P-342 - Standardized Technique of Laparoscopic Extralevator Abdominoperineal Excision (LAP-ELAPE)

Date 04 July 2015
Event WorldGI 2015
Session Posters
Topics Gastrointestinal Cancers
Surgery and/or Radiotherapy of Cancer
Presenter M. Hamada
Citation Annals of Oncology (2015) 26 (suppl_4): 1-100. 10.1093/annonc/mdv233
Authors M. Hamada, T. Matsumoto, R. Inada, M. Oishi, F. Maruyama, H. Miki, S. Iwamoto
  • Kansai Medical University, Hirakata/JP

Abstract

Introduction

Extralevator abdominoperineal excision (ELAPE) for low rectal cancer has been accepted to decrease the positive rate of circumferential resection margin (CRM) and intra-operative perforation. However cylindrical abdominoperineal excision require intraoperative postural change. We present our laparoscopic technique for extralevator APE (LAP-ELAPE) and short-term outcomes.

Methods

The abdominal part of the operation is performed as in conventional laparoscopic TME with the lithotomy position. In order to achieve the CRM negative specimen, incision of the levator muscle with sufficient surgical margin should be made before completion of TME taking the MRI findings in account. The incisional landmarks of levator muscle are posterior margin of the anococcygeal raphe, caudal margin of the pelvic plexus. Dissection of anterior side has no limitation. After incision of the levator muscle bilaterally, adipose tissue of the ischiorectal fossa is incised as far caudally as possible, finally transect the anococcygeal raphe from the coccyx. Coccyx is removed laparoscopically, if required. In the perineal phase, skin incision of the conventional APE is made. After incise the adipose tissue at the posterior side, we can reach the abdominal cavity easily. After postero-lateral incision of the adipose tissue and exteriorization of the specimen, dissection of the anterior side of the rectum is performed as the conventional procedure. Using these steps cylindrical specimen is extirpated.

Results

A series of 26 patients underwent curative APR between 2008 and 2014, with11 receiving neoadjuvant chemo (radio) therapy (NAC(RT)). One patient underwent lateral node dissection. Male Female ratio was 18:8. BMI was 20.9(14.2-27.9). Pathological T were Tx:3,T2:11, T3:9, T4b:3. Duration of surgery and blood loss were 62(0-315)ml, 283(195-462)(min). There was no morality. No case encountered intra-operative accident and mean postoperative hospital stay was 15 (10-25)days. 22cases were pCRM negative (pCRM 1mm≦) and 4 cases were positive (pCRM1mm>). After a median follow-up of 32 months (range 8-63 months), Nine cases experienced recurrence (lung:5 liver:1 brain :1 lateral lymph node :3). No case experienced presacral recurrence. Three cases have died of disease. One case experienced perineal hernia radiologically.

Conclusion

As laparoscopic procedure provides the anatomical landmarks for levator transection in the deep pelvic cavity, LAP-ELAPE can be standardized.