“Incisionless” Laparoscopic Proctectomy: An Ideal Natural Orifice and Laparoscopic Surgery Hybrid

Introduction: To evaluate the safety and efficacy of laparoscopic proctectomy with per-anal delivery of the specimen for rectal cancer, avoiding an incision for specimen extraction while accomplishing sphincter preservation we review our experience.

Methods: Between 2001 and 2009, in a prospective database, 51 patients with invasive adenocarcinoma of the rectum underwent laparoscopic total mesorectal excision (TME) with delivery of the specimen transanally without the need for an additional incision to remove the specimen. Patients undergoing APR were excluded. Demographics were as follows: men=33, women=18, mean level in the rectum=1.5 cm (-0.5-5.0 cm). Pretreatment T stage was T1=1, T2=11, T3=39. Mean size of cancer was 4.2 cm (2-10 cm). Fixity of the tumor was: mobile=33, tethered=15, fixed=2. Patients receiving chemotherapy: N=44. Mean radiation dose was 5385 (4500-8040cGy). Mean BMI=26.2 (17.4-47.5).

Results: Mean follow up was 21.2 months (1.4-80.3 months). There were no perioperative mortalities. There were no laparoscopic conversions. Mean EBL was 302 cc (75-1900cc). Transfusion rate was 2.0%. The mean size for the largest incision was 1.9cm (1.2-3cm). The mean total length of all incisions was 4.6cm (1.8-8cm). All patients were protected with a temporary stoma. Overall morbidity rate was 31%, major morbidity rate was 5.8% and included pelvic abscess N=2, fistula N=1. Pathology was complete response = 21%. ypT stage : T0=11, T1=8, T2=17, T3=15. ypN positive=15; ypN negative=36. Local Recurrence rate (LR) was 2.0%. One patient had a positive margin, undergoing subsequently an APR. Permanent 5 year stoma rate was 86%.

Conclusion: For distal rectal cancer in need of a coloanal anastomosis, “incisionless” laparoscopic TME using the natural orifice, per-anal route for specimen delivery is a safe and accomplishable technique with good early oncologic results. Long term follow up and multi-institutional studies will be required to establish the widespread applicability of this promising technique.

Session: Poster of Distinction

Program Number: P019

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