Nobuhiro Takiguchi, PhD, MD, Soda Hiroaki, PhD, MD, Toru Tonooka, PhD, MD, Yoshihiro Nabeya, PhD, MD, Atsushi Ikeda, PhD, MD, Tomofumi Chibana, MD, Yusuke Hanzawa, MD, Wataru Takayama, PhD, MD, Satoshi Chiba, PhD, MD, Isamu Hoshino, PhD, MD, Hidehito Arimitsu, MD, Hiroo Yanagibashi, MD. Division of Gastroenterological Surgery, Chiba Cancer Center
Background: Laparoscopic low anterior resection (L-LAR) for rectal cancer has been increasing because of the development of the laparoscopic procedure such as setting good operative view, lateral node dissection method, and anastomotic technique. However, laparoscopic abdominoperineal resection (L-APR), which has the complexity of the maneuver such as retroperitonealization (suturing skills to close the peritoneal defect) and creation of sigmoid colostomy, is more complicated than L-LAR. We demonstrate the L-APR with lateral node dissection and discuss the techniques of creation of sigmoid colostomy and retroperitonealization.
Methods: Laparoscopic operation is performed with five ports under right side head down position. Dissection and mobilization of the left side of the colon is performed from a medial-to-lateral retroperitoneal approach. Lymph node dissection with ligation of the inferior mesenteric artery and total mesorectal excision to expose the levator ani muscle are performed. The proximal rectum is transected by linear stapler. Rect-anal specimen with total mesorectum was retrieved through the perineal wound. The perineal wound is closed by two layers. Laparoscopic lateral lymph node dissection is performed with enlarged view and by using energy device. Sigmoid colostomy is constructed in left abdomen by retoroperitoneal approach. A skin incision in a circle and splitting rectus abdominis muscle was done with exfoliating peritoneum enough. Sigmoid colon is drawn outside of the abdominal wall. Intracorporeal closure of the pelvic cavity to suture the peritoneum by using 3–0 V-Loc™ is performed. In female, the uterus is used as the floor of the pelvis to suture the peritoneum and uterus by using 3–0 V-Loc™. Drain is set up through the retroperitoneal route at the port of left lower abdomen.
Results: Between April 2006 and March 2016, we experienced 280 laparoscopic rectal surgeries with reginal lymph node dissection. Among them, L-APR is only nine cases composed with 6 males and 3 females. Although all patients successfully underwent L-APR of the rectum and colostomy formation, two emergency operations were required due to Richter's hernia of ileum and stoma necrosis for early postoperative period. Four patients were received lateral lymph node dissections with safety.
Conclusion: Though the total laparoscopic abdominoperineal resection of rectum is difficult procedure, we should master this procedure as minimally invasive surgery. It is necessary to pay attention not to have a suture gap and to avoid ischemic change of colostomy. We think the use of 3-0 V-Loc™ for intracorporeal closure reduces intra-operative surgeon’s stress in L-APR.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 77838
Program Number: P218
Presentation Session: Poster (Non CME)
Presentation Type: Poster