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11 Laparoscopic Hand-Assisted Low Anterior Resection
127
Fig. 11.20 Use of the hand port facilitates division of the proximal
bowel. With permission from Watanabe M. Laparoscopic anterior
resection for rectal cancer In : Milsom JW , Bohm B , Nakajima K , eds.
Laparoscopic colorectal surgery. Springer , New York 2006 ; pp : 170 - 187 .
© Springer 2006
Fig. 11.22 Anterior dissection in a male. With permission from
Watanabe M. Laparoscopic anterior resection for rectal cancer In :
Milsom JW , Bohm B , Nakajima K , eds. Laparoscopic colorectal sur-
gery. Springer , New York 2006 ; pp : 170 - 187 . © Springer 2006
Fig. 11.21 The colon can be brought out through the hand-port to provide traction and help complete rectal dissection. With permission from
Yuko Tonohira
(d) A laparoscopic energy device can be used to com-
plete the dissection sequentially as described with the
prior technique; utilizing posterior dissection initially, followed by lateral dissection, and fi nally anterior dissection are carried out with cautery or an
energy device (Figs.
11.22 and 11.23 ).
Fig. 11.23 Anterior dissection in a female With permission from Yuko
Tonohira
Resection
The distal bowel is transected with a reticulating stapler after
clearing the mesorectum at the appropriate level (note: this
step can also be done through the hand port). Many surgeons
feel that this is the rate-limiting step of a laparoscopic LAR
with the currently available stapling technology. In this light,
the hand-assisted approach retains many of the advantages of
laparoscopy while permitting the use of an open technique to
aid in this more diffi cult step of the operation.
128
G. Nandakumar and S.W. Lee
Anastomosis
The anastomosis is typically completed with a circular stapler. The hand port is very useful for this portion of the
operation. The proximal bowel is prepared and checked for
pulsatile blood fl ow. The anvil of an EEA stapler (typically
28 or 31 mm) is secured to the end of the bowel with a
purse string. Alternatively, a side-to-end anastomosis can
be performed by securing the anvil to the antimesenteric
edge of the proximal bowel. The shaft of the EEA stapler
is brought in transanally and the anastomosis completed. It
is our preference that care is taken to ensure that the pin of
the stapler is brought through the center of the TA staple
line (Fig.
peritoneum can be reestablished to perform the anastomosis
laparoscopically.
scope. A leak text is performed with CO 2 insuffl ation, while
the anastomosis is kept under saline. The fl exible scope permits complete colonoscopy at this stage if the tumor was
obstructive and preoperative complete colonoscopy was not
possible. The hand-access device permits easy intervention
should there be bleeding or a leak identifi ed on colonoscopic
evaluation. Reinforcing or hemostatic sutures can also be
placed through the hand port under colonoscopic guidance,
if required.
pelvis and a hand-sewn colo-anal anastomosis fashioned
with interrupted absorbable sutures.
11.24 ).
After securing the anvil to the proximal bowel, pneumo-
The anastomosis is evaluated with a fl exible sigmoido-
For very low tumors, the conduit can be positioned in the
Postoperative Care
Complications
The routine complications associated with a low anterior
resection and colorectal surgery are well described. This section focuses on specifi c complications as related to the laparoscopic hand-assisted LAR.
Wound Complications
Pfannenstiel incisions generally heal well with a low incidence of incisional hernia [ 3 ]. Our practice is to leave a
small portion of the wound open to decrease the incidence
of surgical site infection. Rectus sheath hematomas can
occur and usually present as severe focal pain in the postoperative period. Careful attention to the perforating vessels when raising fl aps can decrease the incidence of
hematomas. Our practice is to close the posterior fascia to
decrease the possibility of bowel herniating between the
rectus muscles.
Operative Technical Complications
Bleeding
• Bleeding at the time of retro-mesenteric dissection is usually due to dissecting into the retroperitoneum or into the
mesentery. If persistent bleeding is encountered, attempting dissection from an alternative approach may be
useful.
• Bleeding from the pedicle can typically be controlled
with clips. ENDOLOOPS (Ethicon, Cincinnati, OH) are
useful to have available in all cases to control pedicular
bleeding (especially with calcifi ed vessels).
• Visualization can be easily maintained by placing a laparotomy pad or gauze through the hand-port to clean the
fi eld. This pad can also be used to keep the camera clean.
• Splenic injury can be avoided by dissecting away from
the spleen and maintaining dissection in the plane close to
the colon. Pressure and compression can easily be used to
control splenic bleeding with a laparotomy pad through
the hand-port, though hemostatic topical adjuncts may be
required.
Fig. 11.24 The anvil of the EEA stapler is brought through the middle
of the transverse staple line
Ureter
• Ureteral injury should be rare if the ureter is identifi ed
prior to division of any vessels.
• Inability to fi nd the ureter is an indication to convert to an
open operation in diffi cult cases.
• Preoperative stents may help recognize an injury, but do
not always prevent injury to the ureter.
11 Laparoscopic Hand-Assisted Low Anterior Resection
129
Bowel Injury
• Can be thermal secondary to the dissecting tool.
• Traction and tearing of the bowel are possible during
mobilization and “running the bowel.”
• Puncture injury from trocars and instruments is a concern
and care should be taken to handle instruments under
direct vision.
Outcomes
Randomized control trials comparing open and hand-assisted
colectomy have shown that the procedure is safe, has
decreased blood loss, and is associated with a quicker postoperative recovery with a shorter length of stay [ 5 ]. Hand-
assisted colectomy compared to open surgery has also been
associated with a higher cost and longer operative times,
especially in the early experience with this technique. There
was no signifi cant difference in the complication rate
between the open and hand-assisted surgery. Of note, these
studies included all colectomies and included benign and
malignant disease.
There are several studies that have compared hand-
assisted colectomy to straight laparoscopic colectomy. The
HALS study was a multicenter study out of Europe and
America that found no difference in outcome between the
straight laparoscopic and hand-assisted techniques. However,
the conversion rate was much lower in the hand-assisted
group [ 6 ]. The Minimally Invasive Therapy and Technology
(MITT) found a lower conversion rate with the hand-assisted
technique. This study also found a decrease in operative time
with the hand-assisted approach [ 7 ].
Tjandra et al. conducted a prospective non-randomized
case-control study on ultralow anterior resection [ 8 ]. There
was no difference in the number of lymph nodes harvested or
the margin positivity. The operative time was shorter with
the hand-assisted technique, while the need for postoperative
narcotics and the time to fl atus were slightly longer, with no
difference in the length of stay. The clinical signifi cance of
these fi ndings is unclear, however, this study showed that
there might be some difference in recovery. In contrast, a
study out of the Lahey Clinic did not fi nd any difference in
bowel function recovery [ 9 ].
In summary, studies comparing straight laparoscopic ver-
sus hand-assisted approached have found:
1. HALAR retains many of the benefi ts of a pure laparoscopic approach.
2. Comparable complication rate and length of stay.
3. Shorter operative time and lower conversion rate.
4. Longer incision compared to straight laparoscopy.
5. Increased level of infl ammatory markers—though of
unclear clinical signifi cance.
6. Longer need for narcotics and longer time to fl atus compared to straight laparoscopy—also of unclear clinical
signifi cance.
Overall, we feel it is clear that HALAR helps broaden the
reach of laparoscopy to more complex patients such as obese
patients and those with diffi culty anatomy. The benefi ts of
the hand-assisted device in teaching residents and fellows
are also signifi cant. A comparative study that looked at the
benefi t of the hand-assisted device in training found that less
intervention was required by the attending surgeon in completing left-sided resection with the hand-assisted device
(hand-assisted 72 % vs. laparoscopic 72 %, P = 0.06) [
10 ].
Pearls and Pitfalls
Hand-Access Device Placement
(a) The Pfannenstiel incision is, in general, preferred to the
lower midline incision; however, especially early in your
experience and for cases with a high likelihood of conversion, a lower midline incision may be preferred.
(b) The anterior fascia should be mobilized widely off the
rectus as this permits retraction with the wound
protector.
(c) Perforators from the rectus should be seen clearly and
controlled to prevent a postoperative rectus sheath
hematoma.
Visualization
(d) Use of a tagged laparotomy pad or sponge can be very
useful in cleaning the camera and retracting the small
bowel out of the fi eld.
(e) Positioning the patient in steep Trendelenburg and left
side up is critical in achieving adequate exposure.
(f) Dexterity with the hand and ensuring that it does not
obstruct the fi eld of vision are a must. In general, keep
the hand away from the camera, and use a “C-shape”
confi guration with your hand and maximal thumbforefi nger apposition for dissection.
(g) Use of laparotomy pads and lighted retractors are impor-
tant for the pelvic portion of the operation (Fig. 11.16 ).
Traditional St. Mark’s retractors are diffi cult to use
through a small incision.
Splenic Flexure
(h) Posterior dissection to the inferior border of the pancreas
followed by lesser sac dissection at the distal transverse
130
G. Nandakumar and S.W. Lee
colon prior to taking down the lateral attachments will
help with diffi cult splenic fl exure takedown.
(i) Positioning the patient in reverse Trendelenburg can
help complete splenic fl exure dissection.
(j) Traction and dissection towards the spleen rather than
away from the spleen will prevent splenic trauma.
Pelvic Dissection
(k) Using two lighted bright tract retractors to provide
medial and lateral traction helps in a narrow pelvis.
(l) The uterus can be suspended to the abdominal wall or
retracted using the ring of the hand-assisted device.
(m) Intraoperative proctoscopy is very useful in assessing
the distal extent of the resection.
Conclusion
Hand-assisted low anterior resection is a useful tool in the
armamentarium of an experienced laparoscopic colorectal
surgeon. It broadens the scope of laparoscopy to technically challenging cases and allows for a safe platform to
train future colorectal surgeons. The operative time is
often reduced without compromising the other benefi ts
of straight laparoscopy. HALAR can also be used as a
fi rst step for surgeons who are new to the fi eld and as a
bridge prior to conversion to open following straight
laparoscopy.
References
1. Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A,
Guillou PJ, Thorpe H, Brown J, Delgado S, Kuhrij E, Haglind E,
Påhlman L, Transatlantic Laparoscopically Assisted vs Open Colectomy
Trials Study Group. Laparoscopically assisted vs open colectomy
for colon cancer: a meta-analysis. Arch Surg. 2007;142(3):298–303.
2. Nakajima K, Lee SW, Cocilovo C, Foglia C, Kim K, Sonoda T,
Milsom JW. Hand-assisted laparoscopic colorectal surgery using
GelPort. Surg Endosc. 2004;18(1):102–5.
3. Sonoda T, Pandey S, Trencheva K, Lee S, Milsom J. Longterm
complications of hand-assisted versus laparoscopic colectomy. J
Am Coll Surg. 2009;208(1):62–6.
4. Nakajima K, Milsom JW, Margolin DA, Szilagy EJ. Use of the sur-
gical towel in colorectal hand-assisted laparoscopic surgery
(HALS). Surg Endosc. 2004;18(3):552–3.
5. Meshikhes AW. Controversy of hand-assisted laparoscopic colorec-
tal surgery. World J Gastroenterol. 2010;16(45):5662–8.
6. HALS Study Group. Hand-assisted laparoscopic surgery vs stan-
dard laparoscopic surgery for colorectal disease: a prospective randomized trial. Surg Endosc. 2000;14(10):896–901.
7. Marcello PW, Fleshman JW, Milsom JW, Read TE, Arnell TD,
Birnbaum EH, Feingold DL, Lee SW, Mutch MG, Sonoda T, Yan Y,
Whelan RL. Hand-assisted laparoscopic vs. laparoscopic colorectal
surgery: a multicenter, prospective, randomized trial. Dis Colon
Rectum. 2008;51(6):818–26.
8. Tjandra JJ, Chan MK, Yeh CH. Laparoscopic- vs hand-assisted
ultralow anterior resection: a prospective study. Dis Colon Rectum.
2008;51(1):26–31.
9. Chang YJ, Marcello PW, Rusin LC, Roberts PL, Schoetz DJ. Hand-
assisted laparoscopic sigmoid colectomy: helping hand or hindrance? Surg Endosc. 2005;19(5):656–61.
10. Champagne BJ, Lee EC, Valerian B, Armstrong D, Ambroze W,
Orangio G. A novel end point to assess a resident's ability to perform hand-assisted versus straight laparoscopy for left colectomy:
is there really a difference? J Am Coll Surg. 2008;207(4):554–9.
Laparoscopic Abdominoperineal Resection
Jennifer S. Davids and Justin A. Maykel
12
K e y P o i n t s
• For low rectal cancer, small randomized prospective
controlled trials have shown that, compared to open APR,
laparoscopic APR has equivalent oncologic outcomes and
is associated with earlier postoperative recovery and
shorter hospital stay.
• Although there are few absolute contraindications to laparoscopic APR, strategic patient selection is essential to a
successful outcome.
• There are a variety of innovative approaches to laparoscopic abdominoperineal resection that can be used to
individualize patient management.
• The overall principles of laparoscopic APR are the
same as for open surgery; total mesorectal excision is the
cornerstone.
• Conversion to an open procedure for any reason should
not be considered a “failure.”
Introduction
Indications
Regardless of the surgical approach, abdominoperineal resection (APR) is indicated primarily for the treatment of malignant diseases but may also be appropriate for benign disease
in selected circumstances. In terms of malignancy, APR is performed for low rectal cancer, recurrent rectal cancer, as well
as salvage therapy for anal cancer or melanoma. While ade-
Electronic supplementary material: Supplementary material is avail-
able in the online version of this chapter at
. Videos can also be accessed at http://www.springerimages.com/
1_12
videos/978-1-4939-1580-4
J. S. Davids , M.D. • J. A. Maykel , M.D. (*)
Division of Colorectal Surgery of Colon and Rectal Surgery ,
University of Massachusetts Memorial Hospital Center ,
67 Belmont Street, Suite 201 , Worcester , MA , USA
Justin.maykel@umassmemorial.org
e-mail:
.
10.1007/978-1-4939-1581-
nocarcinomas involving the sphincter complex traditionally
mandate APR, the technique of intersphincteric resection and
coloanal anastomosis can be offered for patients who refuse
a stoma and are willing to accept the risk of positive microscopic margins and compromised postoperative continence.
Other patients are best treated with APR due to technical
limitations in achieving an adequate distal margin and/or performing an anastomosis deep in the pelvis. Additionally, APR
may provide better quality of life compared to low anterior
resection (LAR) with primary anastomosis for patients who
also have marginal baseline continence or are at risk for low
anterior resection syndrome. There are a few indications for
APR for benign disease. APR may be appropriate for selected
patients with severe refractory anorectal Crohn’s disease,
although in one small retrospective study ( N = 10 patients)
it was associated with increased likelihood of new severe
proximal colonic disease [
completion proctectomy in a patient with ulcerative colitis or
Crohn’s colitis who has undergone previous abdominal colectomy or who is not a candidate for or who does not desire
a restorative procedure. Lastly, APR may improve quality of
life and facilitate wound healing for patients with spinal cord
injuries and/or sacral decubiti, who are already diverted but
suffer from persistent mucous discharge.
1 , 2 ]. APR may be performed as a
Outcomes
Large randomized multicenter trials have demonstrated that
laparoscopic colectomy for colon cancer is associated with
equivalent oncologic outcome to conventional open surgery
and has the benefi t of superior short-term outcomes including
faster recovery, reduced length of stay, and less analgesic use
[ 3 – 5 ]. For rectal cancer, current data is limited to two pro-
spective randomized trials, with anticipation of more solid
data upon completion of the American College of Surgeons
Oncology Group (ACOSOG) Z6051 trial, which aims to
enroll 650 patients by December 2013 [ 6 , 7 ]. The United
Kingdom Medical Research Council trial of conventional
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_12, © Springer Science+Business Media New York 2015
131
132
J.S. Davids and J.A. Maykel
versus laparoscopic-assisted surgery in colorectal cancer
(CLASICC) trial compared short-term end points after laparoscopic ( N = 253) versus open ( N = 128) rectal resections for
cancer (including both LAR and APR) and concluded that
there was no statistically signifi cant difference in intraoperative complications (14 % vs. 13 %) or 30-day postoperative
complications (40 % vs. 37 %) [
a subset of patients who underwent open ( N = 36) versus
laparoscopic ( N = 60) APR. The two groups had similar
rates of positive circumferential resection margins (20 % vs.
26 %). While these rates are quite high, equivalent 5-year
overall survival rates (41.8 % open vs. 53.2 % laparoscopic,
P = 0.310), disease-free survival rates (36.2 % vs. 41.4 %,
P = 0.618), and distant recurrence rates (40.8 % vs. 35.7 %,
P = 0.762) were found [ 9 ].
A prospective randomized trial by Ng et al. specifi cally
evaluated perioperative outcomes in patients with low rectal
cancer undergoing open ( N = 48) versus laparoscopic ( N = 51)
APR [ 10 ]. In this study , the laparoscopic group had earlier
return of bowel function (3.1 days until fl atus vs. 4.6 days
until fl atus, P < 0.001), as well as improved time until inde-
pendent ambulation (4.4 days vs. 5.9 days, P = 0.005). They
did note that the laparoscopic approach had a longer operative time (213 min vs. 163 min, P < 0.001) and higher cost
($9,588 vs. $7,517, P < 0.001). Lastly, in concordance with
the CLASICC data, they also reported equivalent 5-year survival (75 % vs. 76 %, P = 0.20).
In conclusion, the existing data on laparoscopic versus
open APR suggests that, when performed by laparoscopic rectal cancer experts, this technique delivers equivalent oncologic
outcomes with improved in-hospital recovery at the expense
of longer operating room time and overall higher cost. The
adequacy of oncologic resection remains unsettled due to high
reported positive surgical margins. We anticipate that data
from the ongoing larger trials will quantify outcomes pertaining to survival, morbidity, and cost, as well as sexual function and quality of life. These results will undoubtedly have
the potential to impact policy, as current American Society
of Colon and Rectal Surgeons (ASCRS) practice guidelines
(last updated in 2005) note the uncertainty of the “oncologic
effectiveness” of laparoscopic rectal cancer surgery given the
absence of large prospective randomized controlled trials [ 11 ] .
8 ]. The analysis included
Total Mesorectal Excision (TME)
The cornerstone of rectal cancer surgery is the total mesorectal excision (TME), popularized by Heald [ 12 ]. Early on,
concerns regarding the potential to achieve a proper laparoscopic TME were fueled by the results of the CLASICC trial,
in which patients who underwent laparoscopic low anterior
resection ( N = 129 patients) had a higher rate of positive
circumferential resection margin compared to the open
procedure ( N = 64), although this did not reach statistical
signifi cance (12 % vs. 6 %, P = 0.19) and did not translate to
a difference in 5-year survival [ 8 , 9 ]. Notably, as mentioned
above, CRM rates were high, but equivalent for laparoscopic
and open APR. Undoubtedly, these data refl ect the technical
challenges associated with laparoscopic low anterior resection with primary anastomosis. Inability to palpate the extent
of the tumor to determine margins, as well as limitations on
stapler angulation, can make distal transection challenging.
Fortunately, neither of these technical constraints is relevant
to laparoscopic APR. Particularly with the narrow male pelvis, the ability of the surgeon to access the plane of resection
from both the abdominal and perineal approaches is a technical advantage of APR compared to LAR.
Patient Selection and Preoperative Considerations
Patient selection for laparoscopic APR is the key to a successful operation and a good patient outcome. Candidates for
laparoscopic APR should be fi t enough to tolerate a larger,
open surgery, should it be necessary. The only absolute contraindication to laparoscopic APR is the inability to tolerate
pneumoperitoneum and steep Trendelenburg positioning.
Relative contraindications include morbid obesity, prior pelvic surgery, and suspected or known dense intra-abdominal
adhesions. In the obese patient with a narrow pelvis and foreshortened/thickened mesentery, it can be challenging to
retract the small bowel out of the pelvis and maintain good
visualization when entering the presacral space.
The surgeon must perform a thorough history and physical examination on all candidates for APR. The history
should include preoperative bowel control and continence
for patients who are being considered for LAR versus
APR. For all malignancies, a careful digital rectal exam
should be performed, focusing on tumor location relative to
the sphincter complex, size, mobility, and response to neoadjuvant therapy. At the time of cancer diagnosis, patients
should be staged with CT scans of the chest, abdomen, and
pelvis. Blood work includes carcinoembryonic antigen
(CEA) and a complete blood count. Imaging with MRI,
endorectal ultrasound, or both is based somewhat on individual surgeon preference and expertise and will not be discussed in detail in this chapter. Pelvic imaging can give the
surgeon additional information related to the tumor and adjacent structures, providing valuable data points to optimize
operative planning.
A thorough preoperative evaluation is required for patients
undergoing APR. This includes a complete blood count,
electrolytes, coagulation studies, type and screen, urinalysis,
and, if age appropriate, chest X-ray and EKG. Evaluation by
a pulmonologist or cardiologist is recommended if the
12 Laparoscopic Abdominoperineal Resection
133
patient has baseline cardiopulmonary disease. Nutrition labs
including albumin and prealbumin should be obtained if the
patient is clinically malnourished. All patients should be
seen by an enterostomal therapist preoperatively for counseling and site marking. Consultation preoperatively with a
plastic surgeon should be considered if a large pelvic defect
is anticipated (see section below on reconstruction of the
defect). Lastly, ureteral stent placement should be considered for patients with bulky pelvic tumors, radiation therapy,
or prior pelvic surgery. In colorectal surgery, ureteral stents
have not been shown to decrease the likelihood of injury, but
they do increase intraoperative injury identifi cation, allowing
for immediate repair [
13 ]. Lighted stents in laparoscopic pel-
vic surgery have been described, but are not essential [ 14 ].
Operative Technique (Video 12.1 )
Anesthesia, Prophylaxis, and Positioning
Prior to case, appropriate antibiotics are administered. The
patient is initially in supine position. Venous thromboembolism (VTE) prophylaxis includes Venodyne boots placed
before induction of general endotracheal anesthesia. The surgeon should consider administering either unfractionated or
low-molecular-weight heparin subcutaneously preoperatively as well. In a large database study, laparoscopic proctectomy did not have decreased incidence of VTE compared
to the open approach [ 15 , 16 ]. Following intubation, an oro-
gastric tube is placed.
The patient is moved into the lithotomy position, with
legs in Yellowfi n boots. Ureteral stents are placed at this
time, if needed. Prior to prepping, the surgeon ensures there
is adequate exposure of the anus and perineum off the edge
of the bed. Bony prominences are carefully padded and legs
are positioned in the boots to avoid pressure on the peroneal
nerve. The Yellowfi ns are eventually brought downward,
decreasing the amount of hip fl exion, to maximize workspace with the laparoscopic instruments. Both arms are
padded and tucked to the patient’s side using a drawsheet.
Next, the patient is secured to the table, in order to prevent
shifting during steep Trendelenburg and left-right tilting. The
upper body is secured at the chest and shoulders as a blue
towel is folded into thirds, laid across the chest, and wrapped
around the bed twice with 3-in. tape. In our experience,
beanbag or infl atable devices add unnecessary bulk, lift the
patient higher off the bed, and limit instrument mobility during the laparoscopic dissection. One-liter IV saline bags may
be carefully placed parallel to the shoulders and are wrapped
twice circumferentially around the bed with wide cloth
tape (Fig. 12.1 ). In rare instances, with improperly placed
shoulder supports coupled with prolonged time in the
Trendelenburg position, shoulder supports have been associated with brachial plexus injuries [ 17 ] and should be used
with caution. A Foley catheter is placed under sterile technique if ureteral stents are not used. The surgeon should perform a fi nal digital rectal examination to confi rm
appropriateness of resection and to assess response to neoadjuvant therapy, if relevant. Residual stool may be evacuated
from the rectum with enemas containing a Betadine-saline
mixture. The anus is sewn closed with a 2–0 silk purse
string suture to prevent contamination of stool (Fig. 12.2 ).
The abdomen is then prepped with chlorhexidine and the
perineum prepped with Betadine. Prior abdominal incisions
are marked with a pen, and the stoma site can be confi rmed
and reinforced. The patient is draped, and the operation
begins after a time-out is performed.
Port Placement and Entry into the Abdomen
Entry into the peritoneal cavity can be accomplished using
the Hasson or Veress technique in the infraumbilical position. If the patient is obese or has had previous surgery at the
umbilicus (prior laparotomy, umbilical hernia repair), a
safer alternative is to use the Veress or Visiport technique in
the left upper quadrant. Pneumoperitoneum is established to
15 mmHg, and additional 5-mm ports are placed under
Fig. 12.1 Supine OR positioning
depicting patient secured to bed,
shoulder rolls in place, in the
lithotomy position, buttock off
end of the bed, with thighs as
parallel as possible to the
abdomen
134
J.S. Davids and J.A. Maykel
Fig. 12.2 Anus sewn closed at initiation of case
direct vision in the following locations: suprapubic, right
lower quadrant, and left mid-abdomen (future colostomy
site) (Fig. 12.3 ). An additional trocar may be placed in the
epigastrium if needed, taking care not to place it too far to
allow laparoscopic instruments to reach the deep pelvis. The
laparoscopic abdominal portion has also been described
using single-port access, with a single-port device (SILS
Port, Covidien, Inc., Norwalk, CT, or the GelPOINT
Advanced Access Platform, Applied Medical, Rancho Santa
Margarita, CA) [ 18 ], and positioned at the colostomy site,
umbilicus, or Pfannenstiel location. Since the specimen can
eventually be removed via the perineal incision, the laparoscopic APR procedure does not need any extension of
abdominal incisions for specimen extraction, as required for
laparoscopic colectomy procedures. This is another reason
why we do not typically utilize the hand port routinely,
although some surgeons fi nd the insertion of the hand helpful for pelvic retraction (Fig. 12.4 ). A 5-mm or 10-mm
30-degree scope is used. The Olympus EndoEYE camera
(Olympus, Central Valley, PA) may help facilitate visualization in the pelvis, particularly with the single-port laparoscopic approach. Once the ports are placed, both the surgeon
and assistant may stand on one side of the patient, but we
prefer to have the surgeon stand on the patient’s right side
and assistant on the left. Monitors are positioned to the
patient’s left and right at the foot of the bed. An additional
monitor may be placed above the patient’s left shoulder to
facilitate splenic fl exure mobilization, when needed.
Colon Mobilization and Division of the Superior Hemorrhoidal Vessels
The liver and peritoneal surfaces are visually inspected for
evidence of metastases. The patient is placed in steep
Trendelenburg position with the right side down. The small
bowel is swept out of the pelvis using 2 atraumatic graspers.
The descending colon and sigmoid colon are mobilized from
the sigmoid fossa along the white line of Toldt in a lateral-tomedial fashion, using Endo Shears (Covidien, Inc., Norwalk,
CT) with cautery. An alternative approach is the medial dissection where the sigmoid is lifted, the peritoneum incised,
and the plane between the mesorectal fascia and the retroperitoneum is created, taking particular care to leave the ureter in the retroperitoneum and sweep it down from the
specimen. In most cases, the splenic fl exure and proximal
descending colon do not need to be mobilized in order to
have suffi cient length for the end colostomy. The sigmoid
colon is grasped and retracted upward, and the superior hemorrhoidal vessels are identifi ed within the mesentery. Using
the Endo Shears and atraumatic grasper, windows in the
mesentery are created around the superior hemorrhoidal vessels. After demonstrating once more that the ureters are out
of the line of transection, the vessels are ligated at their origin. This maneuver can be performed with a 5- or 10-mm
(depending on the amount of tissue to be divided) advanced
bipolar device or laparoscopic stapler with white 2.5-mm
staple cartridge (Fig.
12.5a, b ). A grasper should be posi-
tioned and ready to obtain prompt control of the vascular
stump, in the event of inadequate hemostasis.
Total Mesorectal Excision
The presacral plane is further developed into the wispy areolar tissue, using either Endo Shears or the L-hook cautery.
Alternative instruments such as ultrasonic energy devices
(Harmonic Scalpel
ing laparoscopic instruments (Cambridge Endo, Framingham,
MA) may facilitate the exposure and dissection. The hypogastric nerves are visualized medially along the sacrum as
well as laterally along the pelvic sidewall and are left intact
(Fig.
12.6 ). The total mesorectal dissection proceeds into the
pelvis to the pelvic fl oor (levators), fi rst posteriorly and then
laterally, and lastly the anterior plane is approached. The
colon and rectum can be retracted out of the pelvis with the
assistance of gravity, a laparoscopic grasper, or suture
secured to the abdominal wall or trocar. In women, the uterus
and adnexa can be suspended with a suture passed through
the abdominal wall or by a uterine manipulator placed at the
initiation of surgery. During the dissection it is imperative to
identify and preserve both ureters, the pelvic sympathetic
and parasympathetic nerves, iliac blood vessels, presacral
™
, Ethicon, Cincinnati, OH) or articulat-
12 Laparoscopic Abdominoperineal Resection
Fig. 12.3 OR setup with trocar,
surgeon, and monitor positioning
135
Fig. 12.4 Laparoscopic APR through a hand port. JP sewn to specimen
to pull through the perineal wound and leave the JP in the pelvis to drain
veins, vagina, seminal vesicles, and prostate. Of course,
tumor involvement of any of these structures mandates en
bloc resection. The posterior dissection will take you to and
through Waldeyer’s fascia and the anterior curve of the pelvis
to the muscular pelvic fl oor. At this level, it is particularly
important not to “cone in” on the specimen, taking care to
leave a waist of muscle and adipose tissue covering the
thinned rectum as it dives into the pelvic fl oor musculature
(corresponding with the location of the majority of these low
rectal tumors). The anterior plane is the most challenging,
particularly below the anterior peritoneal refl ection
(see Fig.
10.8 ). Developing the posterior and lateral planes
fi rst allows for improved visualization of the proper anterior
plane of dissection. The use of multiple graspers to create
tissue tension helps fi nd the correct plane. Rigid sizers placed
in the vagina may help better retract and defi ne the rectovaginal septum dissection in women. The laparoscopic suction
irrigator is useful to remove smoke and fl uid and as a deep
pelvic retractor. Alternatively, there are cautery instruments
with side ports for smoke evacuation controlled by the surgeon with trumpet valves.
Dissection anteriorly begins with opening of the peritoneal refl ection in a horseshoe (i.e., upside down U) fashion.
Maintaining cephalad retraction on the distal sigmoid and
upper rectum allows the plane to be more easily delineated.
This anterior refl ection of the peritoneum is variable, though,
in general, the lower one-third of the rectum is without a
peritoneal covering. Just deep to this are the seminal vesicles
in men, characterized by their white tubular appearance.
Dissection continues caudally along the endopelvic fascia,
also referred to as Denonvilliers fascia, with identifi cation of
the smooth posterior border of the prostate gland. The
periprostatic plexus is located along this anterior dissection
(see Fig.
10.8 ). This plexus contains both sympathetic and
parasympathetic fi bers that innervate the prostate, prostatic
and membranous urethra, seminal vesicles, ejaculatory
ducts, and bulbourethral glands. The neurovascular bundles
are normally located anterolaterally along the pelvic sidewall
prior to joining the plexus. Damage to these nerves can result
in incomplete erection, lack of ejaculation, retrograde ejaculation, or complete impotence.
Controversy and differing opinions exist regarding the
proper plane of dissection anteriorly, as well as the exact
136
Fig. 12.5 Intracorporeal exposure ( a ) and ligation ( b ) of the inferior mesenteric/superior hemorrhoidal vessels
J.S. Davids and J.A. Maykel
Fig. 12.6 Dissection in the presacral plane. The white arrow indicates
the superior hemorrhoidal artery (ligated) in a patient with Crohn’s
proctitis. Hypogastric nerves are visible laterally
location of Denonvilliers fascia. Many surgeons feel that
Denonvilliers fascia is more adherent to the prostate than the
rectum. Therefore, dissection immediately on the fascia propria of the rectum in the plane of the TME will allow for
complete removal of an intact anterior mesorectum while
leaving Denonvilliers fascia on the prostate and avoiding
damage to the nerves. Others suggest that Denonvilliers fascia is more closely adherent to the rectum, without a plane
posterior to it. In this case, the fascia will be removed along
with the rectum during a standard TME dissection. In either
light, most colorectal surgeons are aware of the loose areolar
tissue immediately outside the fascia propria, providing
familiar territory for initial dissection. The choice distally
then remains whether to perform dissection on the rectal side
or prostatic side of Denonvilliers fascia and to understand the
potential consequences of each. Likely the optimal approach
is to dissect on the prostate and seminal vesicles for large
anterior tumors to minimize the risk of a positive anterior
margin. This comes with the obvious increased risk of nerve
damage. In women, a similar dissection should occur along
the posterior vaginal wall.
Division of the Sigmoid Colon and Ostomy Creation
The sigmoid colon is grasped and retracted toward the anterior abdominal wall, and a window is created in the mesentery that is suffi ciently large to accommodate the 45-mm or
60-mm blue-load laparoscopic stapler. Two fi rings may be
necessary to fully divide the colon. The remaining mesentery
between the colon and the superior hemorrhoidal vessels is
divided with the energy sealing device (Video 12.2 ). The
proximal end is grasped with a ratcheted grasper. A 19-French
round Jackson-Pratt drain is placed into the pelvis using the
right lower quadrant port site and can be sutured to the specimen to assure it is pulled down into the pelvis during specimen extraction through the perineal wound. The end is
brought through the abdominal wall at the right-sided port
and secured to the skin with a nylon suture. Insuffl ation is
maintained. The skin site for the ostomy is created centered
at the left lower quadrant 5-mm port. A ring of skin and subcutaneous tissue is cored out using electrocautery. ArmyNavy retractors are used for exposure. The anterior fascia is
incised with a cruciate incision, the rectus is splayed using a
large Kelly clamp, and the abdomen is entered by dividing
the posterior sheath and peritoneum in a cruciate fashion
using electrocautery. The proximal colon end is brought
through the abdominal wall. The 12-mm umbilical port site
is closed with a Vicryl suture through the fascia, and skin is
closed on all ports with 4–0 Monocryl and either Dermabond
or Mastisol and Steri-Strips. The staple line is excised from
the end of the colon, and the colostomy is matured with 3–0
Vicryl sutures in a Brooke fashion. The stoma appliance is
applied. Having completed the abdominal portion of the dissection, the team prepares for the perineal dissection.