Combined Robotic-Assisted Bio-absorbable Mesh Placement and Gluteal Fasciocutaneous Flap Reconstruction: a Novel Technique for the Repair of a Symptomatic Perineal Hernia Following Extralevator Abdominoperineal Resection for Rectal Cancer

Extralevator abdominoperineal resection for rectal cancer has predominated over the common technique during recent years providing better oncologic results. However, extralevator abdominoperineal resection has been associated to a higher incidence of wound complications and perineal hernia. Several risk factors including preoperative pelvic radiotherapy, laparoscopic abdominoperineal resection, women, previous hysterectomy, obesity, coccygectomy, long small bowel mesentery, postoperative wound infection, and open pelvic peritoneum have been correlated to increased perineal hernia rate. Despite the minor clinical manifestation of a perineal hernia, its effect on the quality of life remains remarkable. Therefore, the surgical management of a perineal hernia after abdominoperineal resection is still a challenge for colorectal surgeons. Several techniques have been used including biologic meshes and myocutaneous flaps. Nevertheless, the ideal technique has not yet been proved. During last years, colorectal surgeons have utilized minimally invasive techniques such as robotic repair of perineal hernias. We presented the first case in the literature of a combined approach of robotic-assisted repair using a bio-absorbable mesh and a gluteal fasciocutaneous flap reconstruction.

A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival.

Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach. This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures. A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively. Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study).

To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia. BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing). This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic. Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome. Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.

Robotic Partial Excision of Levator-Ani Muscle for Locally Advanced Low Rectal Cancer Invading Ipsilateral Pelvic Floor

Tumors at the level of the anorectal junction had required APR to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle (LAM), en bloc resection of the rectum with LAM including tumor would be possible. This video is to show the critical anatomic steps of this procedure. A video was produced from the robotic right PELM performed in a 57-year-old female patient with rectal cancer at 3 cm from the anal verge, invading the ipsilateral anorectal ring, who had received nCRT. The patient discharged at POD #8 without complication. The pathology of the surgical specimen revealed ypT3N1bM0. The secure resection margin from the tumor was achieved. Robotic PELM is the sphincter-preserving technique that can be an alternative treatment option for low rectal cancer invading the ipsilateral LAM, which has been an indication for abdominoperineal resection (APR) or extralevator APR.

Robotic Partial Excision of Levator-Ani Muscle for Locally Advanced Low Rectal Cancer Invading Ipsilateral Pelvic Floor.

Tumors at the level of the anorectal junction had required abdominoperineal resection (APR) to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle (LAM), en-bloc resection of the rectum with LAM including tumor would be possible. This video is to show the critical anatomic steps of this procedure. A video was produced from the robotic right partial excision of LAM (PELM) performed in a 57-year-old female patient with rectal cancer at 3 cm from the anal verge, invading the ipsilateral anorectal ring, who had received neoadjuvant chemoradiotherapy. The patient discharged at postoperative day 8 without complication. The pathology of the surgical specimen revealed ypT3N1bM0. The secure resection margin from the tumor was achieved. Robotic PELM is the sphincter-preserving technique that can be an alternative treatment option for low rectal cancer invading the ipsilateral LAM, which has been an indication for APR or extralevator APR.