Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan.
Department of Surgery, Fukuoka University Hospital, Fukuoka, Japan.
Surg Endosc. 2019 Feb;33(2):437-447. doi: 10.1007/s00464-018-6316-8. Epub 2018 Jul 9.
Laparoscopic abdominoperineal resection (APR) for low rectal cancer (LRC) is performed worldwide. However, APR involves technical difficulties and often causes intractable perineal complications. Therefore, a novel and secure technique during APR is required to overcome these critical issues. Although the usefulness of the endoscopic trans-anal approach has been documented, no series of the endoscopic trans-perineal approach during laparoscopic APR for LRC has been reported.
Trans-perineal minimally invasive surgery (TpMIS) has been used during laparoscopic APR in our institution since April 2014. TpMIS is defined as an endoscopic trans-perineal approach using a single-port device and laparoscopic instruments. In this study, we retrospectively evaluated 50 consecutive patients with LRC who underwent laparoscopic APR at our institution from February 2011 to June 2017 and compared the outcomes of the patients who underwent TpMIS [trans-perineal APR (TpAPR) group, n = 21] versus the conventional trans-perineal approach (conventional group, n = 29). We investigated our experiences with TpMIS in detail and evaluated the safety and utility of TpMIS for patients with LRC. Moreover, major features and difficulties of TpMIS were examined from a surgical viewpoint.
Intraoperative blood loss (median (range) 55 (10-600) vs. 120 (20-1650) ml) and severe perineal wound infection (Clavien-Dindo grade 3, 0 vs. 5 cases) were significantly lower in the TpAPR than conventional group. TpMIS led to a shortened hospital stay (median (range), 14 (10-74) vs. 23 (10-84) days), and neither mortality nor conversion to open surgery occurred in the TpAPR group.
Magnified visualization via endoscopy provided more accurate dissection and less blood loss during surgery. Minimal skin incisions enabled a reduction in postoperative perineal complications, and consequently shortened the hospital stay. TpMIS during laparoscopic APR is safe and beneficial for patients with LRC.
腹腔镜腹会阴联合切除术（APR）已在全球范围内用于治疗低位直肠癌（LRC）。然而，APR 涉及技术难度，常导致难以处理的会阴并发症。因此，需要一种新的安全技术来克服这些关键问题。尽管内镜经肛入路的有效性已得到证实，但尚未有报道腹腔镜 APR 治疗 LRC 时经内镜经会阴入路的系列病例。
自 2014 年 4 月以来，我们医院在腹腔镜 APR 中使用经会阴微创外科（TpMIS）。TpMIS 定义为使用单孔装置和腹腔镜器械的内镜经会阴入路。在这项研究中，我们回顾性评估了 2011 年 2 月至 2017 年 6 月在我院接受腹腔镜 APR 的 50 例 LRC 连续患者，比较了经会阴入路（TpAPR 组，n=21）与传统经会阴入路（常规组，n=29）的结果。我们详细研究了 TpMIS 的经验，并评估了 TpMIS 对 LRC 患者的安全性和实用性。此外，从手术角度检查了 TpMIS 的主要特点和难点。
TpAPR 组术中出血量（中位数（范围）：55（10-600）ml）和严重会阴伤口感染（Clavien-Dindo 分级 3，0 例与 5 例）明显低于常规组。TpMIS 缩短了住院时间（中位数（范围）：14（10-74）天与 23（10-84）天），TpAPR 组无死亡或中转开腹手术。
通过内镜放大可视化提供了更准确的解剖和减少手术中的出血量。最小的皮肤切口减少了术后会阴并发症，并缩短了住院时间。腹腔镜 APR 期间的 TpMIS 对 LRC 患者是安全和有益的。
