Bo Feng, MD, Minhua Zheng, MD. Surgery Department of Ruijin Hospital,Shanghai,China
Recent advances in laparoscopic instruments and techniques allow transabdominal transection of levator muscles under direct vision. Therefore, a laparoscopic-dominant APR becomes possible. This approach offers a transabdominal individualized transection of levator muscle, lowers the meeting level down to the ischiorectal fat, and at the same time provides guidance for the extent of perineal resection. The resection line therefore is predominantly determined by the laparoscopic procedure, rather than a synchronous approach. In this way, a more precise, less invasive procedure depending tumor stage and patient characteristics can be provided. We present our 30 cases experience of this laparoscopic-dominant APR with a high definition quality videos as well as drawings. Technical tips are shown in the video. During laparoscopic-dominant APR, a patient-tailored surgery can be provided according to tumor size and invasion (T-stage) pre-assessed by MRI and finally determined by intra-operative exploration. For tumors located below the levator hiatus, the transection line is kept outside musculus pubococcygeus to leave more musculus illiococcygeus for direct closure. For tumors situated above the levator hiatus, levators should be removed at their origins at the tumor side, while more muscles are kept on the other side to facilitate perineal reconstruction. Extensive resection of coccyx and sacral 4-5 might necessary for caudally grown tumors while an exenterative surgery is often required for anteriorly located lesions.
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