Postanal minimally invasive surgery "PAMIS" assisted extra-levator abdominoperineal excision "ELAPE" for cancer: A novel approach in supine position.

Local recurrences are more common after abdominoperineal excision (APE) than after anterior resection of rectal cancer. Extralevator APE was introduced to address this problem. The post anal minimally invasive approach had been used by other authors for transperineal mesh rectopexy but not in cancer management. Our aim is to use the post-anal minimally invasive approach for better visualization and division of the levator Ani during the Extralevator abdominoprineal excision in 2 cases of carcinoma of the anal canal. After laparoscopic exploration of the abdomen and performing a laparoscopic nerve sparing TME down to the levator ani from the abdominal side, the perineal phase was started by a purse string suture followed by a postanal incision and division of the Anococcygeal ligament, the gel port was inserted where visualization of the levator ani allows its division under vision posteriorly and laterally in order to achieve a good circumferential resection margin in the studied 2 cases. Good circumferential resection margin was reported pathologically and photographed in one of them. Postanal minimally invasive PAMIS assisted technique facilitates the extralevator abdominoperineal "ELAPE" in supine position. However a large multicenter trial comparing this new assisted technique with the traditional ELAPE id needed for a final conclusion.