Laparoscopic total pelvic exenteration using transanal minimal invasive surgery technique with en bloc bilateral lymph node dissection for advanced rectal cancer
© The Author(s). 2016
Received: 24 May 2016
Accepted: 1 July 2016
Published: 26 July 2016
A 59-year-old man presenting with fecal occult blood visited our hospital. He was diagnosed with advanced lower rectal cancer, which was contiguous with the prostate and the left seminal vesicle. There were no metastatic lesions with lymph nodes or other organs. We performed laparoscopic total pelvic exenteration (LTPE) using transanal minimal invasive surgery technique with bilateral en bloc lateral lymph node dissection for advanced primary rectal cancer after neoadjuvant chemoradiotherapy. The total operative time was 760 min, and the estimated blood loss was 200 ml. LTPE is not well established technically, but it has many advantages including good visibility of the surgical field, less blood loss, and smaller wounds. A laparoscopic approach may be an appropriate choice for treating locally advanced lower rectal cancer, which requires TPE.
Total pelvic exenteration (TPE) was first described by Brunschwig as a palliative treatment for the terminal stages of advanced pelvic malignancies . Although TPE is highly invasive, it is a potentially curative procedure for locally advanced rectal cancer invading adjacent organs. One drawback of TPE is its high rate of postoperative complications and high morbidity [2, 3]. Recently, the usefulness of laparoscopic extended surgery for rectal cancer was reported, and it can decrease a complication rate [4, 5]. Here, we report our experience of laparoscopic total pelvic exenteration (LTPE) with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer.
A 59-year-old man was admitted to our hospital for the treatment of a rectal tumor.
An ileal conduit and a sigmoidostomy were then constructed extracorporeally through the extended umbilical incision. The total operative time was 760 min, and the estimated amount of bleeding was 200 ml. The postoperative course was good, and the patient was discharged on postoperative day 15. Histopathological analysis revealed no apparent invasion of the tumor to adjacent organs, and the pathological stages were ypT3 and ypN0.
Currently, laparoscopic technique is used for various surgeries; thus, opportunity to perform laparoscopic surgery has increased for many surgeons. The laparoscopic approach has advantages not only for patients but also for surgeons, i.e., less pain, smaller wounds, earlier recovery, and a magnified view. LTPE is a challenging and complicated operation, but some studies have reported on the safety and feasibility of it not only for urologic or gynecologic malignancies [6, 7] but also colorectal malignancies [3, 5, 8, 9]. This is our initial experience with LTPE, and so far, we have not encountered any complications. We have routinely performed lateral lymph node dissection for locally advanced lower rectal cancer, and we believe that this previous experience enabled our current success. Upon histopathological analysis, no apparent invasion of the tumor to adjacent organs was observed, but this was difficult to detect before the surgery; therefore, this patient should have been treated by TPE. This case did not include a posterior invasion, so the surgery time was comparatively short. We did not reconstruct the perineal defect, change the patient’s position, or place ureteral catheters after dissecting the ureters. We believe that these factors contributed to shortening the surgery time. We did not monitor the urine volume after dissecting the ureters, but intraoperative and postoperative complications did not occur.
During the anal-side procedure, we used the TAMIS technique. With the TAMIS technique, we could keep a good visual field even after penetration to the abdominal cavity because the pressure of pneumoperirectum can be kept by the pneumoperitoneum. In addition, the perineal wound becomes smaller, which may lead to reduction in the perineal surgical site infection, and pnuemoperirectum can reduce the amount of bleeding. In the middle of the procedure, the wound retractor broke due to contact with the blade of the Sonicision™ (Covidien) and the pneumoperirectum could not be kept thereafter, which will require further attention.
In conclusion, LTPE is a potentially safe and feasible procedure. However, reports on LTPE for advanced rectal cancer are scarce; therefore, more studies are necessary to evaluate the long-term safety of LTPE.
A consent was obtained from the patient for publication and presentation, when we obtained an informed consent for surgery.
KH and MK drafted the manuscript. MK performed the surgery. MH and KH participated in the surgery. MK and TH revised the manuscript. DK and SY performed peroperative management. YK, CH, KO and TH helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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