Laparoscopic Extralevator Abdominoperineal Resection for Rectal Carcinoma with Transabdominal Levator Transection
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ORIGINAL ARTICLE – COLORECTAL CANCER—STREAMING VIDEO
Laparoscopic Extralevator Abdominoperineal Resection for Rectal Carcinoma with Transabdominal Levator Transection Pan Chi, MD, Zhi-Fen Chen, MD, Hui-Ming Lin, MD, Xing-Rong Lu, PhD, MD, and Ying Huang, PhD, MD Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
ABSTRACT Background. The extralevator abdominoperineal resection (ELAPR) is a new surgical technique for patients with low advanced rectal cancer. This technique requires an extra excision of the levator muscles to avoid the surgical waist caused by the conventional abdominoperineal resection, with the patient’s position changed to a prone jackknife position and using a myocutaneous flap to repair the pelvic defect. To simplify this operation, we applied a laparoscopic technique to perform controlled transabdominal transection of the levator muscles under direct visualization without a position change and pelvic floor reconstruction using human acellular dermal matrix (HADM). Methods. In our department from 2010–2011, six patients with rectal adenocarcinoma within 3 cm of the anal verge underwent laparoscopic ELAPR with transabdominal levator transection, with no position change during the perineal operation. In three patients, pelvic reconstruction was performed with HADM. Results. All procedures were successfully performed without any intraoperative complications, laparoscopyassociated morbidity, or conversion to the open approach. The mean operation time and intraoperative blood loss were 186.7 min and 101.7 ml. All specimens had a cylindrical shape with levator muscles attached to the mesorectum and negative circumferential margins. No complications were seen with the use of HADM.
Electronic supplementary material The online version of this article (doi:10.1245/s10434-012-2675-x) contains supplementary material, which is available to authorized users. Ó Society of Surgical Oncology 2012 First Received: 18 January 2012 P. Chi, MD e-mail: [email protected]
Conclusions. Laparoscopic transabdominal transection of the levator muscles without position change and with pelvic floor reconstruction using human acellular dermal matrix mesh is feasible. With the transection of the levator muscles under laparoscopic surveillance, the procedure of the extralevator abdominoperineal resection, which is aggressively invasive and operatively complicated, is simplified and has an advantage of minimal invasiveness. With the introduction of total mesorectal excision (TME), the oncologic outcome of abdominoperineal resection (APR) is not better than the low anterior resection (LAR) or ultralow anterior resection (ULAR). The positive rate of circumferential resection margins (CRM) and the local recurrence rate after APR are higher than with LAR and ULAR, but the 5-year survival rate after APR is lower.1–4 To solve these problems of APR, Holm et al. reported extralevator abdominoperineal resection (ELAPR) in 2007. This operation requires changing the patient’s posit
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