A 73-year-old male presented with a local recurrence for rectal cancer. Initially, the patient had a cT4N1 3 cm from the anal verge, received neoadjuvant treatment and underwent a transanal intersphincteric resection (ypT3N0). No adjuvant treatment was indicated. A year later he presented with a pulmonary metastatic nodule, which was resected followed by chemotherapy. Three years later, a perianal nodule below the anastomosis was detected, associated with elevated CEA levels, positive imaging, and positive pathology for malignancy. An abdominoperineal resection by a two-team approach (Cecil approach) was then indicated.
The patient is placed in the lithotomy position, and a Foley catheter is inserted. First the anus is closed and the perianal skin is scored circumferentially with a cautery. Extraelevator dissection is not performed in our center. The dissection is continued from the skin into the subcutaneous tissue circumferentially, creating a skin flap to place the Lonestar retractor. Further open resection is carried out through the fatty tissue in order to create enough space for the transanal platform to sit. At this point, a purse-string is created along the skin border so that, whenever the transanal platform is placed, the perianal skin can be adjusted around the platform. A continuous running silk suture is used, removing the Lonestar as the purse-string progresses.
Different transanal platforms are available. For abdominoperineal resections, a plastic flexible platform may adjust more adequately to the skin, tying the purse-string around it (GelPOINT mini®, Applied Medical, Inc). Trocars are placed on the gel platform lid, one of them for the continuous flow insufflation device (Airseal®, Conmed). The lid is adjusted onto the transanal platform and a pneumorectum is created. A laparoscopic 3D flexible tip camera, a hook cautery and a grasper are used through the transanal platform in order to continue the mesorectal dissection.
Operative time was 150 minutes. The post-operative period was uneventful and the patient was discharged on 4th post-operative day.
In conclusion, the transanal approach to abdominoperineal resection is a safe and feasible technique in our experience. Technical steps are critical in order to perform this technique transanally as the available instruments are adapted for the procedure.