Single-Incision Plus One Port Laparoscopic Total Pelvic Exenteration After Neoadjuvant Chemotherapy for Advanced Primary Rectal Cancer: A Case Report

Single-incision laparoscopic surgery (SILS) has been successfully introduced for colectomy.^1–5 Total pelvic exenteration (TPE) is the only curative procedure for T4 rectal cancer that directly invades the urinary or gynecologic tract.⁶ Cases of laparoscopic and robotic TPE for urologic or gynecologic malignancies have been reported,^7–10 and multiport laparoscopic TPE for advanced rectal cancer has been reported.¹¹ However, SILS plus 1 port (SILS+1) TPE for advanced primary rectal cancer has not been examined. In this report, we describe the SILS+1 TPE for advanced primary rectal cancer.

Patient and Methods

A 64-year-old man was referred to our hospital with anemia. Physical examination and urine and blood tests revealed hemoglobin of 5.7 g/dL. Computed tomography (CT) revealed a rectal tumor (Fig. 1a) that was contiguous with the seminal vesicle and bladder (Fig. 1b). Rectoscopy revealed an ulcerated, bleeding, and stricturing lesion in the rectum with 9 cm from anal verge, which was defined as an adenocarcinoma with a moderate degree of differentiation on histologic examination (Fig. 2). The level of carcinoembryonic antigen (CEA) was 25 ng/mL. The patient received neoadjuvant chemotherapy using capecitabine, oxaliplatin, and bevacizumab without radiotherapy. After 3 courses of chemotherapy, the patient had fecaluria. A rectovesical fistula was suspected from examination of CT images and magnetic resonance image (MRI). CT demonstrated intramural gas in the urinary bladder, which suggested a diagnosis of emphysematous cystitis (Fig. 3a). MRI demonstrated a rectovesical fistula (Fig. 3b). Thus, we constructed a transverse loop colostomy. Preoperative findings showed a rectal cancer with the staging of cT4bN2M0 stageIIIc. Two months after the last administration of chemotherapy, we performed SILS+1 TPE. This operation was performed by 2 colorectal surgeons who have experience of hundreds of laparoscopic operations.

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Surgical technique

The patient was placed in the Trendelenburg semiright lateral position under general anesthesia. The surgeon and cameraman stood on the right side of the patient. First, a Lap protector (LP; Hakko Co, Ltd, Tokyo, Japan) was inserted through a 35-mm incision in the right side of the umbilicus (using the urostomy site). Next, an EZ-access (Hakko) was mounted on the LP and three 5-mm ports were placed in the EZ-access. A 12-mm port was inserted into the right quadrant (Fig. 4). The operative procedures and instruments were the same as those for standard laparoscopic low anterior resection with a flexible 5-mm scope (Olympus Medical Systems Corp, Tokyo, Japan). Operations were performed using a surgical technique similar to the standard laparoscopic (medial-to-lateral) approach. The inferior mesenteric artery and the inferior mesenteric vein were both skeletonized and clipped and divided. Then, we dissected downwards from the mesenteric window to the pelvis on the right side of the rectum. The next step was to mobilize the sigmoid colon up to the splenic flexure. The descending colon and sigmoid colon was pulled anteromedially to clearly identify the left ureter. The rectum was posteriorly mobilized at first. The left ureter was dissected to the level of the ureterovesical junction, where it was clipped and divided. The same procedure was performed for the right ureter.

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The external iliac artery and vein were exposed at the lateral border of the lateral pelvic lymph node dissection. The hypogastric nerves were divided bilaterally at their bifurcations from the superior hypogastric plexus. The lymphatic tissue was dissected laterally along the surface of the internal obturator muscle, dorsally along the sciatic nerve, and down to the levator ani muscle. The obturator nerve and vessels were preserved. The surface of the internal iliac vein was exposed, and the superior and inferior vesical arteries were divided at their origins. The main trunk of the internal iliac artery was preserved. The planes of rectorectal and lateral dissection were connected with the dissection of the pelvic splanchnic nerves. The anterior bladder should always be dissected after transecting the lateral and posterior rectum. The reason is that because only 2 clamps are used in our SILS+1 TPE technique, we can use gravity traction by leaving the anterior anatomy until as late as possible.

Dorsal dissection was then performed in the avascular plane between the bladder and the parietal pelvic fascia. The dorsal dissection was carried out to the level of the levator ani muscle. The peritoneum was incised up to the medial umbilical ligaments, and the vas deferens was divided. Retzius' space and the paravesical space were opened to the level of the endopelvic fascia. In our SILS+1 TPE technique, the patient must be placed in the right lateral position when the left endopelvic fascia is incised because there is no traction by assistants. This allows us to use the gravity effectively and tract the bladder to the right side more easily, leading to the operation becoming easier. The puboprostatic ligament was divided, and the dorsal vein complex (DVC) was exposed. After transfixing ligation of the DVC with 2–0 vicryl intracorporeally, the urethra and DVC were divided (Fig. 5). The rectum was then transected normally using endoscopic linear stapler (Endo GIA; Covidien LLC, Mansfield, Massachusetts) with a purple cartridge inserted from the right lower quadrant 12-mm port. The specimen was retrieved and an ileal conduit reservoir was extracorporeally constructed through the incision in the right side of the umbilicus. An additional 10-mm incision was needed because of the size of the specimen. Total operating time was 751 minutes, and estimated blood loss was 1100 mL (including urine). The final operative view is shown in Fig. 6. Although postoperative urinary tract infection occurred, no postoperative anastomotic stenosis or hydronephrosis was observed.

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Discussion

The use of minimally invasive surgery is widely accepted, and the number of ports has been reduced to decrease parietal trauma and improve cosmetic results. Reports of SILS in colon and rectal surgery have recently emerged in the literature.^1–5 For T4b rectal cancer invading neighboring organs such as the bladder, laparoscopic surgery remains controversial.¹² Cases of laparoscopic and robotic TPE for urologic or gynecologic malignancies have been reported,^7–10 and multiport laparoscopic TPE for advanced rectal cancer has been reported.¹¹ Many surgeons have attempted to reduce the number of ports in laparoscopic surgery. Reduced port surgery aims to reduce the size and number of ports for preserving the view afforded by the laparoscope, while making the surgery less invasive. Some reports have successfully mentioned its advantages in reducing the number of laparoscopic ports, including better cosmetic results, reduced postoperative pain, and shorter recovery time.^13–17 To our knowledge, this is the first reported case of SILS+1 TPE for advanced rectal cancer.

In our institution, SILS for colon cancer and SILS+1 for rectal cancer following lateral pelvic lymph node dissection have been standardized. Almost all procedures were performed with an operator's 2 hands and a cameraman. We also have experience with multiport laparoscopic TPE. Also, complex procedures such as Boari flap were successfully performed with SILS (manuscript submitted). With regards to the TPE procedure, ligation of DVC is the critical point for TPE. In a reported case of multiport laparoscopic TPE, ligation of the DVC was performed under direct visualization.¹¹ In other reported cases, the DVC was ligated intracorporeally.^7–10 In these multiport or robotic surgeries, 3 or 4 arms made it possible to ligate the DVC in the fine operative field. In our SILS+1 TPE, ligation of DVC could be carried out intracorporeally with the surgeon's 2 arms, demonstrating the possible advantage of solo surgery. There is a merit in our SILS+1 TPE technique that because only 2 clamps are used, the operative field can be changed freely by the decision of the operator himself. However, at the same time, there is a demerit that there is no traction by assistants. Posture change and sequence of dissecting the structure become important to resolve this problem. We believe that by giving attention to the above two points, the natural anatomic position and gravity of the structure can be used effectively and the surgery can be performed with only 2 clamps.

Discussing a surgical time, blood loss, Kaufmann et al have reported that they performed robotic radical anterior pelvic exenteration in females in 12 patients, with a median total surgical time of 384 ± 90 minutes with median console and diversion times of 282 ± 54 and 150 ± 90 minutes respectively.⁹ Mukai et al performed multiport laparoscopic TPE and reported a surgical time of 831 minutes (including reconstruction of bilateral V–Y advancement of the gluteus maximus musculocutaneous flap, a blood loss of 600 mL.¹¹ Our results with SILS +1 TPE compare favorably with those of robotic or multiport laparoscopic TPE.

In the case of pelvic exenteration involving the anus, the specimen can be retrieved through the perineum scar site. However, the anal sphincter and anal canal could be preserved with a safe surgical margin in the present case, and we used the urostomy site for specimen retrieval and mounting the Lap protector. This technique offers the clear advantage that the final view appears to be almost “scarless.”

In conclusion, we have documented the safety and feasibility of SILS+1 TPE for advanced primary rectal cancer. This procedure is a technically promising alternative method for the treatment of selected patients with T4b rectal cancer. Further studies are needed to demonstrate the advantages of SILS+1 TPE over conventional laparoscopic surgery.