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Single port-assisted fully laparoscopic abdominoperineal resection (APR) with immediate V-RAM flap reconstruction of the perineal defect


Abdominoperineal resection (APR) of anorectal cancers after neoadjuvant chemoradiotherapy may incur significant perineal morbidity. While vertical rectus abdominis muscle (V-RAM) flaps can fill the pelvic resection space with health tissue, their use has previously been described predominantly in association with laparotomy. Here, we describe a means of combination laparoscopic APR with V-RAM flap reconstruction that allows structural preservation of the entire abdominal wall throughout the oncological resection and of the deep parietal layers after V-RAM donation. Furthermore, a single port access device used at the end colostomy site allows a second senior surgeon assist with an additional two working instruments for the purpose of improved pelvic tissue retraction, especially useful in obese patients.

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  1. Chadwick MA, Vieten D, Pettitt E, Dixon AR, Roe AM (2006) Short course preoperative radiotherapy is the single most important risk factor for perineal wound complications after abdominoperineal excision of the rectum. Colorectal Dis 8:756–761

    PubMed  Article  CAS  Google Scholar 

  2. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA (2005) Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 48:438–443

    PubMed  Article  Google Scholar 

  3. Wiatrek RL, Thomas JS, Papconstantinou HT (2008) Perineal wound complications after abdominoperineal resection. Clin Colon Rectal Surg 21:76–86

    PubMed  Article  Google Scholar 

  4. Taylor GI, Corlett R, Boyd JB (1983) The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 72(6):751–765

    PubMed  Article  CAS  Google Scholar 

  5. Lefevre JH, Parc Y, Kernéis S, Shields C, Touboul E, Chaouat M, Tiret E (2009) Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneous flap on survival, recurrence, morbidity, and wound healing. Ann Surg 250:707–711

    PubMed  Article  Google Scholar 

  6. Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J et al (2005) Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 12:104–110

    PubMed  Article  Google Scholar 

  7. Horch RE, D’Hoore A, Holm T, Kneser U, Hohenberger W, Arkudas A (2012) Laparoscopic abdominoperineal resection with open posterior cylindrical excision and primary transpelvic VRAM flap. Ann Surg Oncol 19:502–503

    Google Scholar 

  8. Hompes R, Lindsey I, Jones O, Guy R, Cunningham C, Mortensen N et al (2011) Step-wise integration of single-port laparoscopic surgery into routine colorectal surgical practice by use of a surgical glove port. Tech Coloproctol 15:165–171

    Google Scholar 

  9. Jefferies MT, Evans MD, Hilton J, Chandrasekaran T, Beynon J, Khot U (2011) Oncological outcome after laparoscopic abdominoperineal excision of the rectum. Colorectal Dis. doi:10.1111/j.1463-1318.2011.02882.x

  10. Liang JT, Lai HS, Lee PH (2006) Multimedia article. Laparoscopic abdominoperineal resection for lower rectal cancers: how do we do it? Surg Endosc 20:695–696

    PubMed  Article  Google Scholar 

  11. Ng SS, Leung KL, Lee JF, Yiu RY, Li JC, Teoh AY et al (2008) Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial. Ann Surg Oncol 15:2418–2425

    PubMed  Article  Google Scholar 

  12. Koh DC, Law CW, Kristian I, Cheong WK, Tsang CB (2010) Hand-assisted laparoscopic abdomino-perineal resection utilizing the planned end colostomy site. Tech Coloproctol 14:201–206

    PubMed  Article  CAS  Google Scholar 

  13. Cahill RA, Lindsey I, Jones O, Guy R, Mortensen N, Cunningham C (2010) Single-port laparoscopic total colectomy for medically uncontrolled colitis. Dis Colon Rectum 53:1143–1147

    PubMed  Article  Google Scholar 

  14. Borowski DW, Kanakala V, Agarwal AK, Tabaqchali MA, Garg DK et al (2011) Single-port access laparoscopic reversal of Hartmann operation. Dis Colon Rectum 54:1053–1056

    PubMed  Article  CAS  Google Scholar 

  15. Baig N, Moftah M, Deasy J, McNamara D, Cahill RA (2012) Implementation and usefulness of single access laparoscopic segmental and total colectomy. Colorectal Dis [Epub ahead of print]

  16. Lauritsen ML, Bulut O (2012) Single-port access laparoscopic abdominoperineal resection through the colostomy site: a case report. Tech Coloproctol 16:175–177

    Google Scholar 

  17. Singh B, Lloyd G, Nilsson PJ, Chaudhri S (2012) Laparoscopic extralevator abdominal perineal excision of the rectum: the best of both worlds. Tech Coloproctol 16:73–75

    PubMed  Article  CAS  Google Scholar 

  18. Vaughan-Shaw PG, King AT, Cheung T, Beck NE, Knight JS et al (2011) Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting: analysis of short-term outcomes and quality of life. Ann R Coll Surg Engl 93:451–459

    PubMed  Article  CAS  Google Scholar 

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The authors declare no conflict of interest.

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Correspondence to Ronan A. Cahill.

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Ali, S., Moftah, M., Ajmal, N. et al. Single port-assisted fully laparoscopic abdominoperineal resection (APR) with immediate V-RAM flap reconstruction of the perineal defect. Updates Surg 64, 217–221 (2012).

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  • Anorectal cancer
  • Laparoscopic abdominoperineal resection
  • Single port laparoscopy
  • Vertical rectus abdominis muscle (V-RAM) flap