title: Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy.
abstract: OBJECTIVE
  Transanal minimally invasive surgery using single port instrumentation is now well described for the performance of total mesorectal excision with restorative colorectal/anal anastomosis most-often in conjunction with transabdominal multiport assistance. While non-restorative abdomino-endoscopic perineal excision of the anorectum is conceptually similar, it has been less detailed in the literature.
  
  
  METHODS
  Consecutive patients undergoing non-restorative ano-proctectomy including a transperineal endoscopic component were analysed. All cases commenced laparoscopically with initial medial to lateral mobilisation of any left colon and upper rectum. The lower anorectal dissection started via an intersphincteric or extrasphincteric incision for benign and malignant pathology, respectively, and following suture closure and circumferential mobilisation of the anorectum, a single port (GelPOINT Path, Applied Medical) was positioned allowing the procedure progress endoscopically in all quadrants up to the cephalad dissection level. Standard laparoscopic instrumentation was used. Specimens were removed perineally.
  
  
  RESULTS
  Of the 13 patients (median age 55 years, median BMI 28.75 kg/m2, median follow-up 17 months, 6 males), ten needed completion proctectomy for ulcerative colitis following prior total colectomy (three with concomitant parastomal hernia repair) while three required abdominoperineal resection for locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Median operative time was 190 min, median post-operative discharge day was 7. Eleven specimens were of high quality. Four patients developed perineal wound complications (one chronic sinus, two abscesses needing drainage) within median 17-month follow-up.
  
  
  CONCLUSIONS
  Convergence of transabdominal and transanal technology and technique allows accuracy in combination operative performance. Nuanced appreciation of transperineal operative access should allow specified standardisation and innovation.
authors.affiliation: Department of Colorectal Surgery, Mater Misericordiae University Hospital; Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland.
authors.forename: Hazar
authors.initials: H
authors.lastname: Al Furajii
authors.affiliation: Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
authors.forename: Niall
authors.initials: N
authors.lastname: Kennedy
authors.affiliation: Department of Colorectal Surgery, Mater Misericordiae University Hospital; Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland.
authors.forename: Ronan A
authors.initials: RA
authors.lastname: Cahill