Extralevator abdominoperineal resection in the prone position.
The Miles operation is every day more in the limelight. The abdominoperineal resection compared to anterior resection results in increased rate of circumferential resection margin (CRM) infiltration, increased iatrogenic tumor perforation rate and poorer quality of the mesorectum. These worse results may be caused by excessive dissection between the distal mesorectum and the plane of the levator ani and the consequent "resection waist" or "cone" effect in the specimen. A wider excision of the pelvic floor muscles, known as extraelevator abdominoperineal resection (ELAPE), would provide a "cylindrical" specimen which would hypothetically reduce the risk of tumor perforation and CRM infiltration and local recurrence rate. However, there is insufficient evidence to conclude that the ELAPE is oncologically superior compared to standard abdominoperineal resection. Independently from the surgical technique adopted, another actual point of discussion is the position of the patient during the perineal part of the operation. The position on "prone" provides excellent pelvic exposure, a top-down dissection under direct vision and is very comfortable for the operating surgeons. However, there is no clear scientific evidence of the superiority of prone ELAPE over supine ELAPE in terms of oncologic results, morbidity and mortality. The laparoscopy seems to be the best surgical approach for the abdominal part of the operation, although it has not been validated so far by large prospective studies. Prospective, controlled and randomized trials are necessary to resolve all these issues. The current interest in a more accurate and standardized perineal surgery to obtain a cylindrical specimen, undoubtedly, will improve results.
Unidad de Cirugía Digestiva, Servicio de Cirugía General, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España. Electronic address: blasflor@hotmail.com.
Blas
B
Flor-Lorente
Unidad de Cirugía Digestiva, Servicio de Cirugía General, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España.
Matteo
M
Frasson
Unidad de Cirugía Digestiva, Servicio de Cirugía General, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, España.
Erick
E
Montilla
D000005:Abdomen; D013505:Digestive System Surgical Procedures / Q000379:methods; D006801:Humans; D056888:Patient Positioning; D010502:Perineum / Q000601:surgery*; D016684:Prone Position; D012004:Rectal Neoplasms / Q000601:surgery*
Amputación abdominoperineal extraelevadora; Circumferential resection margin; Cáncer de recto; Extralevator abdominoperineal resection; Iatrogenic tumor perforation; Local recurrence; Margen circunferencial de resección; Miles; Morbidity; Morbimortalidad; Mortality; Perforación tumoral iatrógena; Prone; Prono; Recidiva local; Rectal cancer; Supine; Supino