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Trans-perineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer



Laparoscopic abdominoperineal resection (APR) for low rectal cancer (LRC) is performed worldwide. However, APR involves technical difficulties and often causes intractable perineal complications. Therefore, a novel and secure technique during APR is required to overcome these critical issues. Although the usefulness of the endoscopic trans-anal approach has been documented, no series of the endoscopic trans-perineal approach during laparoscopic APR for LRC has been reported.


Trans-perineal minimally invasive surgery (TpMIS) has been used during laparoscopic APR in our institution since April 2014. TpMIS is defined as an endoscopic trans-perineal approach using a single-port device and laparoscopic instruments. In this study, we retrospectively evaluated 50 consecutive patients with LRC who underwent laparoscopic APR at our institution from February 2011 to June 2017 and compared the outcomes of the patients who underwent TpMIS [trans-perineal APR (TpAPR) group, n = 21] versus the conventional trans-perineal approach (conventional group, n = 29). We investigated our experiences with TpMIS in detail and evaluated the safety and utility of TpMIS for patients with LRC. Moreover, major features and difficulties of TpMIS were examined from a surgical viewpoint.


Intraoperative blood loss (median (range) 55 (10–600) vs. 120 (20–1650) ml) and severe perineal wound infection (Clavien–Dindo grade 3, 0 vs. 5 cases) were significantly lower in the TpAPR than conventional group. TpMIS led to a shortened hospital stay (median (range), 14 (10–74) vs. 23 (10–84) days), and neither mortality nor conversion to open surgery occurred in the TpAPR group.


Magnified visualization via endoscopy provided more accurate dissection and less blood loss during surgery. Minimal skin incisions enabled a reduction in postoperative perineal complications, and consequently shortened the hospital stay. TpMIS during laparoscopic APR is safe and beneficial for patients with LRC.

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Author information

D. Yasukawa collected the data, drew the schemas, and wrote the initial draft of the manuscript. T. Hori and D. Yasukawa revised further drafts. Y. Kadokawa, S. Kato, and Y. Aisu provided academic opinions and helped to assess important papers. S. Hasegawa supervised the study. All authors are in agreement with the content of the manuscript, and two corresponding authors.

Correspondence to Daiki Yasukawa or Tomohide Hori.

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Daiki Yasukawa, Tomohide Hori, Yoshio Kadokawa, Shigeru Kato, Yuki Aisu, and Suguru Hasegawa have no conflicts of interest or financial ties to disclose.

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The study was approved by the Institutional Review Board of Tenri Hospital.

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The patients involved in this study provided written informed consent authorizing the use and disclosure of their protected health information.

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Yasukawa, D., Hori, T., Kadokawa, Y. et al. Trans-perineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer. Surg Endosc 33, 437–447 (2019). https://doi.org/10.1007/s00464-018-6316-8

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  • Rectal cancer
  • Abdominoperineal resection
  • Endoscopic trans-perineal approach
  • Minimally invasive surgery
  • Laparoscopy
  • Perineal complication