title: Transperineal minimally invasive approach for extralevator abdominoperineal excision.
abstract: Recently, the efficiency of transanal minimally invasive surgery (TAMIS) for rectal cancer has been demonstrated (Velthuis et al. in Surg Endosc 28:3494-3499, 2014; Fernandez-Hevia in Ann Surg 261:221-227, 2015; Atallah et al. in Tech Coloproctol 18:473-480, 2014). We present our procedure of TAMIS for extralevator abdominoperineal excision (ELAPE) (Holm et al. in Br J Surg 94:232-238, 2007).
  
  
  
  The patient had a rectal cancer located 4 cm from the anal verge with suspected invasion of the levator ani (cT4bN0M0). A skin incision was made around the tightly closed anus, and a GelPOINT device was placed. The fat tissue of the ischioanal fossa was divided until the levator ani muscle was widely exposed. Anterior dissection was performed just behind the transverse perineal muscle, and the arms of the puborectalis sling were identified at 1 and 11 o'clock. The levator muscle was divided from the posterior to bilateral sides, and dissection was entered into the mesorectal plane. Posterior dissection was performed until the sacral promontory was reached. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o'clock positions, and special care was taken to preserve them. At the anterior side, the arms of the puborectalis sling and perineal body were divided. Special care should be taken to avoid inadvertent injury to the anterior tissues (urethra or prostate) because the dissection tends to go toward the anterior-lateral side of the prostate in this approach. Once the dissection plane behind the prostate was established, it was easy to dissect the mesorectum circumferentially while preserving the pelvic autonomic nerves. Vascular division, mobilization of left colon and stoma creation were performed laparoscopically.
  
  
  
  This approach provides better exposure of the surgical field, especially at the anterior side, compared with the conventional perineal approach of ELAPE. Since January 2014, we have performed seven cases using this procedure. There was no conversion to the conventional approach, and no major complication was encountered.
  
  
  
  TAMIS is a promising approach for the perineal phase of ELAPE.
authors.affiliation: Department of Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo, Kyoto-city, Kyoto-fu, 606-8507, Japan. shase@kuhp.kyoto-u.ac.jp.
authors.forename: Suguru
authors.identifier: 0000-0002-8641-8197
authors.initials: S
authors.lastname: Hasegawa
authors.affiliation: Department of Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo, Kyoto-city, Kyoto-fu, 606-8507, Japan.
authors.forename: Tomoaki
authors.initials: T
authors.lastname: Okada
authors.affiliation: Department of Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo, Kyoto-city, Kyoto-fu, 606-8507, Japan.
authors.forename: Koya
authors.initials: K
authors.lastname: Hida
authors.affiliation: Department of Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo, Kyoto-city, Kyoto-fu, 606-8507, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Kawada
authors.affiliation: Department of Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo, Kyoto-city, Kyoto-fu, 606-8507, Japan.
authors.forename: Yoshiharu
authors.initials: Y
authors.lastname: Sakai
mesh_terms: D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D017776:Autonomic Pathways; D003106:Colon; D003125:Colostomy / Q000379:methods*; D013505:Digestive System Surgical Procedures / Q000379:methods; D004210:Dissection / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008646:Mesocolon / Q000601:surgery; D059351:Organ Sparing Treatments; D017773:Pelvic Floor / Q000601:surgery*; D010502:Perineum / Q000601:surgery; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D054047:Surgical Stomas; D000067368:Transanal Endoscopic Surgery / Q000379:methods*
keywords: Abdominoperineal excision; Rectal cancer; Transperineal approach