Abstract: Objective:To explore the application value and clinical efficacy of the transanal specimen extraction via prolapsing approach in laparoscopic anterior resection for ultralow rectal cancer.
Methods:The clinical data of 27 patients with ultralow rectal cancer who underwent transanal specimen extraction via prolapsing approach in laparoscopic anterior resection for ultralow rectal cancer at the Shengjing Hospital of China Medical University from July 2010 to July 2013 were analyzed retrospectively. The average operation time, average volume of intraoperative blood loss, average number of lymph nodes dissection, average distance to resection margin, average length of resected specimen, results of postoperative pathological examination, time for postoperative outoffbed activity, time to anal exsufflation, gastric tube removal time and postoperative complications were recorded. The visual analogue scale (VSA) pain score and Wexner score for evaluating fecal incontinence were performed at postoperative week 1 and at postoperative month 1, respectively. The anal function was tested at postoperative month 3 and 12. The followup including tumor metastasis and recurrence, Wexner score and anorectal anometry was performed by outpatient examination and telephone interview once every 3 months for 2 years after operation and then once every year up to October 2014. Measurement data with normal distribution was presented as  ±s and average (range). Repeated measures data were analyzed by the repeated measures ANOVA.
ResultsAll the patients received successful operations without procedure change or intraoperative accident. The average operating time, average volume of intraoperative blood loss, average number of lymph nodes dissection, average distance to distal resection margin and average length of resected specimen were 140 minutes(range, 115-173 mintues), 27 mL(range, 15-55 mL), 17(range, 14-20), 1.7 cm(range, 1.3-2.2 cm) and 18.5 cm(range, 14.7-22.4 cm), respectively. Postoperative TNM stages: T2N0M0 was detected in 19 patients, T2N1M0 in 3 patients，T3N0M0 in 4 patients and T3N1M0 in 1 patients. The time for postoperative outoffbed activity and time to anal exsufflation were 8.8 hours (range, 7.0-13.0 hours) and 51 hours (range, 30- 79 hours). Twentyseven patients had the gastric tube removal after operation with fluid diet intake at postoperative hour 24 and semifluid diet intake at postoperative hour 48. One male patient was complicated with urinary retention at postoperative day 3 and 1 with anastomotic leakage at postoperative day 9, they were cured by symptomatic treatment. VSA pain scores in all patients from 1 day to 6 days postoperatively were 5.6, 4.6, 4.0, 3.2, 2.2 and 1.3. The average duration of hospital stay was 11.1 days (range, 7.0-19.0 days). Patients had good healing of abdominal incision at postoperative week 2. All the patients were followed up for a average time of 24.8 months (range, 15.0-32.0 months) without tumor metastasis and recurrence. Wexner score was 2.6 (range, 1.0-4.0) at postoperative month 1. The results of anorectal anometry: maximum anorectal resting pressure (MARP) and maximum anorectal systolic pressure were (267±23)mmHg (1 mmHg=0.133 kPa) and (305±23)mmHg before operation, (266±40)mmHg and (300±38)mmHg at postoperative month 3, (267±33)mmHg and (315±30)mmHg at postoperative month 12, respectively, with no significant difference in the changing trend between pre and postoperation (F=0.510, 1.390, P>0.05). Anorectal resting vector volume and anorectal systolic vector volume were (45 594±1 981)cm(mmHg)2 and (98 480±8 165)cm(mmHg)2 before operation, (40 310±3 465)cm(mmHg)2 and (78 461±6 777)cm(mmHg)2 at postoperative month 3, (40 385±3 379)cm(mmHg)2 and (82 082±10 383)cm(mmHg)2 at postoperative month 12, respectively, with significant differences in the changing trend between pre and postoperation (F=26.845, 48.090, P<0.05).
Conclusion:Transanal specimen extraction via prolapsing approach in laparoscopic anterior resection for ultralow rectal cancer is safe, aesthetic and minimally invasive compared with the traditional laparoscopic surgery, with the advantages of radical cure of tumor and protection of anal function.