Extraperitoneal Route Research Articles

Total Bilateral Extraperitoneal Varicocelectomy with Hernioplasty

Background: A varicocele is characterized by the abnormal dilation of veins draining the testis. In many cases, a varicocele coexists with an inguinal hernia, either presenting with symptoms or remaining asymptomatic. This study aimed to evaluate the efficacy of laparoscopic total extraperitoneal varicocelectomy with concomitant hernioplasty. Method: A 27-year-old male presented to the surgical outpatient department with a painless inguinoscrotal swelling. Physical examination revealed a reducible 3 × 3 cm swelling with a positive cough impulse. Bilateral examination revealed a grade 3 varicocele and a reduced right inguinal hernia. The patient underwent laparoscopic surgery, with caution taken to avoid the use of energy sources. Results: Pre op sperm count was 16 million/ml and after 1 month improved to 34 million/ml. Sperm motility improved grossly, pre op majority of sperms were dead and it improved to 58.3%. Conclusion: Laparoscopic varicocelectomy by extra peritoneal route is a safe procedure and avoids intraperitoneal adhesions and bowel injury as compared to transabdominal pre peritoneal route.

End Sigmoid Colostomy Reconstruction Using Purse-string Subcutaneous Suture via Extraperitoneal Route at the Site of a Previous Transperitoneal Loop Stoma.

We previously experienced two cases of end sigmoid colostomy reconstruction via the extraperitoneal route at the same site as the transperitoneal loop stoma. For an anterior rectus fascia, the transperitoneal route used closed intraperitoneal interrupted sutures and continuous sutures with barbed sutures. A new extraperitoneal route was established through the sutured anterior rectus sheath. Before reconstructing the end stoma, a subcutaneous purse-string with monofilament absorbable sutures tied to create an approximately 2.5 cm diameter was used. There were no early complications associated with the stoma. One year after surgery, a parastomal hernia was not defined. Using the presented technique, two cases were successfully recreated extraperitoneally at the same site's end stoma.

The same parastomal hernia repairs rate in the different approaches to colostomy.

This study aimed to compare the parastomal hernia repairs rate in the different approaches to colostomy and investigate the risk factors for parastomal hernia formation in patients with permanent colostomies. Consecutive rectal cancer patients who underwent abdominoperineal resection from June 2014 to July 2020 in West China Hospital were divided into two groups according to their surgical approach for permanent colostomies. The impact of different approaches to colostomy on parastomal hernia repairs was determined by comparing a group of patients receiving an extraperitoneal route to colostomy with a group receiving transperitoneal. Potential variables were evaluated first with univariate and then multivariate analyses to identify the risk factors for the formation of parastomal hernia. Two hundred two subjects in the transperitoneal group and 103 in the extraperitoneal group attended the follow-up visit with a median follow-up period of 33 (25th-75th percentiles, 17-46) months. Clinically and radiologically detectable parastomal hernias were present in 76 of 202 (37.6%) and 14 of 103 (13.6%) subjects in the transperitoneal and extraperitoneal groups during the follow-up period (p＜0.01). Besides, 10 of 76 (13.1%) subjects in the transperitoneal group and 2 of 14 (14.3%) subjects in the extraperitoneal group underwent a parastomal hernia operation during the follow-up (p = 0.82). In addition, the transperitoneal approach of colostomy (p = 0.002), older age (p＜0.001), and higher body mass index (p = 0.013) were identified as independent risk factors for the occurrence of parastomal hernia. Extraperitoneal colostomy decreased the detectable parastomal hernias but did not reduce the surgical repair rate of parastomal hernias.

Prolapse of intestinal stoma.

Stoma prolapse can usually be managed conservatively by stoma care nurses. However, surgical management is considered when complications make traditional care difficult and/or stoma prolapse affects normal bowel function and induces incarceration. If the stoma functions as a fecal diversion, the prolapse is resolved by stoma reversal. Loop stoma prolapse reportedly occurs when increased intraabdominal pressure induces stoma prolapse by pushing the stoma up between the abdominal wall and the intestine, particularly in cases of redundant or mobile colon. Therefore, stoma prolapse repair aims to prevent or eliminate the space between the abdominal wall and the intestine, as well as the redundant or mobile intestine. Accordingly, surgical repair methods for stoma prolapse are classified into 3 types: methods to fix the intestine, methods to shorten the intestine, and methods to eliminate the space between the stoma and the abdominal wall around the stoma orifice. Additionally, the following surgical techniques at the time of stoma creation are reported to be effective in preventing stoma prolapse: an avoidance of excessive fascia incision, fixation of the stoma to the abdominal wall, an appropriate selection of the intestinal site for the stoma orifice to minimize the redundant intestine, and the use of an extraperitoneal route for stoma creation.

PSOAS ABSCESS:A RARE LOCALIZATION OF TUBERCULOSIS INFECTION

Psoas abscess is a rare disease with various etiologies. The most common pathogen in primary abscess is Staphylo coccus aureus. Crohns disease is the most common cause of secondary abscess. Mycobacterium tuberculosis is considered an extremely rare cause of psoas abscess, The clinical manifestation is insidious, the classic symptoms are pain and fever. Computed tomography (CT) is the gold standard in the diagnosis and follow-up of retroperitoneal abscesses. The treatment of choice is percutaneous drainage guided by imagery. Surgical drainage should be reserved for cases of failure of percutaneous drainage, if possible via the extraperitoneal route, but in the event of a secondary abscess, the transperitoneal approach is preferred to correct the original disease.

Laparoscopic extraperitoneal colostomy has a lower risk of parastomal hernia and bowel obstruction than transperitoneal colostomy.

Several studies indicate that an extraperitoneal colostomy can prevent the development of a parastomal hernia (PSH) as compared to a transperitoneal colostomy. However, the clinical value of laparoscopic extraperitoneal colostomy, and its influence on bowel obstruction and PSH remain unclear. The present study aimed to clarify the impact of laparoscopic extraperitoneal colostomy on the development of a PSH and bowel obstruction. This study included 327 consecutive patients who underwent laparoscopic abdominoperineal resection or Hartmann's procedure between January 2013 and December 2019 after fulfilling selection criteria. The incidence of a PSH (Clavien-Dindo classification ≥ grade I) and bowel obstruction (≥ grade IIIa) in the transperitoneal and extraperitoneal route groups were analyzed using univariate and multivariate analysis. The patients were classified into transperitoneal (n = 222) and extraperitoneal (n = 105) route groups. The patient characteristics, except for body mass index and operative time, were comparable between the groups. A PSH and bowel obstruction occurred more frequently in the transperitoneal than in the extraperitoneal route group (17.1% vs. 1.9% and 15.3% vs. 6.7%, respectively; p < 0.01 and p = 0.03, respectively). The multivariate analysis showed that age ≥ 70years, body mass index ≥ 22.4kg/m2, and a transperitoneal route were independent risk factors for the development of a PSH, and a transperitoneal route was an independent risk factor for bowel obstruction. The transperitoneal route was identified as a risk factor for the development of both a PSH and bowel obstruction after laparoscopic abdominoperineal resection or Hartmann's procedure.

629 Small Bowel Entrapment Secondary to An Acetabular Fracture: A Case Report

Abstract Bowel entrapment within a pelvic fracture is a rare clinical occurrence. The first reported case was documented in 1907, with only 24 further cases reported in the literature since. Entrapment usually involves mobile segments of bowel and various fracture sites within the pelvis have been implicated. We report a case of a 31-year-old ‘trauma alert’, who sustained pelvic fractures following a pedestrian vs car ‘RTC’. The patient was initially taken to theatre for an examination under anaesthesia, where an immobile acetabular fragment was identified, but the hip joint was felt to be stable. A Denham pin was placed in the distal femur and traction applied. Two days post admission they developed abdominal pain and vomiting. A subsequent CT scan demonstrated small bowel entrapment within the acetabular fracture causing a mechanical obstruction. Emergency laparotomy confirmed an intra-acetabular hernia which was released via an extra-peritoneal route. A section of necrotic bowel was resected, and a primary anastomosis performed. Bowel entrapment poses a difficult diagnostic challenge and there is often a delay in diagnosis. Despite advances in imaging, initial radiographic features can be subtle, and it can be difficult to distinguish clinically between mechanical bowel obstruction and adynamic ileus. This case highlights that bowel entrapment is an important consideration in patients with pelvic fractures following high energy trauma. Awareness of this rare complication and a high index of suspicion are key to early diagnosis and timely surgical intervention, which has the potential to prevent significant complications including bowel obstruction, acute peritonitis and death.

Extraperitoneal colostomy in robotic surgery for rectal cancer using a tip-up fenestrated grasper.

Although extraperitoneal colostomy could reduce the risk for parastomal hernia formation, it is often technically demanding to dissect the extraperitoneal route laparoscopically. Here, we demonstrate our original surgical technique for extraperitoneal tunneling using a robotic instrument. After total mesorectal excision (TME) and before specimen retrieval, the edge of the outer leaf of the parietal peritoneum was elevated by the grasper in the left hand and the tip-up fenestrated grasper (Tip-Up) in the right hand. The extraperitoneal tissue was opened using the scissor forceps (right hand). Then, extraperitoneal tunneling (inner tunnel) was performed using a Tip-Up with a width of approximately 4cm that could reach adjacent to the lateral border of the abdominal rectus muscle. A round incision was made at a preoperatively marked site on the skin. The anterior rectal sheath was cut in a cruciate fashion. The abdominal rectus muscle was split, and then the posterior rectus sheath was cut longitudinally not just below the stoma marking site but also at a slant on the lateral side. The peritoneum was dissected with care to avoid opening the peritoneum. The outer side of the tunnel was broken through to the inner tunnel using an easy blunt dissection with two fingers. Kelly forceps were introduced through the extraperitoneal tunnel along with the fingers, and the stump of the sigmoid colon was grasped and exteriorized through this tunnel. Robotic retroperitoneal tunneling using a Tip-Up is easy and useful for preventing parastomal hernia.

Atrophic change of the abdominal rectus muscle significantly influences the onset of parastomal hernias beyond existing risk factors after end colostomy.

To investigate optimal risk factors, including atrophy of the abdominal rectus muscle (ARM) for postoperative parastomal hernia (PH) in patients who underwent end colostomy at left lower quadrant. This single-institution retrospective study included 91 patients who underwent end colostomy between April 2004 and December 2015. The surgical and long-term outcomes among patients with or without PH were collected and compared. Altogether, 22 (24.2%) patients had a PH including 15 (68.2%) patients with a simultaneous incisional hernia. Univariate analysis showed that older patients (71 ± 11.9 vs. 64 ± 12.2years, p = 0.03) and those with higher body mass index (BMI) (23.8 ± 3.8 vs. 20.9 ± 3.3kg/m2, p < 0.001) had a statistically significant relation with having PHs. Relative atrophy of left abdominal rectus muscle was more frequently found in patients with PH (ratio of left side/right side; caudal level and medial side: 0.66 vs. 0.92, p < 0.01, caudal level and lateral side: 0.95 vs. 1.03, p = 0.04). Multivariate analysis revealed that BMI > 25kg/m2 [odds ratio (OR) 9.05, 95% confidence interval (CI) 2.06-39.76, p = 0.003] and atrophy of the left lower medial portion of the abdominal rectus muscle (OR 12.85, 95% CI 2.49-66.39, p = 0.002) were independent risk factors for PHs. Neither the laparoscopic approach nor the extraperitoneal route of the colostomy was proven to correlate with a lower rate of PHs. High BMI and atrophic change of ARM were significantly associated with PH development. Surgical techniques for prevention of atrophic change of ARM are expected to reduce the incidence of PHs.

Laparoscopic extraperitoneal sigmoid colostomy using the totally extraperitoneal hernia repair technique after abdominoperineal resection for rectal cancer.

Stoma creation through the extraperitoneal route reportedly reduces the risk of parastomal hernia and stomal prolapse after abdominoperineal resection (APR) for rectal cancer. We describe a new technique for laparoscopic extraperitoneal sigmoid colostomy following APR. After the rectus abdominis muscle is separated, Lap ProtectorTM and EZ AccessTM devices are placed. An extraperitoneal stoma tunnel is created laparoscopically as much as possible. Next, the peritoneum is separated from the inside of the abdominal cavity, and the extraperitoneal tunnel is opened. At the time of writing, we had performed laparoscopic extraperitoneal sigmoid colostomy in eight patients, without any complications or conversion to the conventional procedure. Thus, laparoscopic extraperitoneal sigmoid colostomy is a useful and safe technique for the laparoscopic creation of an extraperitoneal stoma tunnel after APR.

Extraperitoneal laparoscopic ventral hernia repair: one step beyond.

The objective of the study was to analyze the experience of the Department of Surgery of two institutions of high complexity in Colombia, with the extra peritoneal ventral hernia repair by laparoscopy during the last 2 years and characterize the clinical and surgical aspects most relevant in the procedures performed. Observational, descriptive, retrospective study, case series type: collection of data by clinical history and analysis thereof including calculation of frequency and central tendency measurements. 59 Cases of Ventral Hernia Repair by laparoscopy, 41 with Transabdominal Preperitoneal approach and 18 totally Extraperitoneal. In total, 7 complications were presented as follows: 1 Case of recurrence, 1 case of chronic pain, 2 complications Dindo-Clavien IIIa and 1 complication IIIb. The repair of the ventral hernia by Extraperitoneal route is an innovative approach of increasing popularity, which avoids the contact of the mesh with the intestines, thus avoiding the potential complications that this situation generates with good outcomes and at a lower cost.

Laparoscopic radical prostatectomy in 2018: 20 years of worldwide experiences, experimentations, researches and refinements.

After the first feasibility report in 1997, a growing interest has risen in the urologic community for laparoscopic radical prostatectomy (LRP) and several authors have contributed to the evolution of the technique. We attempt a review of the available evidences and provide a broad framework of different technical refinements considering their impact on pentafecta. The PubMed/Medline database was searched. Duplicates and "Expert opinion" papers were removed. Studies were included according to the aim of the present paper to present a selected review on LRP and report our personal experience. In 1999 Guillonneau et al. codified their transperitoneal-posterior-antegrade technique for LRP. Since then, several modifications of the transperitoneal approach were published and the extraperitoneal route was also proposed. Sparing the bladder neck and reconstructing the posterior muscolofascial plate were proven to improve continence rate. Nerve-sparing LRP were performed in order to maximize postoperative recovery of the sexual function. Novel techniques to ligate the Santorini plexus and sew the urethrovesical anastomosis provided improvement in operative time, intraoperative blood loss and reduced the incidence of postoperative urinary-leakages. In the recent years, the single-site approach as pushed the limits of LRP and three-dimensional (3D) systems for endoscopic surgery were developed. Thanks to several technical improvements, LRP provides brilliant oncologic and functional outcomes and it is now considered the treatment of choice in many institutions worldwide. Although it is a technically demanding procedure, the recent introduction of 3D systems will reduce the steepness of its learning curve.

Risk factors for parastomal hernia after abdominoperineal resection for rectal cancer.

This study was designed to identity risk factors for parastomal hernia occurring after abdominoperineal resection for rectal cancer. The study group was comprised of 158 patients with rectal cancer who underwent abdominoperineal resection in our department from January 1990 through December 2014. Twelve variables were studied as risk factors for parastomal hernia. Parastomal hernia developed in 27 patients, including 19 patients who underwent colostomy creation via an intraperitoneal route and 8 patients who underwent colostomy creation via an extraperitoneal route. On univariate analysis, a BMI ≥25kg/m2 was significantly related to the development of parastomal hernia (P=0. 018), and an ASA physical status ≥2 was slightly but not significantly related to parastomal hernia (P=0. 076). Multivariate analysis showed that a BMI ≥25kg/m2 was an independent risk factor (odds ratio=2.9698; P=0. 016). Patients with a BMI ≥25kg/m2 should be instructed about lifestyle modifications to control preoperative bodyweight and to reduce abdominal pressure.

Relationship between stoma creation route for end colostomy and parastomal hernia development after laparoscopic surgery.

The therapeutic benefits of extraperitoneal colostomy with laparoscopic surgery remain unclear. The aim of this study was to investigate the relationship between the route for stoma creation with laparoscopic surgery and stoma-related complications, especially parastomal hernia (PSH). From January 2007 to March 2015, a total of 59 patients who underwent laparoscopic abdominoperineal resection or Hartmann procedure were investigated. Patient demographic and treatment characteristics, including stoma-related complications, were analyzed retrospectively. Transperitoneal and extraperitoneal colostomy were performed in 29 and 30 patients, respectively. Median follow-up duration was 21months (range: 2-95). Patient demographic and treatment characteristics were comparable between the transperitoneal group (TPG) and the extraperitoneal group (EPG). PSH developed in 12 (41%) patients in TPG, and 4 (13%) patients in EPG (p=0.020). The incidence of other stoma-related complications and non-stoma-related complications did not differ significantly between TPG and EPG. No patient characteristics except for transperitoneal route for stoma creation were associated with PSH development. The extraperitoneal route for stoma creation is associated with a significantly lower incidence of PSH development after laparoscopic surgery. Whenever possible, extraperitoneal colostomy should be recommended, even with laparoscopic surgery.

Contribution du score de propension pour comparer la lymphadénectomie lombo-aortique par voies transpéritonéale et rétropéritonéale mono- ou multitrocarts

Endoscopic para-aortic lymphadenectomy (PALN) is a crucial step in the management of gynecological cancers. However, some concerns exist on the completeness of PALN according to the route (transperitoneal vs. extraperitoneal single-port or multiport). We compared these three surgical techniques using a propensity score. We retrospectively reviewed all patients undergoing an endoscopic PALN for a gynecological cancer from May 2010 to Mars 2015. Fifty-one patients had a single-port extraperitoneal PALN, 16 a multiport extraperitoneal PALN and 62 a transperitoneal PALN. Factors independently related to technique performances were tested on a multivariate model adjusted for a propensity score. The number of lymph nodes removed by transperitoneal route was 15 and extraperitoneal route single and multiport was 12. After adjustment for the propensity score of undergoing the extraperitoneal approach, no difference in the number of lymph node removed was noted (P=0.17). There was more lymphocyst after transperitoneal (17%) and multiport extraperitoneal PALN (19%) than after extraperitoneal PALN (2%) (P=0.04). Success rate of single-port extraperitoneal PALN was 94% (n=48). Four patients required a conversion to an open route due to vascular injury. Using a propensity score, single-port extraperitoneal route offers similar efficacy to perform PALN than transperitoneal or multiport extraperitoneal route but with less lymphocysts.

Letter to the Editor on the article “Extraperitoneal vs. intraperitoneal route for permanent colostomy: a meta-analysis of 1071 patients”

Dear Editor: With great interest, we have read the meta-analysis published in the International Journal of Colorectal Disease, Volume 27, 59–64 (2012) by Lian et al. Great effort has been made to provide a complete overview of the effect of extraperitoneal colostomy formation on common surgical complications such as parastomal hernia, stoma prolapse, and bowel obstruction. It is very interesting to see that the extraperitoneal route, although not often used, seems very promising, especially resulting in a lower parastomal hernia rate with an odds ratio of 0.41 (95 % confidence interval 0.23 to 0.73, p=0.02). However, we would like to highlight that in our opinion, an incorrect forest plot (Fig. 4 in the original article) has been published. This figure is mentioned in the text, plotting the stoma prolapse rates of two studies, but in the forest plot, six studies are displayed. The event rates in the plot are identical to the rates in Fig. 2 displaying parastomal hernia rates. With the forest plot being an excellent way of visualizing effect size and direction, it would be very interesting to see the correct figure to get a good picture of the results of the metaanalysis on the effect of extraperitoneal colostomy formation on stoma prolapse. Without the correct figure and event rates, one can only guess the specific study effect.

Single-Port Extra- and Transperitoneal Approach for Paraaortic Lymphadenectomy in Gynecologic Cancers: A Propensity-Adjusted Analysis

Endoscopic paraaortic lymphadenectomy (PALN), an important step in the management of gynecologic cancers, is associated with low morbidity. However, some concerns exist about the completeness of PALN according to the route (transperitoneal vs. single-port extraperitoneal). This study retrospectively reviewed the records of patients who had undergone an endoscopic PALN for a gynecologic cancer from May 2010 to August 2014 at the authors' center. The findings showed that 44 patients had a single-port extraperitoneal PALN and 56 had a transperitoneal PALN. The factors independently related to technical performances were tested with a multivariate model adjusted for a propensity score. A median of 16 lymph nodes were removed by the transperitoneal route and 12 by the extraperitoneal route (p = 0.04). No difference in the number of lymph nodes removed was observed after adjustment for the propensity score of patients who underwent the extraperitoneal approach (p = 0.9). The transperitoneal route was associated with more lymphocysts (20 vs. 2% for the extraperitoneal approach) (p = 0.008). The success rate for the extraperitoneal PALN was 91% (n = 40), with the three remaining patients requiring conversion to the transperitoneal route due to a peritoneal breach. This propensity-score-adjusted study supports the conclusion that the efficacy of the single-port extraperitoneal route is similar to that of the transperitoneal route for PALN.

Laparoscopic permanent sigmoid stoma creation through the extraperitoneal route versus transperitoneal route. A meta-analysis of stoma-related complications.

Objectives:To compare laparoscopic extraperitoneal colostomy with transperitoneal colostomy for construction of a permanent stoma by measuring the incidence of parastomal hernia, and other postoperative complications related to colostomy.Methods:The meta-analysis was carried out in the General Surgery Department of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China in 2014. A literature search of Medline, EMBASE, Cochrane database, and the Chinese Biomedical Literature Database (CBM) from the years 1990 to 2014 was performed. The literature searches were carried out using medical subject headings and free-text words: extraperitoneal colostomy, transperitoneal colostomy, laparoscopic extraperitoneal colostomy, rectal cancer, laparoscopic abdominoperineal resection, parastomal hernia, permanent stoma, and colostomy-related complications. Two different reviewers carried out the search and evaluated studies independently.Results:One randomized controlled trial and 6 retrospective studies were included. A total of 378 patients (209 extraperitoneal colostomy and 169 transperitoneal colostomy) were identified. Our analysis showed that there was a significantly lower rate of parastomal hernia (odds ratio 0.10; 95% confidence interval 0.03-0.29, p<0.0001) in the extraperitoneal colostomy group. However, the other stoma-related complications were not significantly different between the 2 groups.Conclusion:Colostomy construction via the extraperitoneal route using a laparoscopic approach can largely reduce the incidence of parastomal hernia. Laparoscopic permanent sigmoid stoma creation through the extraperitoneal route should be the first choice after laparoscopic abdominoperineal resection.

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a hand inserted from the perineal side

Extraperitoneal colostomy is considered to be more effective at preventing post-colostomy complications than intraperitoneal colostomy. However, this operation is difficult via laparoscopic surgery alone. We present an extraperitoneal colostomy technique using a hand inserted from the perineal side. Extraperitoneal colostomy was performed in five patients. After the rectum was resected, a hand was inserted into the abdominal cavity from the perineal side, and pneumoperitoneum was created. The peritoneum was dissected to make the extraperitoneal route, and the proximal colon was passed along this route with fingers and laparoscopic manipulation. All procedures were completed without tissue damage or hemorrhage. No patient developed a hernia or ileus postoperatively. Laparoscopic abdominoperineal resection for an extraperitoneal colostomy is difficult via laparoscopic ports only. It can be simplified by operating with manual assistance via the perineal wound.

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

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.