Laparoscopic Procedures: Laparoscopic Abdominoperineal Resection
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Abdominoperineal resection (APR) of the rectum remains the standard treatment for a substantial proportion of patients with tumors of the lower third of the rectum. This procedure is ideally suited to the laparoscopic approach, with the specimen evacuated through the perineum avoiding the need for a large abdominal retrieval wound. There is evidence to indicate that laparoscopic APR may enable a reduction in resection margin involvement compared with open surgery. Mobilization of the rectum is performed using the same laparoscopic method as laparoscopic total mesorectal excision; however, the mesorectal dissection is stopped at the level of the origins of the levator ani muscles. Following this a colostomy is created and the perineal dissection performed with wide division of the levator muscles at their origins (Extra-Levator APR). The specimen is then evacuated through the perineum. Reconstruction of the perineum fills the tissue defect left at the level of the levators and can reduce complications such as perineal hernia and wound dehiscence. Options for reconstruction include tissue flaps and biologic mesh. Multidisciplinary team management within an enhanced recovery program should be the standard for perioperative care, with early mobilization and minimization of the stress response to surgery optimizing the benefits offered by laparoscopy.
KeywordsRectal cancer Laparoscopy Abdominoperineal resection Abdominoperineal excision ELAPE ELAPR
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