title: Endoscopically assisted extralevator abdominoperineal excision.
abstract: OBJECTIVE
  Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position.
  
  
  METHODS
  Three male patients with a rectal tumour located at the anorectal junction underwent an endoscopically assisted ELAPE in the lithotomy position after preoperative radiotherapy.
  
  
  RESULTS
  All the procedures were performed successfully with operation times of 180, 390 and 420 mins. There were no instances of intra-operative perforation or other complications. One patient developed postoperative intestinal obstruction which resolved on conservative management. There were no wound complications. Histopathological examination demonstrated clear margins and intact mesorectal planes in each patient.
  
  
  CONCLUSIONS
  We report a good outcome in three patients after endoscopically assisted ELAPE. This approach allows the patient to be operated on in the lithotomy position giving excellent views of the anterior dissection.
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: N C
authors.initials: NC
authors.lastname: Buchs
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: R
authors.initials: R
authors.lastname: Kraus
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: N J
authors.initials: NJ
authors.lastname: Mortensen
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: C
authors.initials: C
authors.lastname: Cunningham
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: B
authors.initials: B
authors.lastname: George
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: O
authors.initials: O
authors.lastname: Jones
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: R
authors.initials: R
authors.lastname: Guy
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: S
authors.initials: S
authors.lastname: Ashraf
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: I
authors.initials: I
authors.lastname: Lindsey
authors.affiliation: Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK.
authors.forename: R
authors.initials: R
authors.lastname: Hompes
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004210:Dissection / Q000379:methods*; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D006801:Humans; D008297:Male; D008488:Medical Illustration; D056888:Patient Positioning / Q000379:methods*; D010502:Perineum / Q000601:surgery*; D011187:Posture; D012004:Rectal Neoplasms / Q000601:surgery*; D016896:Treatment Outcome
keywords: Abdominoperineal excision; bottom up; endoscopy; extralevator; laparoscopy; transanal TME