Transperineal abdominoperineal resection in the prone jackknife position in male patients with low rectal cancer

INTRODUCTION

In male patients with low rectal cancer undergoing abdominoperineal resection (APR), successful dissection of the anterior anorectum is key to reducing the risk of circumferential resection margin involvement, intraoperative bowel perforation, and local recurrence, but it is challenging. To overcome difficulties dissecting the anterior anorectum, we present a safe and feasible procedure using a transperineal endoscopic approach during APR (TpAPR).

MATERIALS AND SURGICAL TECHNIQUE

The male patient is placed in the prone jackknife position. TpAPR precedes the procedure from an abdominal approach. We use some pelvic tissues as clear anatomical landmarks to dissect the anterior anorectum. The key steps of this procedure are shown in the video.

DISCUSSION

The identification of a clear anatomical dissection plane of the anterior anorectum is difficult because of the complex surgical anatomy of the region. Clear anatomical landmarks for dissection of the anterior anorectum are necessary for safe implementation of this procedure. Therefore, TpAPR in the prone jackknife position can be performed to obtain better visualization of each anatomical landmark at a glance.

Transanal total pelvic exenteration in the prone jackknife position for rectal cancer invading the bladder, seminal vesicles, and small intestine

A 58-year-old man had rectal cancer directly invading the urinary bladder and small intestine, without distant metastasis. We successfully performed complete resection using a hybrid approach, including laparoscopic surgery and transanal total pelvic exenteration (TaTPE) with the patient in the prone jackknife (PJK) position. In the PJK position, gravity and pelvic morphology lead to a clear and wide surgical field. This case demonstrates that total pelvic exenteration using laparoscopic surgery and TaTPE in the PJK position provides a better surgical field than either TaTPE or laparoscopic surgery in the supine position. TaTPE in the PJK position may also be useful for curative surgery in locally advanced rectal cancer.