Takashi Akiyoshi1, Toshiya Nagasaki2, Masashi Ueno2. 1. Department of Gastroenterological Surgery, Cancer Institute Hospital, Gastroenterological Center, Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan. takashi.akiyoshi@jfcr.or.jp. 2. Department of Gastroenterological Surgery, Cancer Institute Hospital, Gastroenterological Center, Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan.
Abstract
BACKGROUND: Extended surgery for locally recurrent rectal cancer is technically demanding because of the severe fibrosis around the tumor, which makes it difficult to achieve R0 resection. Although laparoscopic total pelvic exenteration has been carried out in patients with primary rectal cancer,1 (,) 2 to our knowledge ours is the first report of this laparoscopic procedure for locally recurrent rectal cancer. METHODS: A 70-year-old man who underwent laparoscopic low anterior resection for stage II rectal cancer was diagnosed as having two separate local recurrences near the anastomotic site. We decided to perform laparoscopic total pelvic exenteration after neoadjuvant chemoradiotherapy. The branches of the internal iliac vessels were carefully identified and divided. Presacral dissection behind the neorectum was carried out above the anastomotic site. Ligation of the dorsal vein complex was performed under direct visualization, with the patient in the jack-knife position. The perineal defect was reconstructed using a bilateral V-Y advancement of the musculocutaneous flaps of the gluteus maximus. An ileal conduit was constructed extracorporeally via an umbilical incision, after placing the patient in the lithotomy position. RESULTS: The total operative time was 18 h and 5 min, with an estimated blood loss of 750 mL. Final pathology showed negative resection margins. CONCLUSIONS: Laparoscopic total pelvic exenteration for locally recurrent rectal cancer is a technically challenging procedure requiring a long operative time. However, as demonstrated by this case, it can provide a very clear view of the operative field, allowing precise dissection, less blood loss, and a smaller abdominal wound.
BACKGROUND: Extended surgery for locally recurrent rectal cancer is technically demanding because of the severe fibrosis around the tumor, which makes it difficult to achieve R0 resection. Although laparoscopic total pelvic exenteration has been carried out in patients with primary rectal cancer,1 (,) 2 to our knowledge ours is the first report of this laparoscopic procedure for locally recurrent rectal cancer. METHODS: A 70-year-old man who underwent laparoscopic low anterior resection for stage II rectal cancer was diagnosed as having two separate local recurrences near the anastomotic site. We decided to perform laparoscopic total pelvic exenteration after neoadjuvant chemoradiotherapy. The branches of the internal iliac vessels were carefully identified and divided. Presacral dissection behind the neorectum was carried out above the anastomotic site. Ligation of the dorsal vein complex was performed under direct visualization, with the patient in the jack-knife position. The perineal defect was reconstructed using a bilateral V-Y advancement of the musculocutaneous flaps of the gluteus maximus. An ileal conduit was constructed extracorporeally via an umbilical incision, after placing the patient in the lithotomy position. RESULTS: The total operative time was 18 h and 5 min, with an estimated blood loss of 750 mL. Final pathology showed negative resection margins. CONCLUSIONS: Laparoscopic total pelvic exenteration for locally recurrent rectal cancer is a technically challenging procedure requiring a long operative time. However, as demonstrated by this case, it can provide a very clear view of the operative field, allowing precise dissection, less blood loss, and a smaller abdominal wound.