Pelvic Peritoneum Closure with Improved Techniques as a Standard Surgical Procedure in Laparoscopic Abdominoperineal Resection: A Retrospective Study of 82 Cases.

Xialin Yan, MD, Jiaoyang Lu, MD, PhD, Sen Zhang, MD, Leqi Zhou, MD, Jianwen Li, MD, PhD, Pei Xue, MD, PhD, Mingliang Wang, MD, PhD, Aiguo Lu, Junjun Ma, Lu Zang, MD, PhD, Feng Dong, MD, PhD, Zirui He, MD, PhD, Fei Yue, MD, PhD, Jing Sun, MD, PhD, Hiju Hong, MD, PhD, Minhua Zheng, Bo Feng, MD, PhD. Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China.

INTRODUCTION: Pelvic peritoneum closure (PPC) is a standard operative procedure in conventional open abdominoperineal resection (APR) to prevent postoperative complications. However, this procedure is not usually performed in laparoscopic APR for its technique difficulty, which may lead to increased rates of complications (Fig. 1). Here, we compared the feasibility and peri-operative outcomes of the laparoscopic APR with and without pelvic peritoneum closure (PPC) for lower rectal cancer.

METHODS AND PROCEDURES: From September 2015 to May 2017, clinical data of 82 patients with lower rectal cancer undergoing APR in our medical center were studied retrospectively. Among all these eligible patients, 38 of them were in the PPC group (received laparoscopic APR with PPC via barbed sutures and Hemo-lock clips, Fig. 2) and the other 44 cases were in the non-PPC group (received laparoscopic APR without PPC). Short-term outcomes were contrasted between these two groups.

RESULTS: None of cases were conserved to open surgery. There was no significant difference in PPC and non-PPC group for operation time (148.1±26.2min vs 141.5±21.0min, P=0.213), the operative time for pelvic peritoneum closure in PPC group was 7.9±2.9min, and intra-operative blood loss (105.5±41.6ml vs 112.9±46.2ml, P=0.471) between these two groups. In terms of postoperative complications, incidence of perineal hernia, perineal wound infection and postoperative bowel obstruction were significantly reduced in PPC group compared with the non-PPC group (Table 1). Besides, no significant difference was found in terms of the number of lymph nodes harvested (14.4±2.4 vs 13.9±2.3, P=0.272), circumferential resection margin (CRM) positivity (2.6% vs 4.5%, P=0.645) and the time of hospital stay ((15.4±3.0) d vs (16.2±4.1) d, P=0.333 ).

CONCLUSIONS: PPC should be served as a standard procedure in laparoscopic APR for lower rectal cancer, which didn’t significantly increase the length of surgery or intra-operative blood loss, and might result in a significantly reduced incidence of postoperative complications including perineal hernia, perineal wound infection and intestinal obstruction. This surgical procedure could be easily managed with barbed sutures and Hemo-lock clips by experienced hands.

Table and figures

Figure 1 APR with (A) and without (B) PPC