Transperineal minimally invasive abdomino-perineal resection: preliminary outcomes and future perspectives

  • Simone ArolfoEmail author
  • Alberto Bullano
  • Marco Ettore Allaix
  • Alberto Arezzo
  • Mario Morino
Original Article


Abdomino-perineal resection (APR) for rectal cancer is challenging, due to the difficult exposure of the surgical field. Many investigations proved worst results in terms of circumferential resection margin (CRM) involvement compared to rectal anterior resection (RAR) with total mesorectal excision (TME). Extralevator abdomino-perineal excision (ELAPE) improved oncologic outcomes, but is burdened by important limitations (positioning, wound closure). Applying the concept of transanal minimally invasive surgery (TAMIS) and the experience in transanal TME (TaTME) to the perineal phase of APR could overcome these limitations. A series of consecutive cases of transperineal minimally invasive APR was matched with an historical series of standard laparoscopic APR. Primary endpoints were global complication rate and CRM involvement, secondary endpoints were operative time, time to flatus and oral feeding and length of hospital stay. Fifteen patients underwent a transperineal minimally invasive APR for cancer, median age was 65 (49–88) years, median distance from the anal verge was 3 (2–5) cm and six patients underwent neoadjuvant chemo-radiotherapy. No intraoperative complications occurred in both groups; need of post-operative blood transfusions was significantly higher in the traditional laparoscopic APR group. No differences were reported in terms of wound dehiscence between the two groups. Positive CRM was reduced in transperineal minimally invasive APR versus standard laparoscopic APR, but the difference was not statistically significant. Transperineal minimally invasive APR appears to be safe and could improve post-operative and oncologic outcomes by means of better vision and reduced surgical trauma.


Rectal cancer Abdomino-perineal resection Minimally invasive surgery Circumferential resection margin 


Compliance with ethical standards

Conflict of interest


Research involving human participants and/or animals

All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (Institutional and National).

Informed consent

Informed consent was obtained from all patients for being included in the study.

Supplementary material

13304_2019_692_MOESM1_ESM.mpg (704.7 mb)
Supplementary material 1 (MPG 721637 KB)


  1. 1.
    Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O, Norwegian Rectal Cancer Group (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47(1):48–58CrossRefGoogle Scholar
  2. 2.
    Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, Dixon MF, Mapstone NP, Sebag-Montefiore D, Scott N, Johnston D, Sagar P, Finan P, Quirke P (2005) The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 242(1):74–82CrossRefGoogle Scholar
  3. 3.
    den Dulk M, Putter H, Collette L, Marijnen CA, Folkesson J, Bosset JF, Rödel C, Bujko K, Påhlman L, van de Velde CJ (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer 45(7):1175–1183CrossRefGoogle Scholar
  4. 4.
    Atallah S, Albert M, DeBeche-Adams T, Nassif G, Polavarapu H, Larach S (2013) Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): a stepwise description of the surgical technique with video demonstration. Tech Coloproctol 17(3):321–325CrossRefGoogle Scholar
  5. 5.
    Buchs NC, Kraus R, Mortensen NJ, Cunningham C, George B, Jones O, Guy R, Ashraf S, Lindsey I, Hompes R (2015) Endoscopically assisted extralevator abdominoperineal excision. Colorectal Dis 17(12):O277–O280CrossRefGoogle Scholar
  6. 6.
    Hasegawa S, Okada T, Hida K, Kawada K, Sakai Y (2016) Transperineal minimally invasive approach for extralevator abdominoperineal excision. Surg Endosc 30(10):4620–4621CrossRefGoogle Scholar
  7. 7.
    Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garrone C (2003) Laparoscopic total mesorectal excision a consecutive series of 100 patients. Ann Surg 237(3):335–342PubMedPubMedCentralGoogle Scholar
  8. 8.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefGoogle Scholar
  9. 9.
    Benson AB 3rd, Bekaii-Saab T, Chan E, Chen YJ, Choti MA, Cooper HS, Engstrom PF, Enzinger PC, Fakih MG, Fuchs CS, Grem JL, Hunt S, Leong LA, Lin E, Martin MG, May KS, Mulcahy MF, Murphy K, Rohren E, Ryan DP, Saltz L, Sharma S, Shibata D, Skibber JM, Small W Jr, Sofocleous CT, Venook AP, Willett CG, Freedman-Cass DA, Gregory KM (2012) Rectal cancer. J Natl Compr Canc Netw 10(12):1528–1564CrossRefGoogle Scholar
  10. 10.
    Nagtegaal ID, van de Velde CJH, Marijnen CA, van Krieken JH, Quirke P, Dutch Colorectal Cancer Group, Pathology Review Committee (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23(36):9257–9264CrossRefGoogle Scholar
  11. 11.
    Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN, Norwegian Rectal Cancer Group, Norwegian Gastrointestinal Cancer Group (2004) Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 91(2):210–216CrossRefGoogle Scholar
  12. 12.
    den Dulk M, Marijnen CA, Putter H, Rutten HJ, Beets GL, Wiggers T, Nagtegaal ID, van de Velde CJ (2007) Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg 246(1):83–90CrossRefGoogle Scholar
  13. 13.
    Birbeck KF, Macklin CP, Tiffin NJ, Parsons W, Dixon MF, Mapstone NP, Abbott CR, Scott N, Finan PJ, Johnston D, Quirke P (2002) Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 235(4):449–457CrossRefGoogle Scholar
  14. 14.
    Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, O’Callaghan C, Myint AS, Bessell E, Thompson LC, Parmar M, Stephens RJ, Sebag-Montefiore D, MRC CR07/NCIC-CTG CO16 Trial Investigators, NCRI Colorectal Cancer Study Group (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR1 and NCIC-CTG CO16 randomised clinical trial. Lancet 373:821–828CrossRefGoogle Scholar
  15. 15.
    Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238CrossRefGoogle Scholar
  16. 16.
    Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer: a systematic overview. Int J Colorectal Dis 26(10):1227–1240CrossRefGoogle Scholar
  17. 17.
    de Campos-Lobato LF, Stocchi L, Dietz DW, Lavery IC, Fazio VW, Kalady MF (2011) Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum 54(8):939–946CrossRefGoogle Scholar
  18. 18.
    Martijnse IS, Dudink RL, West NP, Wasowicz D, Nieuwenhuijzen GA, van Lijnschoten I, Martijn H, Lemmens VE, van de Velde CJ, Nagtegaal ID, Quirke P, Rutten HJ (2012) Focus on extralevator perineal dissection in supine position for low rectal cancer has led to better quality of surgery and oncologic outcome. Ann Surg Oncol 19(3):786–793CrossRefGoogle Scholar
  19. 19.
    Foster JD, Pathak S, Smart NJ, Branagan G, Longman RJ, Thomas MG, Francis N (2012) Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorectal Dis 14(9):1052–1059CrossRefGoogle Scholar
  20. 20.
    Holm T (2014) Controversies in abdominoperineal excision. Surg Oncol Clin N Am 23(1):93–111CrossRefGoogle Scholar
  21. 21.
    Aquina CT, Blumberg N, Becerra AZ, Boscoe FP, Schymura MJ, Noyes K, Monson JRT, Fleming FJ (2017) Association among blood transfusion, sepsis, and decreased long-term survival after colon cancer resection. Ann Surg 266:311–317CrossRefGoogle Scholar
  22. 22.
    Yasukawa D, Hori T, Kadokawa Y, Kato S, Aisu Y, Hasegawa S (2018) Transperineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer. Surg Endosc.[Epub ahead of print] CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2019

Authors and Affiliations

  1. 1.Department of Surgical SciencesUniversity of TorinoTurinItaly

Personalised recommendations