New Approach To the Modified Extralavator Abdominoperineal Resection for Low Rectal Cancer With Direct Wound Closure

Eun Jung Park, MD, Seung Hyuk Baik, MD, PhD, Jeonghyun Kang, MD, Byung Soh Min, MD, PhD, Kang Young Lee, MD, PhD, Nam Kyu Kim, MD, PhD, Seung-Kook Sohn, MD, PhD. Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea

INTRODUCTION This study aims to demonstrate a new surgical procedure for the modified extralevator abdominoperineal resection, which satisfies both an extended cylindrical resection and a convenient perineal wound closure by modification of the surgical dissection plane.

METHODS AND PROCEDURES From September 2011 to February 2014, 12 consecutive patients (5 males and 7 females) underwent the modified extralevator APR in Severance Hospital, Yonsei University College of Medicine, South Korea. Patients with T3/4 low rectal cancer or positive lymph nodes received preoperative chemoradiotherapy for down-staging before surgery. Surgical procedures were performed by open, laparoscopic or robotic surgeries with informed consents. Intraoperative and postoperative outcomes were evaluated. Pathologic outcomes were assessed for the oncologic results.

RESULTS The mean age was 55.3±15.1 years and body mass index was 21.8±3.1 kg/m². Ten patients (83.3%) received preoperative chemoradiotherapy. The operations were performed by 5 cases of laparoscopic surgery, 6 cases of open surgery, and 1 case of robotic surgery. The mean operation time was 258.8±58.0 min. There were no conversions and no tumor perforations. Days to 1st soft diet was 4.7±3.4 days, and the mean hospital stay was 11.2±4.7 days. Postoperative complications were 2 cases of grade I, 2 cases of grade II and 1 case of grade III. There was 1 patient (8.3%) with a positive circumferential resection margin and there was 1 case of local recurrence. The modified extralevator APR was performed by three steps: the abdominal dissection, the perineal dissection and the perineal wound closure.

CONCLUSION The modified extralevator APR was feasible and safe for patients with low rectal cancer or anal cancer with extended perineal dissection and convenient direct wound closure by modification of the surgical plane. The surgical procedures were feasible in open, laparoscopic and robotic surgeries. In spite of the decreasing numbers of patients who underwent APR due to the development of sphincter-saving surgeries, a new approach to overcome the previous limitations of APR should be considered.

[Figure] The surgical dissection plane. A, conventional APR. B, extralevator APR. C, the modified extralevator APR.