|Year : 2017 | Volume
| Issue : 1 | Page : 7-12
Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy
Hazar Al Furajii1, Niall Kennedy2, Ronan A Cahill1
1 Department of Colorectal Surgery, Mater Misericordiae University Hospital; Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland
2 Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
|Date of Submission||06-Jan-2016|
|Date of Acceptance||05-Mar-2016|
|Date of Web Publication||30-Nov-2016|
Ronan A Cahill
47 Eccles Street, Dublin 7, Ireland
Source of Support: None, Conflict of Interest: None
Purpose: Transanal minimally invasive surgery using single port instrumentation is now well described for the performance of total mesorectal excision with restorative colorectal/anal anastomosis most-often in conjunction with transabdominal multiport assistance. While non-restorative abdomino-endoscopic perineal excision of the anorectum is conceptually similar, it has been less detailed in the literature. Methods: Consecutive patients undergoing non-restorative ano-proctectomy including a transperineal endoscopic component were analysed. All cases commenced laparoscopically with initial medial to lateral mobilisation of any left colon and upper rectum. The lower anorectal dissection started via an intersphincteric or extrasphincteric incision for benign and malignant pathology, respectively, and following suture closure and circumferential mobilisation of the anorectum, a single port (GelPOINT Path, Applied Medical) was positioned allowing the procedure progress endoscopically in all quadrants up to the cephalad dissection level. Standard laparoscopic instrumentation was used. Specimens were removed perineally. Results: Of the 13 patients (median age 55 years, median BMI 28.75 kg/m2, median follow-up 17 months, 6 males), ten needed completion proctectomy for ulcerative colitis following prior total colectomy (three with concomitant parastomal hernia repair) while three required abdominoperineal resection for locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Median operative time was 190 min, median post-operative discharge day was 7. Eleven specimens were of high quality. Four patients developed perineal wound complications (one chronic sinus, two abscesses needing drainage) within median 17-month follow-up. Conclusion: Convergence of transabdominal and transanal technology and technique allows accuracy in combination operative performance. Nuanced appreciation of transperineal operative access should allow specified standardisation and innovation.
Keywords: Abdominoperineal resection, rectal cancer, transanal minimally invasive surgery, transanal proctectomy, transanal total mesorectal excision
|How to cite this article:|
Al Furajii H, Kennedy N, Cahill RA. Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy. J Min Access Surg 2017;13:7-12
|How to cite this URL:|
Al Furajii H, Kennedy N, Cahill RA. Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy. J Min Access Surg [serial online] 2017 [cited 2018 Nov 18];13:7-12. Available from: http://www.journalofmas.com/text.asp?2017/13/1/7/194976
| ¤ Introduction|| |
Endoscopic proctectomy, performed 'down to up', using single access laparoscopic devices has been recently proposed and validated among selected expert groups as being a safe and potentially better means of access to the mid and low rectum.,,,, The operation has been most often described via a transanal approach (transanal minimally invasive surgery) to assist with laparoscopic total or partial mesorectal excision (TME or PME) in patients undergoing low anterior resection with sphincter preservation for cancer to enable improved circumferential margin clearance, most especially in those with a narrow pelvis. Aside from simple demonstration of feasibility, considerable endeavour continues to be spent in the standardisation of this approach's practice and dissemination to ensure the highest quality in this innovation's implementation into clinical practice so that the procedure can become a true, broadly applicable step-advance in care for our patients.,,
Truly, transperineal endoscopic proctectomy has however only been included sporadically in early experience reports concerning transanal TME (taTME),, most often for conditions of the rectum needing extriprative excision (e.g., completion proctectomy after prior total colectomy for ulcerative colitis and abdominoperineal resection for cancer). Importantly also, there is potential for this access to facilitate wide extralevator resection without prone repositioning from the patient's standard lithotomy position where needed although of course this needs the inner aspect of the access device to lie below the levator sling., While such abdomino-endoscopic perineal excision (AEPE) is conceptually similar and indeed overall somewhat simpler then taTME given the lack of anastomosis in these procedures, there are significant technique and technical considerations in set-up and performance when starting with the lower incision point and of course this too can differ with respect to the patients exact pathology, needed procedure and pre-operative care (including neoadjuvant therapy for those with locally advanced low malignant disease). This is important to detail given that many recommend early selection of such cases as part of any centre's learning curve of taTME experience.
Here, we detail the technique and both short and intermediate term outcomes in a consecutive cohort experience of 13 patients undergoing transperineal AEPE of the rectum and mesorectum for both benign (n = 10) and malignant disease (n = 3). We discuss also adaptions in technical aspects of both pre-operative procedural planning and the single port access systems needed to ensure that procedure efficiency and quality are maximised.
| ¤ Methods|| |
Consecutive patients attending for proctectomy with sphincter resection between March 2013 and May 2015 (26 months) underwent their surgery using a hybrid abdominoperineal approach using two laparoscopic sets and systems. One system was used in the conventional transabdominal manner while the second was used to view and operate from the perineal aspect. A Gelport Path ® device (Applied Medical) was used to achieve transperineal insufflation and allow instrumentation insertion. Each patient was pre-operatively assessed, optimised and enrolled in our Enhanced Recovery after Surgery programme. All were admitted for their operation on the morning of the surgery. A rectal washout was performed in all cases while those with an in-continuity rectum also received a phosphate enema on the admission ward prior to arrival in theatre.
Operative management: After induction of general anaesthesia, transurethral catheterisation and placement in standard lithotomy position with antimicrobial (povidone-iodine skin preparation and intravenous co-amoxiclav) and antithrombosis prophylaxis, each patient was draped both abdominally and perianally.
A standard three port laparoscopic set-up (10 mm port and two 5 mm) was generally employed. A 30° camera was introduced through the 10 mm subumbilical port that had been placed by means of a Hassan technique. The other two 5 mm ports were inserted in the right iliac fossa at the level of the anterior superior iliac spine and in the right lumbar region at the level of the umbilicus. In patients with previous total colectomy, the trans-peritoneal approach was limited to any necessary adhesiolysis and securing mobilisation of the small bowel out of pelvic cavity in addition to identification of the rectal stump and dissection of the cephalad one-third of the rectum (to the level of the seminal vesicles or recto-vaginal plane as applicable anteriorly). In two cases with prior total colectomy, end ileostomy and parastomal hernia, the laparoscopic component was performed instead via a single port placed at the site of their mobilised end ileostomy. For those undergoing abdominoperineal resection for cancer, the left colon was mobilised via a medial to lateral approach with high ligation of the inferior mesenteric artery. The left ureter was always identified and protected.
An anal retractor (Lonestar, Cooper Medical) was applied perineally to allow visualisation and accessibility of the anorectum. For benign cases, this was placed to allow intersphincteric dissection and thereafter anal closure with a strong nylon purse-string. For those with malignant disease, the anal canal was securely sutured closed before initial wide circumferential dissection of the subcutaneous tissues and thereafter retractor placement. The ischiorectal fat was divided using diathermy ensuring haemostasis of any inferior rectal arterial or venous branches. Once sufficient space was obtained, the Gelport Path was positioned and the gel cap (with trocars in situ) affixed [Figure 1]. A 30° 5 mm or 10 mm videoscope was used with the former preferred to aid in the reduction of instrument clash. Continuing this previous dissection circumferentially with a laparoscopic hook or ligasure device (Medtronic) and a non-traumatic grasper holding the closed anorectum to provide countertraction, allowed exposure of the inferior surface of the levator ani muscle and this muscle could then be followed to its insertion in the obturator muscle as previously described for conventional abdomino perineal excision. The dissection could then be continued either within or through the levator sling depending on the operative requirements of the disease. Above this, Waldeyer's fascia was followed as the operative plane taking care to leave the parietal fasical on the pelvic side wall. Ventrally, the perineal muscle was divided to expose the bulb of the penis in male patients or the posterior vaginal wall in female patients and dissection proceeded circumferentially paying, especial attention bilaterally and anteriorly. Entry into the peritoneum by connection with the prior operative dissection was often easiest achieved anteriorly. Posteriorly dissection continued along the line of the sacral curve towards the sacral promontory aiming also to open into the peritoneal space just below this level [Figure 2], [Figure 3], [Figure 4]. As the rectum can then occupy a considerable amount of the pelvic space, its inversion into the peritoneal space may be helpful in completing the proximal rectal dissection. The final step of the resective procedure entailed extraction of the specimen transanally by disconnecting the perineal access port. In three patients, the port was reinserted and after washing of the device and pelvic cavity, used to assist in the repair of a concomitant parastomal hernia. The parastomal hernia mesh was tacked via the transanal port with satisfactory visualisation. Perineal wounds were closed with three layers of interrupted sutures, namely the muscle layer, subcutaneous fat and skin.
|Figure 1: Photograph showing the transanal minimal access device (Gelport Path, Applied Medical) in situ in a patient's perineum after initial mobilisation of the anorectum|
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|Figure 2: Sequential intraoperative photographs showing (a) initial view via the transperineal access device of the suture-closed anorectum (b) anterolateral dissection alongside the closed anorectum (c) anterior views just before removal of the anorectal specimen (d) pelvic cavity as seen from below after removal of the anorectum via a transperineal approach|
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|Figure 3: Sequential intraoperative photographs via the transperineal access device in another patient showing (a) suture-closed anorectum (b) lateral dissection of the closed anorectum from below (c) initial entry into the peritoneal cavity from below (d) anterior view of the dissection anorectum including view into the peritoneal cavity from below|
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|Figure 4: Similar sequence of intraoperative photographs as Figures 2 and 3 although this time as seen from the intra-abdominal laparoscope (a) anterior view of the mid rectum from above (b) lateral view of mid-rectum noting the inner aspect of the transperineal access device. (c) conclusion of anterior dissection of the mid rectum being done from below (d) view of transperineal camera entering into the peritoneal cavity from below as seen by intra-abdominal laparoscope|
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Perioperative management and data collection
All patients were managed intra and postoperatively as per our standard care protocol. This included recording of vital statistics along with pain control and laboratory marker measurement and early mobilisation and oral intake as tolerated was encouraged. Each patient was reviewed daily by the pain team until either the patient controlled analgesia was withdrawn or the patient was fit to continue on simpler analgesic care. Any perioperative epidural was generally removed prior to discharge from high-dependency care unit. All patient data were recorded prospectively including their registration on the LOREC taTME international registry.
| ¤ Results|| |
Thirteen patients underwent surgery during the study period, all of whom have now over 6 months of follow-up data available. Their median age overall at the time of surgery was 55 years and six were male. Ten patients needed completion proctectomy for ulcerative colitis following prior total colectomy (nine had this performed laparoscopically, the other had had open total colectomy). Therefore, all of these patients were re-operative with regards to the abdominal component of their surgery. Three patients in this group also needed concomitant parastomal hernia repair for symptomatic peristomal hernia. One patient also needed concomitant cholecystectomy having had recent gallstone pancreatitis. Three patients required abdominoperineal resection for locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Their specific demographics overall and by each disease category are shown in [Table 1].
Total median (range) operating time was 190 (140–250) min with the median (range) operating time for the abdominal component being 100 (60–140) min with a median of 100 (60–140) min for the perineal part. Of the ten patients with colitis, three (including the one patient with prior open colectomy) required significant adhesiolysis (one female patient had considerable adhesions between her uterus and the residual rectal stump, her upper rectal mobilisation incurred some intraoperative haemorrhage from the in situ residual superior rectal artery) and indeed one (male patient with prior laparotomy) needed conversion to laparotomy to complete the abdominal component (his endoscopic component proceeded without conversion however).
With regard to the perineal dissection, all 13 were completed endoscopically. There was considerable difficulty in determining the correct intraoperative plane due to considerable fibrosis in the mesorectum in two patients. One was a female with severe ongoing proctitis who also had connective tissue disease (Sweet's syndrome), the other was an obese male with rectal cancer after long-course radiotherapy with long interval. Both of these specimens had mesorectal defects, distant from the rectal cancer site in the latter case who also was found histopathologically to have had a complete response. Therefore 11 specimens were judged as high quality.
Median post-operative day of discharge was seven. One patient with colitis needed a post-operative red cell transfusion for symptomatic anaemia due to a post-operative bleed while two (one with colitis and one with rectal cancer and pre-operative chemoradiotherapy) developed perineal wound infections (one needed return to theatre for incision and drainage). Another patient (male with colitis and significant adhesiolysis) had culture-negative post-operative fever that settled with antipyretic therapy alone. In-hospital postoperative morbidity therefore as classified by Clavian Dindo was as follows: 0–9, I-1, II-1 and IIIb 2. There were no post-operative life-threatening complications or deaths.
One patient (the 85-year-old female with rectal cancer and general fragility) was readmitted early post-operatively from her planned nursing home convalescence with a perineal surgical site infection needing antibiotic therapy and had a prolonged second hospital admission as she needed further social supports put in place before being able to return home. One other patient (male with colitis) developed a perineal sinus after discharge that needed prolonged dressing after discharge. One male patient had erectile dysfunction diagnosed 5 months following procedure and has responded well to pharmacological therapy. Median follow-up is now 17 months (range 7–34).
| ¤ Discussion|| |
While many published transanal operative experiences include a small number of anoproctectomies and many proponents advise commencement of a new departmental experience with benign disease, technical description and reports of true transperineal access are uncommon. This access entails some technical nuance (including patient and port selection, gas-sealing and dissection vector) different to trans-sphincteric surgery as we here describe in this dedicated cohort experience-the largest pure cohort, to our knowledge, to date. Unusually too, this series also contains four patients who had additional intra-abdominal pathologies addressed synchronously, of whom three (all parastomal hernia repairs) had their intra-abdominal procedure aided by inclusion of the transperineal access.,
While this series were all done with a single type of single access device, other groups have used rigid steel systems such as the transanal endoscopic microsurgery (Wolf) and operation (Storz) sets. Their rectoscopes have a similar diameter but the tube itself is elongated and fixed to the operating table via a series of rigid rods. Single access systems have a practical advantage in that the camera, rather than being fixed, can move and rotate relative to both the focus of dissection and other instrumentation. However, it has the disadvantage that it requires secure fixation within the perineal incision and defect that is developed at commencement of the perineal operating phase. Intersphincteric dissection leaves a neater incision for more snug device insertion (and is associated with reduced incidence of perineal healing defects). However, perineal access does tend towards increased gas leak as compared to a cross-sphincteric transanal approach. This tendency can be offset by suture closure of the defect around the device once in situ or, more usefully, by use of an advanced sufflation system such as the AirSeal that can provide variable flow to ensure stability of distension volume despite the open circuit effect of incomplete gas sealing.
While placement of the Gelport transanally, across the sphincters, tends to position its innermost rim just above the puborectalis muscle, this is somewhat variable depending on the habitus and anatomy of the patient. There increased manoeuvrability of the port when it is sited in a perineal wound as compared to transsphincterically and it is quite possible thereby to access the lowermost side of the levator ani and so facilitate extralevator resection as has recently been described. This can achieve wide clearance at the level the specimen typically 'waists' if the mesorectal plane is followed which may perhaps reduce circumferential margin positivity and local recurrence rates. Of course, both anal canal length and pelvic outlet dimensions are however calculable pre-operatively by specific pre-operative imaging. While both computed tomography and magnetic resonance imaging (MRI) are commonly performed anyway for disease staging, the latter tends to be a better assessor of these factors but ideally needs inclusion of an imaging sequence focussed on the anal canal rather than the tumour. While standard 'one size fits all' devices are sufficient for use in most patients, biometric characteristic profiling in association with rapid iterative manufacturing ('3D Printing') raises the possibility of making simple ports that fit perfectly ahead of operative trialling. Furthermore, such ports could be of variable firmness or configuration by channelling gas flow through their structure or by variable stiffness printing which may help further in ensuring gentle tissue handling. Improved MRI selection can also of course help with understanding dissection vectors and include the possibility of real-time, intraoperative feedback via stereotactic augmentation of instrument tip and direction to help with correct planar orientation and ensure completeness of mesorectal excision.
Although some monitoring and indeed manipulation of the colorectum can be helpful from the abdominal side, in general, we prefer to perform the majority of the perineal dissection without significant synchronous transabdominal assistance. This limits somewhat the time-saving potential of having two operative teams working concurrently, but does mean simplified focus on each component dissection individually and also alleviates the need to have two expert surgical teams working in tandem. Cameras and advanced energy devices can be shared also between the two operative fields as an added advantage. There may be some advantage for preservation of the mesorectum in patients needing proctectomy for benign disease. The concept is that leaving this tissue may fill the pelvic space and perhaps reduce the risk of iatrogenic neurological injury and other pelvic complications and that the increased tendency to bleeding during dissection is offset by the high quality of applied energy devices now available. While close rectal dissection is certainly feasible, it is a different procedure to the one employed for neoplastic disease and likely needs distinct experience.
While some groups have completed the entire operation from below, the fact that three patients had considerable intraoperative adhesions (one mandating open conversion) means that commencement with laparoscopy seems crucial in patients with prior surgery. Interestingly in the case converted, perineal endoscopic access could still continue and proved a considerable aid in this obese male with hostile peritoneum. Other intraoperative events such as haemorrhage fromthe in situ superior rectal artery (while not requiring specific therapy other the control) also indicate caution in these re-operative cases. New accesses also confer the potential for new complications, especially during any early experience. To mitigate against this, we undertook dedicated cadaveric training and also engaged a proctor to assist in our understanding and delivery of the procedure. The increased incidence of perineal wound complications in the patients with malignancy likely relates to their having pre-operative neoadjuvant chemoradiotherapy, and also by their tendency to being a frailer population.
| ¤ Conclusion|| |
Convergence of transabdominal and transanal technology and technique allows accuracy in combination operative performance although more nuanced appreciation of transperineal operative access as opposed to transanal should allow specified standardisation and innovation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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