This case report demonstrates the first attempt to utilize a hybrid approach comprising conventional open laparotomy and TEA for recurrent pelvic malignancy to achieve sphincter preservation. By starting transanally using the so-called bottoms-up approach using TEA, sphincter preservation was accomplished without any difficulty. Further, TEA allowed for a more advanced horizontal dissection from the perineum to the deepest part of the pelvis under laparoscopic guidance than is possible with conventional APR or intersphincteric resection under direct vision, resulting in safer and more secure surgery. TEA therefore has the potential to expand the indications of SPS to recurrent pelvic malignancy.
TEA has a substantial advantage in pelvic disease recurrence. Regardless of the site of recurrence, adhesions to the sacrum from the initial rectal mobilization are frequently hard and dense even in the absence of a tumor. Additionally, dissection of the scar along the surface of the parietal fascia on the sacrum permits access to the pelvic floor, but further advancement is frequently difficult because the dissection route changes from vertical to horizontal, and direct visualization is limited. In general, diathermy of the scar tissue generates much smoke, which contributes to the poor visibility. The AIR Seal iFS® maintains a clear field with sufficient CO2 insufflation and better smoke evacuation, allowing for separation of the scar tissue with secure hemostasis under laparoscopic guidance. In this case, although complete connection to the abdominal dissection could not be created by TEA alone, a subsequent additional dissection from the abdomen provided an opening to the pelvic field and left the levator muscles intact.
The guidance port created using the hybrid procedure is important for allowing sufficient dissection. Distortion from the initial surgery accompanied by dense scar tissue does not usually allow for the creation of an appropriate surgical plane. We predict that this secure and reliable guidance port in the pelvis will be confirmed to play an important role in the safe surgical resection of recurrent pelvic tumors. Insertion of a finger into the abdominal opening allows the dissection plane to be identified. Preservation of the urinary system requires an intact pelvic plexus, uninvolved bladder trigone, and sufficient ureter length. This posterior finger-guided dissection is helpful for identifying the pelvic plexus. The anterior dissection between the vagina and rectum is not difficult under TEA because the dissection plane remains unchanged following the prior surgery and facilitates construction of the terminal space, which is the final goal of the entire pelvic resection. In the present case, the extensive dissection from the posterior guidance port was advanced both laterally and anteriorly, leaving the specimen finally found connected to the tissue around the vagina. Although the region around the vagina can be the site of massive bleeding, the rapid procedure toward the terminal space made it possible to minimize blood loss. We therefore consider it important to emphasize that the creation of both this terminal space and guidance port are essential components of TEA for recurrent pelvic surgery.
The application of TEA to recurrent pelvic tumors should be considered carefully. Currently, TEA for redo pelvic surgery has been described in a small case series necessitated by problems such as anastomotic stenosis, persistent leakage, or severe pouchitis, but in which no recurrent tumors were identified ; however, TEA for recurrent pelvic malignancy has not been reported. Resection should be limited without sacrificing the oncologic principle of R0 resection, which may be achieved with extensive and wide resection. With our present limited resection, preoperative magnetic resonance imaging or computed tomography is required to achieve cancer-free margins. It is clear that posterior recurrence, which necessitates resection of the sacrum, is not a candidate for TEA or a hybrid procedure . Our case was of ovarian malignancy, and not rectal adenocarcinoma. Moreover, it is important to keep in mind that different surgical indications are possible depending on the histology. Future studies should evaluate this method for its safety and efficacy, such as with regard to anal function, local recurrence rate, and survival in accumulated cases.
TEA has a substantial advantage not only in primary pelvic surgery but also in redo pelvic surgery. A hybrid approach comprising conventional open laparotomy and TEA in highly selected cases with recurrent pelvic tumors may allow more patients to achieve successful sphincter preservation.