Laparoscopic Procedures: Laparoscopic Abdominoperineal Resection
Abdominoperineal resection (APR) of the rectum remains the standard treatment for a substantial proportion of patients with tumors of the lower third of the rectum. This procedure is ideally suited to the laparoscopic approach, with the specimen evacuated through the perineum avoiding the need for a large abdominal retrieval wound. There is evidence to indicate that laparoscopic APR may enable a reduction in resection margin involvement compared with open surgery. Mobilization of the rectum is performed using the same laparoscopic method as laparoscopic total mesorectal excision; however, the mesorectal dissection is stopped at the level of the origins of the levator ani muscles. Following this a colostomy is created and the perineal dissection performed with wide division of the levator muscles at their origins (Extra-Levator APR). The specimen is then evacuated through the perineum. Reconstruction of the perineum fills the tissue defect left at the level of the levators and can reduce complications such as perineal hernia and wound dehiscence. Options for reconstruction include tissue flaps and biologic mesh. Multidisciplinary team management within an enhanced recovery program should be the standard for perioperative care, with early mobilization and minimization of the stress response to surgery optimizing the benefits offered by laparoscopy.
KeywordsRectal cancer Laparoscopy Abdominoperineal resection Abdominoperineal excision ELAPE ELAPR
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- 10.Araujo SE, da Silva eSousa Jr AH, de Campos FG, Habr-Gama A, Dumarco RB, Caravatto PP, Nahas SC, da Silva J, Kiss DR, Gama-Rodrigues JJ. Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial. Rev Hosp Clin Fac Med Sao Paulo. 2003;58:133–40.CrossRefGoogle Scholar
- 12.van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, Bonjer HJ, COlorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14:210–8.CrossRefGoogle Scholar
- 13.Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, Lim SB, Lee TG, Kim DY, Kim JS, Chang HJ, Lee HS, Kim SY, Jung KH, Hong YS, Kim JH, Sohn DK, Kim DH, Oh JH. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 2010;11:637–45.CrossRefGoogle Scholar
- 14.Fleshman J. American College of Surgeons Oncology Group (ACOSOG)-Z6051. A phase III prospective randomized trial comparing laparoscopic-assisted resection versus open resection for rectal cancer. http://clinicaltrials.gov/ct2/show/NCT00726622. Accessed 17 Apr 2014.Google Scholar
- 32.Vaughan-Shaw PG, Cheung T, Knight JS, Nichols PH, Pilkington SA, Mirnezami AH. 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. Tech Coloproctol. 2012;16:355–62.CrossRefGoogle Scholar
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