Perineal Operation Research Articles

Lone-Star retractor perineal exposure method for laparoscopic abdominal perineal resection of rectal cancer.

The abdominal perineal resection (APR), historically referred to as Mile's procedure, stands as a time-honored surgical intervention for rectal cancer management. Advancements in surgical techniques and the advent of neoadjuvant therapies have significantly improved the rate of sphincter preservation among patients afflicted with rectal cancer, including those with ultralow rectal cancer. Despite these improvements, APR maintains its irreplaceable role in the clinical landscape, particularly for cases involving low rectal cancer with encroachment on the external anal sphincter or levator ani muscles. Optimal perineal exposure stands as a pivotal phase in APR, given that the precision of this maneuver is directly correlated with both the safety of the surgery and the patient's subsequent long-term prognosis. To evaluate the value of Lone-Star retractor (LSR) perineal exposure method in the treatment for laparoscopic APR of rectal cancer. We reviewed the records of 38 patients with rectal cancer at Anqing Municipal Hospital from January 2020 to December 2023, including 20 patients who underwent the APR procedure with a LSR perineal exposure method (LSR group) and 18 patients who underwent the APR procedure with a conventional perineal exposure method (control group). In the LSR group, following incision of the skin and subcutaneous tissue, the LSR was placed and dynamically adjusted according to the surgical plane to fully expose the perineal operative field. A total of 38 patients underwent laparoscopic APR, none of whom were found to have distant metastasis upon intraoperative exploration. Perineal blood loss, the postoperative hospital stays and the wound pain scores in the LSR group were significantly lower than those in the control group. A single surgeon completed the perineal operation significantly more often in the LSR group than in the control group (P < 0.05). The incidence of infection via the perineal incision in the LSR group was significantly lower than that in the control group (P < 0.05). No cases of distant metastasis or local recurrence were found among the patients at the postoperative follow-up. The application of the LSR technique might be helpful for performing perineal exposure during APR for rectal cancer and could reduce the incidence of perineal complications, shorten the postoperative hospital stay, improve postoperative pain, and allow one surgeon to perform the perineal operation.

A novel perineal exposure method in laparoscopic abdominal perineal resection of rectal cancer: a case series study

BackgroundAbdominal perineal resection (APR) of rectal cancer, also known as Mile’s procedure, is a classic procedure for the treatment of rectal cancer. Through the improvement of surgical skills and neoadjuvant therapy, the sphincter-preserving rate in rectal cancer patients has improved, even in patients with ultralow rectal cancer who underwent APR in the past. However, APR cannot be completely replaced by low anterior resection (LAR) in reality. APR still has its indications, when the tumor affects the external sphincter, etc. Good perineal exposure in APR is difficult and can seriously affect surgical safety and the long-term prognosis.MethodsWe reviewed the records of 16 consecutive patients with rectal cancer who underwent APR at Anqing Municipal Hospital from January 2022 to April 2023, including 11 males and 5 females, with an average age of 64.8 ± 10.3 years. The perineal operation was completed with the Lone-Star® retractor-assisted (LSRA) exposure method. After incising the skin and subcutaneous tissue, a Lone-Star® retractor was placed, and the incision was retracted in surrounding directions with 8 small retractors, which facilitated the freeing of deep tissues. We dynamically adjusted the retractor according to the plane to fully expose the surgical field.ResultsAll 16 patients underwent laparoscopic-assisted APR successfully. Thirteen procedures were performed independently by a single person, and the others were completed by two persons due to intraoperative arterial hemostasis. All specimens were free of perforation and had a negative circumferential resection margin (CRM). Postoperative complications occurred in 4 patients, including urinary retention in 1 patient, pulmonary infection in 1 patient, intestinal adhesion in 1 patient and peristomal dermatitis in 1 patient, and were graded as ClavienDindo grade 3 or lower and cured. No distant metastasis or local recurrence was found for any of the patients in the postoperative follow-up.ConclusionsThe application of the LSRA exposure method might be helpful for perineal exposure during APR for rectal cancer, which could improve intraoperative safety and surgical efficiency, achieve one-person operation, and increase the comfort of operators.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis.

Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse. A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures wereextracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis. Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lowerand anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub groupanalysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches. A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

FTP2.3 A Systematic Review and Meta-Analysis Comparing Outcomes of the Common Perineal Procedures for Rectal Prolapse -Delorme Vs Altemeir

Abstract Introduction There is no consensus yet as to the best surgical option for treatment of rectal prolapse. In this systematic review and meta-analysis we compared the outcomes for the two most commonly employed perineal operations for rectal prolapse – Delorme’s and Altemeier’s procedure. Methods A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme’s and Altemeier’s procedures were extracted. Primary outcomes included total operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. The analysed secondary outcomes were operation time, volume of blood loss and length of hospital stay. Revman 5.3 was used to perform statistical analysis. Results 10 studies including a total of 605 patients were selected; 286 patients had Altemeier procedure, 39 patients had Altemeier and Plasty (perineoplasty or levatoroplasty) whilst 280 patients had Delorme procedure. Recurrence was found to be significantly lower in the Altemeier group compared to the Delorme group (OR: 0.66; 95% CI [0.44 – 0.99], P= 0.05). Anastomotic leak was found to be significantly less in the Altemeier group than in the Delorme group (RD: 0.05; 95% CI [0.00 – 0.09], P= 0.03). Hospital stay was significantly more after Altemeiers procedure than after Delorme procedure (MD: 3.05, 95% CI [0.95 – 5.51], p=0.004). No significant difference was found with respect to operative time, Intra operative blood loss and mortality rates. Conclusion Our study indicates that between the two common perineal procedures, Altemeier’s operation has better outcomes. Future high quality RCTs with long follow up are required to corroborate these findings.

O140 Delorme vs. Altemeier: a systematic review and meta-analysis comparing the common perineal procedures for rectal prolapse

Abstract Introduction Rectal prolapse is a particularly distressing condition for patients, and there is no consensus yet as to the best surgical option for treatment. In this systematic review and meta-analysis we compared the outcomes for the two most commonly employed perineal operations for rectal prolapse – Delorme's and Altemeier's procedure. Methods A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic leak rate, and length of hospital stay. The secondary outcomes were operation time, volume of blood loss and length of hospital stay. Revman 5.3 was used to perform statistical analysis. Results 10 studies including a total of 605 patients were selected. Recurrence (OR: 0.66; 95% CI [0.44–0.99], P= 0.05) and anastomotic leak (RD: 0.05; 95% CI [0.00–0.09], P= 0.03) were found to be significantly less in the Altemeier group than in the Delorme group. However on subgroup analysis Altemeiers with plasty (perineoplasty or levatoroplasty) failed to show significant differences in comparison to Delorme's. Hospital stay was significantly more after Altemeiers procedure than after Delorme procedure (MD: 3.05, 95% CI [0.95–5.51], p=0.004). No significant difference was found with respect to operative time, intra operative blood loss and mortality rates. Conclusion Our study indicates that between the two common perineal procedures, Altemeier's operation has better outcomes. Future high quality RCTs with long follow up are required to corroborate these findings.

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer.

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Management of full thickness rectal prolapse

Rectal prolapse occurs when the rectum invaginates and descends into the anal canal or beyond the anal sphincter muscles. Patients often report fecal incontinence, obstructed defecation, pain, and urgency and of patients who present with rectal prolapse, up to 30% will also have anterior or middle compartment prolapse. This review describes the preoperative management of patients with rectal prolapse and principles for determining the operative approach.All patients should be optimized ahead of surgery with attention to bowel habits, pelvic floor strength and coordination, and baseline nutrition and fitness. If multi-compartment prolapse is identified, those patients should be referred for multidisciplinary management. Determining the best operation for an individual patient is best done through a shared decision-making model weighing the risks and benefits of abdominal versus perineal operations. Many patients can tolerate minimally invasive abdominal operations, but for those who cannot, perineal operations are a safe and effective option.

SHORT TERM OUTCOME OF DIVERSION LOOP COLOSTOMY IN CHILDREN OF ANORECTAL MALFORMATION.

Purpose: Colostomy for patients with anorectal malformations decompresses an obstructed colon, avoids fecal contamination of the urinary tract, and protects a future perineal operation. The procedure is associated with several signicant complications. Objective: To study relation of various demographic factors, clinical features, complications and patient related factors with outcomes. Methods-All necessary data of these 50 patients were obtained from case sheets and attendants of patients admitted in SNCU, NICU and wards of department of paediatrics and surgery. All the details (demographic, patients related, surgery) of patient was lled in predesigned structured proforma. Results- More than half of babies were males (68%). The male to female ratio was 2.1:1. The mean weight at post-operative 7 days was 4.74±0.21 kgs which increased to 5.19±0.41 kgs at post-operative 1 month, 5.73±0.88 kgs at post-operative 2 months and 6.28±0.6 kgs at post op 3 months. There was signicant (p=0.001) increase in weight from post-operative 7 days to postoperative 1 month, 2 months and 3 months. Peri stomal skin excoriation was seen in 8% at post-operative 7 day, 14% at postoperative 1 month, 12% at 2 months and 4% at 3 months. Stomal prolapse was seen in 2% patients at post-operative 7 days and in 4% patients at 1 month &amp; 2 months and became nil at 3 months post-operatively. There was signicant (p=0.001) difference in weight gain from 7 days to 3 months post-operative between groups of age &lt;30 days (1.67±0.33 kgs) and ≥30 days (1.08±0.65 kgs). Conclusion- Minimal post-operative complications of diversion loop colostomy in children of anorectal malformation and hence we can conclude that loop colostomy is safe in patients with anorectal malformations. we recommend, a study with a large sample size and longer duration of follow up, needs to be done to have a more effective and rationale conclusion.

Feasibility and safety of laparoscopic Parks procedure for chronic radiation proctopathy

Objective: To preliminarily evaluate the feasibility and safety of laparoscopic Parks procedure for chronic radiation proctopathy (CRP). Methods: A descriptive cohort study was carried out. The clinical and follow-up data of 19 patients who received laparoscopic Parks procedure due to CRP in the Sixth Affiliated Hospital of Sun Yat-sen University from July 2013 to March 2019 were retrospectively analyzed. Inclusion criteria: (1) serious late complications occurred after pelvic radiotherapy, e.g.serious intractable hematochezia (hemoglobin <70 g/L), intractable anal pain (numerical rating scale >7), rectostenosis, perforation, and fistula. (2) imaging examinations including colonoscopy, pelvic MRI and/or chest, abdomen and pelvic CT were performed before surgery to confirm the lesions. Exclusion criteria: (1) preoperative or intraoperative diagnosis of tumor recurrence; (2) only ostomy was performed after laparoscopic exploration; (3) after neoadjuvant radiotherapy for rectal cancer; (4) incomplete medical records. Surgical procedures: (1) Laparoscopic exploration: tumor recurrence was excluded, and the range of radioactive damage in the intestine was determined. Marks were made on the proximal sigmoid colon without grossly obvious edema, thickening or radioactive injuries. (2) Abdominal operation: the right mesentery of sigmoid colon and rectum was opened, inferior mesenteric vein and inferior mesenteric artery were divided and the Toldt gap was expanded inwards and cephalad. The outside of left hemicolon was freed, the gastrocolic ligament was opened, the splenic flexure was fully mobilized, and the rectum was separated from the rear, side and front to the lowest point. Then perineal operation was performed. (3) Perineal operation: the whole layer of rectum wall was cut thoroughly at 1cm below the lesion's lower margin, the space around the rectum was fully separated, the rectum and sigmoid colon was pulled out through the anus and cut off at the site of the grossly normal intestine, the diseased bowel was removed and a coloanal anastomosis was made. (4) A protective stoma was performed. Conditions of operation, complication and symptom relief were summarized. A descriptive statistic method was used to analyze the results. Results: All the 19 patients were female with a median age of 53 (interquartiles, 50, 56) years old, of whom 18 patients had primary cervical cancer. Surgical indications: 9 cases were rectovaginal fistula; 9 cases were intractable anal pain, among whom 7 were complicated with deep rectal ulcer; and 1 case was intractable hematochezia with deep rectal ulcer. Eighteen cases completed laparoscopic Parks procedure, while 1 case was converted to laparotomy. The median operative time was 215 (131, 270) minutes, the median bleeding volume was 50 (50, 100) ml, and the median hospital stay was 12 (11, 20) days. There was no perioperative death. Ten cases had postoperative complications, including 3 cases of serious complications (CD grade IIIb and above) within 30 days after operation, of whom one case developed pelvic infection caused by rectovaginal, rectovesical and rectourethral fistula and acute renal failure (IVa); 2 cases developed orifice prolapse and parastomal hernia (IIIb). Seven cases had anastomosis-related complications, including 4 cases of grade A anastomotic leakage and 3 cases of anastomotic stenosis. Symptoms of CRP in the whole group were significantly relieved or disappeared after one year of the operation. Five cases achieved stoma closure. Conclusions: Laparoscopic Parks procedure for chronic radiation proctopathy is safe and feasible, and can effectively improve symptoms. However, the incidence of anastomotic complications is high, so the surgical indications should be strictly controlled.

Technological innovation and patent transformation in rectal cancer surgery

Surgery for rectal cancer has obtained quick improvement in techniques and concepts in recent years but still has challenging areas. Colorectal surgeons always seek to make operations clearer and easier, so that surgery can be safer and less time-consuming while guaranteeing surgical goals. With this purpose, our team have explored to make innovations in operations for rectal cancer and translate relevant patents from 2009. We summarize our achievements in this article as follows: (1) Reverse Miles operation (perineal operation first then laparoscopic abdominal operation) with two relevant patents-specialized instruments bag for laparoscopic operations (patent number ZL201520442331.0) and accessory spotlight for ultrasound scalpel (patent number ZL20102 0137689.X). (2) Laparoscopic sphincter-saving surgery for low rectal cancer through marker meeting approach with two patents-vacuum rectal drainage tube with functions of irrigation and ventilation (patent number ZL201520374385.8) and sterile sleeve cover of ultrasound scalpel handle (patent number ZL201920648102.2). (3) Laparoscopic radical resection of colorectal cancer and natural orifice specimen extraction. Different methods were designed according to the location of the tumor that classified as 20-40 cm, 10-20 cm and 5-10 cm to anus. Two relevant patents were specialized instruments for natural orifice specimen extraction (patent application number ZL2017101480141) and plastic film sleeve for natural orifice specimen extraction (patent application number ZL 201921169857.0). Reformation of surgical technique and innovation of surgical instruments should be conducted by surgeons with innovative thinking who always seek the way to translate ideas to patents and then real products to promote surgical treatment.

Comparative Efficacy of Intrathecal Pethidine with Lignocaine 5% (Heavy) as Sole Anaesthetic Agent for Perineal Operations

Background: The discovery of opioid receptors and ligand in the brain and spinal cord lead to the feasibility of their use intrathecally. Pethidine is the only narcotic that has been shown to be effective intrathecally for surgery. This is probably because it as a phenyl-piperidine derivative and has a structure and action similar to that of local anaesthetic.Subjects and Methods:50 patients belonging to ASA grade 1 and 2 physical status were randomly assigned to two groups A and B. Patients in group A received 1 ml of 5% lignocaine (heavy) intrathecally and those in group B gained intrathecal Pethidine (preservative-free) 0.5mg/kg body weight. The time for onset and level of sensory blockade, onset and degree of motor blockade, hemodynamic parameters, time for regression of sensory and motor blockade, duration of postoperative analgesia and side effects were noted and compared in both the groups.Results:Two groups were comparable with respect to age, sex, height and weight. The onset of sensory and motor blockade in-group A was 2.00±1.06min and 2.56±0.88 and in-group B it was 3.56±1.64 min and 7.22±1.11 min respectively, which was statistically significant. Grade I motor paralysis was seen in 2 cases (10%) in group A and 15 cases (75%) in groupB. Grade II motor paralysis was seen in 6 cases (30%) in group A and 5 cases (25%) in group B. Grade III motor paralysis was viewed in 12 cases (60%) in group A and 0 cases(0%) in group B. Grade I and III motor paralysis in the groups were statistically significant (p&lt;0.05). Time for sensory regression at L1 was 65.12±4.83 min in-group A and 94.60±6.88 min in-group B that was statistically very significant (p&lt;0.05). The time for regression of motor blockade was 60.40±3.85 in-group A and 60.20±5.02 in group B, which was statistically not significant (p&gt;0.05). The duration of postoperative analgesia was 122.84±9.37 min in-group A and 320.60±23.02 in group B, which was statistically very significant. The incidence of side effects was comparable in both groups.Conclusion:Pethidine (preservative-free) 0.5mg/kg body weight can be used intrathecally as a sole anaesthetic agent to provide prolonged postoperative analgesia associated with hemodynamic stability and early ambulation in patients undergoing perineal surgeries.

Surgical decision-making for rectal prolapse: one size does not fit all

ABSTRACT Background Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. Methods 91 consecutive patients ≥18 years old diagnosed with external and/or high-grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgment, and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. Results Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p < 0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with a recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. Conclusions With multiple options available for the treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon’s practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.

Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences.

PurposeRectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures.MethodsBetween 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted.ResultsThe median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058).ConclusionRadiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.

Досвід використання препаратів хлоргексидину в акушерстві та гінекології

The objective: generalization of the experience of using chlorhexidine drugs in obstetric and gynecological practice. Materials and methods. The efficacy of using Depantol and Hexicon for non-specific colpitis in patients of adolescent, reproductive age, pregnant women, women in perimenopause, as well as in patients after cervical, vaginal and perineal operations was evaluated and generalized. The surveyed groups contained 30 to 50 patients. The diagnosis of nonspecific vaginitis was verified by clinical and laboratory examination. Criteria for recovery were complete clinical and bacterial sanation. The effectiveness of therapy was evaluated immediately after treatment and after 1 and 3 months. The data were compared with the appropriate control groups or with the condition prior to treatment. Results. High efficiency of chlorhexidine preparations in the treatment of nonspecific colpitis in patients of different age categories and conditions was noted. The experience of using Depantol and Gecikon in obstetrics and gynecology is generalized, priorities are determined in the application of these drugs. Conclusion. Preparations of chlorhexidine Geksikon and Depantol are highly effective against the main pathogens of inflammatory nonspecific vulvovaginitis. They do not interfere with the functional activity of lactobacilli, which helps maintain a normal vaginal biocenosis. The drug Geksikon with success can be recommended both for the treatment of gynecological patients of reproductive age, and pregnant women. The use of Depantol, due to the regenerative activity of the dexpanthenol component, is a priority in the treatment of infectious processes in adolescence, perimenopausal age and in patients after operations on the cervix, vagina and perineum. Key words: chlorhexidine preparations, obstetrics and gynecology, Depantol, Geksikon.

Safety and usefulness of needle-guided resection of levator muscles in laparoscopic abdominoperineal resection for low rectal cancer.

IntroductionDuring laparoscopic abdominoperineal resection (APR) for low rectal cancer, it is difficult to resect the levator muscles and remove a cylindrical specimen without venturing close to the rectal wall to ensure negative circumferential resection margins (CRM). To solve this problem, we developed a needle-guided, laparoscopic, abdominoperineal resection (LAPR) technique.AimTo present the safety and superiority of our technique, “needle-guided LAPR”.Material and methodsIn 2015, we performed needle-guided LAPR in 5 patients. In brief, the procedure is performed as follows. After total mesorectum excision to the level of the levator muscles, a needle is inserted through the perineum from the dorsal side of the internal aspect of the anus toward the sacral tip. The levator muscles and fat tissue are resected laparoscopically by following the needle. After the levator muscles have been resected, the needle is followed in a similar manner to resect the specimen from the perineum, enabling easy access to the intra-abdominal space and removal of the specimen. No position change is required during the perineal operation or pelvic floor reconstruction.ResultsMean age was 68 years and 3 patients were male. There were no intraoperative complications or conversions to open surgery. The mean operation time and intraoperative blood loss were 319 min and 131 ml, respectively. All specimens were cylindrical in shape and had negative CRM. There were no postoperative complications.ConclusionsNeedle-guided LAPR was easily and safely performed to achieve accurate resection of the levator muscles. This technique could contribute to standardization of LAPR.

Can we expect a favorable outcome after surgical treatment for an anorectal malformation?

The aim of this study was to retrospectively review the classification, surgical experience, and the functional outcome of anorectal malformations (ARMs) according the type of ARM. A total of 311 children (M:F=200:111) who underwent surgical treatment for ARM between 1990 and 2011 were reviewed. Functional outcomes were evaluated using the Krickenbeck classification. The mean follow-up period was 112.2 ± 76.7months (range: 36.8-414.9months). In the male patients, 90 (45%) had perineal fistulas, 60 (30%) had urethral fistulas, and 7 (3.5%) had rectovesical fistulas. There were 17 cases of ARM without a fistula (8.5%), and we could not determine the type of fistula in 26 boys (13%) because of follow-up losses and death. In the female patients, 34 (30.6%) had perineal fistulas, 71 (64%) had rectovestibular fistulas, and 2 (1.8%) had rectovaginal fistulas. Four patients did not have a fistula (3.6%). For 264 patients, we did anoplasty (121 cases), fistula transposition (14 cases), and posterior sagittal anorectoplasty (PSARP, 129 cases). We found that 224 (84.8%) patients showed voluntary bowel movements. The overall rate for constipation was 30.7% and for soiling was 6.5%. The continence outcome was good for 82.2% of children, fair for 2.7%, and poor for 15.2%. For rectovestibular fistulas, constipation was higher in the perineal operation group, but the continence outcome was similar. Through a review of 20years' experience, an accurate diagnosis based on the Krickenbeck classification and operations following the principles of PSARP are crucial to achieve a good functional outcome in children with an ARM.

OC-082 The results of a multi-centre study of surgery for full thickness rectal prolapse: Abstract OC-082 Table 1

Introduction Rectal prolapse is a disabling condition which is under-reported and affects the quality of life of our ageing population. Despite this there is ‘no accepted standard procedure’1a given patient should receive. The perceived risk of surgery has meant that elderly patients often undergo a perineal operation with an abdominal operation being reserved for younger patients or those with recurrence. Randomised controlled trials have found it challenging to recruit patients making comparison between outcomes difficult for abdominal and perineal operations. Method The Surrey and South West London Pelvic floor group was founded in 2014 and includes the following hospitals – Ashford and St Peters Hospital, Croydon University Hospital, East Surrey Hospital, Epsom and St Heliers Hospital, Frimley Park Hospital, Kingston Hospital, Royal Berkshire Hospital, St Georges Hospital and Wexham Park Hospital. All patients who underwent surgery for full thickness rectal prolapse between April 2011 and March 2013 were included. Data was collected retrospectively from the notes using a standardised proforma. Results 244 patients underwent surgery for full thickness rectal prolapse in the study period. Seven patients were excluded due to incomplete data leaving 237 patients. All but four patients were female. Median age at time of operation was 78.4 years with an average ASA of 2.1. The recorded overall recurrence for all surgery was 17.7%. Median length of stay (LOS) was 2 days. Conclusion In this retrospective multicentre study abdominal operations for full thickness rectal prolapse had a significantly lower rate of recurrence than the perineal approach. This was despite there being a higher proportion of patients in the abdominal group who had had previous surgery for rectal prolapse. Although patients in the abdominal group were younger and fitter there was no difference in length of stay and complication rates. The rates of recurrence for perineal operations were similar1but the recurrence rate after abdominal operations was higher than previousy reported in the literature.1This may be a reflection of the individual learning curves for laparoscopic rectal prolapse surgery during the study period (2011–2013). Disclosure of interest None Declared. Reference Senapati A, Gray RG, Middleton LJ, et al.; PROSPER Collaborative Group. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis. 2013;15(7):858–68

Rare Presentation of Haematometra and Haematocolpos Presenting as Bleeding Per Vagina

Rare Presentation of Haematometra and Haematocolpos Presenting as Bleeding Per Vagina Haematometra and Haematocolpos are conditions in which blood collects in the uterine cavity and vagina respectively when the outflow tract is obstructed. An imperforate hymen occurs in 0.05% of women. Late discovery of an imperforate hymen may lead to pain, infections, hydronephrosis and endometriosis with sub fertility as a possible consequence. Examination of the external genitalia is necessary in the investigation of girls between the ages of 11 and 18 who have a lower abdominal mass and crypto menorrhea. The patient should be prepared for both abdominal and perineal operations. Prior to incision of the imperforate hymen, a recto abdominal examination should be performed. Early diagnosis, careful evaluation and early treatment are the key points in the management of this treatable condition.

Correlation between functional outcomes and postoperative pelvic magnetic resonance imaging in children with anorectal malformation.

Background:Though the outcomes in operated children with anorectal malformation (ARM) have greatly improved, postoperative soiling and constipation remain major issues. Among the various factors described for poor outcomes; misplaced bowel, hypoplastic sphincters and obtuse anorectal angle bear special mention. The aim of this study was to compare the stooling outcomes, type of anomalies and surgical procedure with postoperative pelvic magnetic resonance imaging (MRI).Materials and Methods:This was a cross-sectional study involving operated children of ARM who had at least 2 years of follow-up, and who were at least 3 years of age. The subtypes of ARM, surgical procedures, and functional outcomes were documented using the Krickenbeck classification. All children were subjected to a pelvic MRI.Results:Thirty-three eligible children were part of this study. Twenty-two patients underwent posterior sagittal anorectoplasty, seven patients underwent abdominoperineal pull-through (APPT) and four patients underwent perineal operations. Local abnormalities were present in 66% patients, and 34% had abnormalities of the spine detected on MRI. Poorer stooling outcomes were twice as common in children with local pelvic MRI abnormalities as compared to asymptomatic children. The highest incidence of local abnormalities were seen in patients treated with APPT (P = 0.0001). No significant difference in the pelvic MRI was seen among children who were constipated and those who had soiling.Conclusion:MRI is a useful imaging modality in operated children of ARM with poor stooling outcomes. Local abnormalities were the most common in children undergoing abdominoperineal pull-through procedure.

A Study of necessity of episiotomy in primigravida

This prospective study has been carried out in Sulaimani Maternity Teaching Hospital, from&#x0D; October 2006 to April 2007 to evaluate the outcome of those primigravida women delivered&#x0D; vaginally without epiotomy who had not undergone episiotomy.&#x0D; Purposive sample of (152) low risk primigravida women in the labour ward during 2nd stage of&#x0D; labour has been selected to collect data properly. It should be noted that previous perineal operation,&#x0D; malposition, instrumental delivery, premature babies, fetal distress, pelvic deformities, induction of&#x0D; labour , short or rigid perineum, medical problems (like hypertension, diabetes, and heart&#x0D; disease...ect), and have been excluded.&#x0D; Questionnaire has been utilized as study institute, observations, checking &amp;follow up for 24 hours,&#x0D; 1 week, 6 weeks have been used to achieve the main goals.&#x0D; Through this study it was found that 34.9% of cases remain with intact perineum, 42.8% of cases&#x0D; had 1st degree p. tear, 22.4% of cases had 2nd degree p. tears, and only 83 cases (54.6%) needed&#x0D; suturing (49 cases with 1st degree tears &amp;34 cases with 2nd degree tears). It was noted also that&#x0D; complications in 1s 24 hours &amp; after 1 week was less common in patients who had intact perineum.&#x0D; On the bases of this study, we recommend that episiotomy should be restricted to specific&#x0D; maternal or fetal conditions &amp;routine use of episiotomy should be abandoned.