Laparoscopic Abdominoperineal Excision Research Articles

Efficacy of transperineal minimally invasive surgery with laparoscopic abdominoperineal excision for lower rectal cancer.

In abdominoperineal excision (APE), the advantages of the "down-to-up" approach are expected to be more obvious when performed as a two-team approach, including transperineal minimally invasive surgery (TpMIS). We investigated the efficacy of TpMIS with laparoscopic APE for lower rectal cancer. Patients who underwent laparoscopic APE with (n = 20) or without (n = 30) TpMIS between December 2013 and April 2020 were retrospectively reviewed. Patient and tumor characteristics, intraoperative outcome, short-term outcome, and pathological findings were compared. Additional subgroup analyses were performed in technically challenging cases, including male patients, obese patients, and patients with tumors located at the anterior wall. There was no marked difference in the patient or tumor characteristics or short-term outcomes, including morbidity and mortality between the two groups. Pathological results were comparable, and the circumferential resection margin (CRM) positive rate was 10% in both groups. TpMIS achieved a significant reduction in operative time (p = 0.02). In a subgroup analysis, the amount of blood loss was also smaller in males (p = 0.02) and patients with a high BMI (> 25) (p = 0.005) than in others. Simultaneously performing TpMIS and laparoscopic APE is feasible owing to the favorable complication and CRM-positive rates. In terms of operative time and blood loss, TpMIS is expected to be advantageous in both easy and challenging cases.

Laparoscopic technique of modified extraperitoneal (retrotransversalis) end colostomy for abdominoperineal excision.

To describe the technique of a modified extraperitoneal retrotransversalis end colostomy as part of a laparoscopic abdominoperineal excision (APR). The colostomy site is preoperatively chosen and used intra-operatively for a trocar. After the rectum has been mobilized the descending colon is freed. The peritoneal margin is gently grasped and the parietal peritoneum and extraperitoneal together with the transversalis fascia are separated from the transverse abdominal muscle fibres upwards for 3-4cm aiming at the trocar site to form the extraperitoneal retrotransversalis canal. The stoma site trocar is partially withdrawn and its head is turned laterally until its tip is positioned in the layer between the abdominal wall muscles and underlying transversalis and extraperitoneal fascia together with the parietal peritoneum. The CO2 source can be attached so that the gas helps to separate the layers, after which the colostomy trephine is formed at the site of the trocar, the grasper is inserted to gently deliver the blunt end of the descending colon through the canal and the end colostomy is formed in a usual way. No procedure-specific complications were noted in 39 patients who had laparoscopic APR with extraperitoneal retrotransversalis end colostomy from 2009 to 2016. In 23 patients who survived for 3.7±1.7years after surgery there were no clinical or CT signs of parastomal hernia or prolapse. This single-institution retrospective case series demonstrates that laparoscopic extraperitoneal retrotransversalis end colostomy is feasible, safe and effective in preventing parastomal hernias and stomal prolapse.

Laparoscopic abdominoperineal excision with trans-abdominal individualized levator transection: interim analysis of a randomized controlled trial.

Extralevator abdominoperineal excision (ELAPR) is challenging 'conventional' abdominoperineal excision (APR), yet the safety and efficacy of ELAPR is still under debate. We therefore developed a laparoscopic APR with trans-abdominal individualized levator transection (LAPR-TILT) approach and compared the outcome with a conventional laparoscopic APR (CLAPR). All eligible patients were entered a single-centre randomized controlled trial to compare CLAPR and LAPR-TILT. We assessed the first 185 patients, including operative findings, complications, histopathology and urogenital function. Ninety-three patients in the CLAPR group and 92 patients in the APR-TILT group were included for analysis. The APR-TILT procedure took less time [137 (101-175) min vs 146 (102-187) min; P=0.03], mainly owing to faster perineal dissection. APR-TILT resulted in a reduced rate of bowel perforation (1.1% vs 8.6%; P=0.04), circumferential resection margin positivity (1.1% vs 10.8%; P=0.01) and postoperative wound complications (5.4% vs 16.2%; P=0.02) compared with the CLAPR procedure. At a median follow-up of 19months after surgery, three patients (3.2%) in the CLAPR group had tumour recurrence while no tumour recurrence occurred in the LAPR-TILT group. Patients who underwent LAPR-TILT reported fewer urinary or sexual problems (LAPR-TILT vs CLAPR, 10.9% vs 24.7% and 17.4% vs 38.7%, respectively). Compared with CLAPR, LAPR-TILT achieved better pathological results for factors that are surrogate parameters for local recurrence. LAPR-TILT could also reduce the risk of urogenital dysfunction.

Laparoscopic extralevator abdominoperineal excision of the rectal cancer in the elderly

Objective To investigate the safety and feasibility of laparoscopic ELAPE for elderly patients with low advanced rectal cancer. Methods Totally 48 cases patients with low advanced rectal cancer surgery aged over 65 years old were analyzed retrospectively, who come from Beijing Hospital between Jan 2012 and Jan 2015.A total of 26 cases underwent Laparoscopic extralevator abdominoperineal excision(L-ELAPE)and 22 cases underwent Laparoscopic abdominoperineal excision(L-APE). Clinical data including general data, operation time, intraoperative blood loss, complications, pathological data, postoperative in hospitalization were retrospectively analyzed in patients. Results The mean operation time between L-ELAPE and APE group was(312±46)min vs.(245±62)min, mean intraoperative blood loss was(170±74)ml vs.(250±109)ml, Operative complications was 26.9% vs.27.3%, harvested lymph node was(16.0±5.8)cm vs.(15.0±7.2)cm, intraoperative bowel perforation(IOP)rate was 0% vs.18.2%, CRM involvement was 3.8% vs.13.6%, mean postoperative hospital stay(days)was(13.1±4.6)d vs.(13.7±6.1)d.The mean operating time of L-ELAPE group was longer and mean intraoperative blood loss was much less than APE group, IOP rate and circumferential resection margin(CRM)involvement were higher in APE group(P<0.05). Conclusions L-ELAPE is a safe and feasibility alternative approach for elder patients with rectal cancer.It is related with less intraoperative blood loss, IOP rate, CRM involvement and longer operating time contrast with L-APE. Key words: Rectal neoplasms; Laparoscopy

P12. A comparison of outcomes between laparoscopic abdominoperineal excision of the rectum (APER) and open procedures

P12. A comparison of outcomes between laparoscopic abdominoperineal excision of the rectum (APER) and open procedures

[Feasibility and short-outcomes of laparoscopic extralevator abdominoperineal excision without changing position for distal rectal cancer].

To evaluate the short-term outcomes of laparoscopic extralevator abdominoperineal excision (ELAPE) without changing position during operation. Totally 51 patients with distal advanced rectal cancer received surgical operation in Peking Union Midical College Hospital from September 2011 to April 2014. There were 29 male and 22 female patients with a mean age of (61 ± 10) years. Twenty-six percent of the patients received preoperative concomitant chemotherapy and radiation. Twenty-seven patients underwent laparoscopic abdominoperineal excision (APE) procedure, while 24 patients underwent ELAPE procedure. In both groups, patients were kept Lithotomy-Trendelenburg position during operation. The fat tissue in ischialrectal fossa was not routinely removed, except the tumor invasion. All the patients' pelvic peritoneum was closed by continuous suturing, and subcutaneous tissue and skin by interrupted suturing. Retrospectively compare the pathoclinical features, operation time, bleeding, node retrieval, lateral margin and complications by t-text and χ(2) test respectively between ELAPE and APE procedures both by laparoscopic approach. No significant differences were found in term of age, gender, BMI, distance from anal verge, percentage of neoadjuvant chemoradiation, and TNM staging between these two groups (all P > 0.05). The operation time was significantly shorter in ELAPE group ((181 ± 41) minutes vs. (228 ± 58) minutes, t = -3.265, P = 0.002). The bleeding volume was less in ELAPEE group (50 (80) ml vs 80 (100) ml (M(QR)), Z = -2.259, P = 0.024). The lateral margin, urinal retention and perineal wound healing were comparable for these two groups. No pelvic hernia was found during the postoperative follow-up (2 to 34 months) in both groups (all P > 0.05). Laparoscopic extralevator abdominoperineal excision without changing position is feasible for distal rectal cancer. Some essential steps can be simultaneously accomplished during operation without changing position. Closing the pelvic peritoneum is important for preventing the intestine dropping from abdominal cavity to presacral cavity.

Raised intraocular pressure (IOP) and perioperative visual loss in laparoscopic colorectal surgery: a catastrophe waiting to happen? A systematic review of evidence from other surgical specialities

Case reports of healthy patients experiencing total perioperative visual loss (POVL) after elective laparoscopic surgery, including colorectal resection, are appearing increasingly frequently in the literature. We reviewed the literature exploring the relationship between patient positioning and intraocular pressure (IOP) across all surgical specialties. This was then applied to the potential risk of developing POVL in patients undergoing laparoscopic colorectal surgery. A systematic review of the relevant literature was performed to identify all studies exploring the relationship between intraocular pressure and patient positioning. Eight relevant studies on both elective patients and healthy non-anaesthetised volunteers in the spinal, neurosurgical and urological fields were identified which explore the changes in IOP according to patient positioning. These all reported significant rises in IOP in both head-down positioning and prone positioning, and the strongest effects were seen in those patients placed in combined head-down and prone position (such as prone jackknife). Rises in IOP were time-dependent in all studies. Patients undergoing laparoscopic colorectal surgery in a prolonged head-down position are likely to experience raised IOP and thus are at risk of POVL. Those having a laparoscopic abdominoperineal excision with prone positioning for the perineal component are probably those in the greatest danger. Surgeons need to be aware of this under-recognised but potentially catastrophic complication.

Use of a balloon catheter in management of the pelvic space following laparoscopic abdominoperineal excision

Management of the pelvic space following laparoscopic abdominoperineal excision remains controversial. We describe a simple technique for obliteration of the pelvic space after laparoscopic abdominoperineal excision. Pneumoperitoneum was re-established after completion of the operative procedure and a Foley catheter Ch. 24 was inserted through the right lower port under direct vision. The balloon of the catheter, placed in the presacral space, was filled with 50 ml of sterile saline and connected to passive drainage. The catheter was removed 10 days postoperatively. This technique was used in 15 patients with the median age of 74 years (range 63-86). Eleven patients were treated with preoperative chemoradiotherapy. The median length of hospital stay was 9 days (range 5-11). Two patients (13.3%) treated with chemoradiotherapy developed a superficial perineal wound infection and four patients (26.6%) had a deep pelvic abscess, which required surgical drainage. The median time of perineal wound healing was 3 months (range 2-8). The median follow-up time was 36 months (range 18-60). None of the patients developed perineal hernia or intestinal obstruction in the follow-up period. One patient underwent small bowel resection due to stenosis caused by radiation enteritis. There was no local recurrence, but two patients developed distant metastases after 12 months. Our results suggest that filling the pelvic cavity with a balloon catheter for 10 days results in the creation of a thin, fibrotic peritoneal layer which keeps the small intestine out of the pelvis and prevents loops of intestine adhering in the pelvic cavity.

A prospective case–control study of extralevator abdominoperineal excision (ELAPE) of the rectum versus conventional laparoscopic and open abdominoperineal excision: comparative analysis of short-term outcomes and quality of life

Conventional abdominoperineal excision (APE) of the rectum is associated with higher circumferential resection margin (CRM) involvement, increased local recurrence, and reduced survival compared to anterior resection. A more radical extralevator APE (ELAPE) technique may improve oncological outcome. However, this technique may confer additional morbidity, and little comparative data on short-term outcomes have been reported. This study compares short-term outcomes and quality of life (QOL) after open and laparoscopic ELAPE, laparoscopic APE (LAPE), and open APE (OAPE). Data on all ELAPE and 10 consecutive LAPE and OAPE were extracted from a prospective database. Perioperative care and follow-up were standardized. QOL was assessed using EORTC questionnaires. Sixteen ELAPE (14 laparoscopic), 10 LAPE, and 10 OAPE were included. Demographics, tumour stage, and neoadjuvant therapy use were comparable. Operative time was higher with ELAPE than LAPE and OAPE (295, 207.5, and 157.5min, respectively, p=0.01). A porcine collagen perineal mesh was used in 9 patients undergoing ELAPE but in no LAPE or OAPE patients. No difference in 30-day complications, re-admission, or length of stay was noted. ELAPE and LAPE were associated with earlier removal of urinary catheter (p=0.02), yet other enhanced recovery after surgery (ERAS) parameters were equivalent. All ELAPE resections were R0 with no positive CRM identified. One LAPE and 2 OAPE were R1 resections. Analysis revealed no deterioration in QOL with ELAPE, with equivalent global health status. The results of this study suggest that ELAPE is not associated with deterioration in short-term outcomes or QOL when compared with LAPE or OAPE.

Circumferential resection margin involvement after laparoscopic abdominoperineal excision for rectal cancer

This study aimed to evaluate circumferential resection margin (CRM) involvement in patients with rectal adenocarcinoma after laparoscopic abdominoperineal excision (APR). Prospectively collected data were analyzed on consecutive patients who underwent laparoscopic APR for histologically proven rectal cancer following neoadjuvant chemotherapy, from 1998 to 2006. Patients with no sphincter involvement were not included and underwent intersphincteric resection with coloanal anastomosis. CRM involvement was defined as ≤ 2 mm using a standardized pathology protocol. Data were presented as mean ± SD or as median (range). Seventy-four patients (60 ± 14 years of age; body mass index = 29.7 ± 7.9 kg/m(2) ) underwent laparoscopic APR. The distance of the tumour from the anal verge was 3.1 ± 0.93 cm. All patients had sphincter involvement. The operative time was 180 ± 73 min, and estimated blood loss was 269 ± 149 ml. There were no conversions and no postoperative mortality. The adverse event rate was 11%. There were two reoperations and three readmissions. Seventy-one patients had a T3 tumour and three patients had a T4 tumour. The median tumour size was 3.1 (range, 0-10) × 3 (range, 0-8.5) × 2 (range, 0-3.6) cm, and 26 (range, 3-41) lymph nodes were harvested. The median CRM was 7 (range, 1-11) mm. This was localized at the waist of the specimen in 12 (16.2%) of patients. Adjuvant therapy was given to 92% and 97% of patients with an involved and an uninvolved CRM, respectively. At 50 ± 27 months of follow up of 73 patients, 12 had CRM involvement and had a significantly decreased cancer-specific survival (log rank test, P = 0.002). Laparoscopic APR resulted in CRM involvement in 16.2% of patients with rectal cancer.

Robotic-assisted total mesorectal excision: should it be considered as the technique of choice in the management of rectal cancer?

The feasibility of robotic surgery has been extensively explored over the past decade with a more recent shift towards defining focused clinical applications for which quantifiable patient benefits can be directly attributed to its use. The aim of this article is to review the current literature on the use of daVinci robotic surgery for the management of rectal cancer and identify the potential benefits, if any, that robotic-assisted total mesorectal excision (RTME) may provide over the current conventional approach. A comprehensive search strategy was used to identify relevant evidence in order to explore the oncological, operative and functional outcome measures for the RTME in addition to quantifying the level of evidence which describes the clinical effectiveness of the daVinci robot in oncological surgery. Both robotic assisted techniques and the primary outcomes are discussed. In total, 23 studies were reviewed across 11 institutions, including one pilot randomised control trial. When data repetition is disregarded, a total of 452 robotic assisted laparoscopic anterior resections and 60 robotic-assisted laparoscopic abdomino-perineal excision of the rectum have been published since the introduction of the daVinci into clinical practice. Feasibility of the daVinci robotic assisted total mesorectal excision is demonstrated, with comparable oncological outcomes presented for rectal cancer excision. A demonstration of a reduced open conversion rate as well as of reduced hospital stay with the use of the robot is highlighted, although further trials are required to confirm both these findings. No functional benefit in using the daVinci could be confirmed due to the lack of focused trials in this area.

Laparoscopic Abdominoperineal Resection with Open Posterior Cylindrical Excision and Primary Transpelvic VRAM Flap

In our own experience over the last 15 years, the primary transpelvic vertical rectus abdominis myocutaneous (VRAM) flap is a reliable tool to prevent perineal wound complications after cylindrical excision in radical anorectal tumor surgery. To minimize the operative trauma in such patients, we performed a laparoscopic abdominoperineal resection combined with an open posterior cylindrical excision and a primary transpelvic vertical rectus abdominis myocutaneous (VRAM) flap via a minimal supraumbilical incision, which is described here for the first time. A 49-year-old patient with recurrent anal cancer received radiochemotherapy with curative intention and underwent laparoscopic abdominoperineal rectal excision with posterior cylindrical excision combined with a primary transpelvic vertical rectus abdominis myocutaneous (VRAM) flap. The rectal stump was clipped and pulled through the pelvis together with the VRAM flap, which was then placed into the sacral defect. We found that the combined operative technical approaches with laparoscopy and minimal incisions for flap harvest and cylindrical excision were technically feasible, and no mesh was needed to close the small-sized laparotomies. We achieved complete tumor removal and flap perfusion, and healing was uneventful. The patient showed no relapse at 3 years postoperative. Our report of the operative technique shows that the combination of minimally invasive methods together with transpelvic VRAM flap transposition is technically feasible, can be performed with operative efficiency, and may become a valuable tool to minimize perioperative complications in advanced colorectal tumor surgery.

Laparoscopy for Rectal Carcinoma: Abdominoperineal Excision

The enthusiasm for laparoscopic procedures in the field of visceral and colorectal surgery, in particular, has increased. Potential advantages include a reduction in pain as a result of less trauma, improved postoperative immune function, the earlier reestablishment of postoperative intestinal transit, shorter hospitalization, improved cosmesis, and reduced formation of intra-abdominal adhesions. In contrast to treatment for benign conditions, laparoscopic surgery with curative intent for malignancy is still controversial. In particular, compliance with the required criteria of oncologic radicality (extent of lymph node dissection, prevention of intraoperative tumor cell dissemination, assurance of acceptable margins of clearance) and thus, the achievement of long-term results identical with those results obtained after laparotomy, are considerations that have repeatedly been questioned. However, a number of published reports have confirmed that all the criteria for oncologic radicality in colorectal surgery can be met. An additional advantage of laparoscopic abdominoperineal excision is that it avoids a number of general problems associated with laparoscopic colorectal surgery. However, despite this encouraging information, a general recommendation for the use of laparoscopic abdominoperineal excision can be made only when definitive long-term results are available. Against this background, we discuss the questions of oncologic radicality and long-term outcome on the basis of currently available published data and our own results.

Laparoscopic Abdominoperineal Excision with High Transection of the Inferior Mesenteric Artery

Excision of the rectum has been increasingly superseded by sphincter-preserving operations. Early rectal cancer also can be curatively treated by rectum-preserving transanal disc excision. Although there are still considerable oncologic objections to the introduction of laparoscopic operative procedures in colorectal carcinoma, the use of laparoscopic abdominoperineal excision for carcinoma of the lower rectum may be the first to be widely accepted in selected cases.

Intracorporeal laparoscopic resections for colorectal cancer: report of cases of abdominoperineal rectal excision and right hemicolectomy with 2 year follow-up.

Techniques for total intracorporeal laparoscopic abdominoperineal excision of rectum and right hemicolectomy for colorectal cancer are described in two patients with 2-year follow-up. Potential advantages over laparoscopically assisted procedures may be offset by increased operating time and expense for right hemicolectomy but the laparoscopic approach seems well suited to abdominoperineal rectal excision. The use of a secure retrieval system is advocated for specimen removal after right hemicolectomy.