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EXTRALEVATOR ABDOMINOPERINEAL
RESECTION(ELAPE)
DrAJoseph Stalin MCh PG
PROFDRRRAJARAMANrsquoS UNITCENTRE FOR ONCOLOGY
GOVT ROYAPETTAH HOSPITALCHENNAI
CONTENTS
bull CONCEPT OF ELAPE
bull SURGICAL TECHNIQUE
bull MERITSDEMERITS
bull EVIDENCE BASED MEDICINE IN ELAPE
bull VIDEO
ELAPE- HISTORY
bull First successful rectal excision by Jacques Lisfranc ndash 1826 ndashperineal approach
bull Next 70 ndash 80 yrs rectal cancer treated through perinealapproach with high morbidity and local recurrance
bull 1908 ndash Earnest Miles described Abdomino perinealexcision(APE)
MILES CONCEPT
bull After a decade-long audit of his rectal resections he noted a local recurrance rate of over 95 within 1ndash3 years
bull He described ldquothree zones of local spreadrdquo from rectal cancers
-Downward to perianal skin
-Lateral along levator ani and internal iliac nodes
-Upward corresponding with proximal lymphatic drainage to the mesocolon
bull When performing the operation the abdominal phase is performed first with the patient in lsquoan exaggerated Trendelenburg posturersquo
bull Once a laparotomy has been performed via a median incision a loop colostomy is fashioned in the left iliac fossawith the apex of the sigmoid colon
bull The sigmoid colon is then divided about 2 inches distal to the stoma site (thus creating a loop sigmoid colostomy with a blind ending distal portion)
bull The lsquopelvic colonrsquo (sigmoid colon) is then mobilized and the inferior mesenteric artery is divided below the sigmoid branches
bull Attention then turns to the rectal mobilization and lsquothe remainder of the operation is now practically bloodless and should be rapidly proceeded withrsquo
bull The anterior and posterior rectal mobilization is done bluntly whereas the lsquolateral ligaments of the rectum are divided with scissorrsquo
bull The rectal mobilization continues lsquodown to the upper surface of the levatores anirsquo
bull The abdominal cavity is then lavaged with saline and closed
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
CONTENTS
bull CONCEPT OF ELAPE
bull SURGICAL TECHNIQUE
bull MERITSDEMERITS
bull EVIDENCE BASED MEDICINE IN ELAPE
bull VIDEO
ELAPE- HISTORY
bull First successful rectal excision by Jacques Lisfranc ndash 1826 ndashperineal approach
bull Next 70 ndash 80 yrs rectal cancer treated through perinealapproach with high morbidity and local recurrance
bull 1908 ndash Earnest Miles described Abdomino perinealexcision(APE)
MILES CONCEPT
bull After a decade-long audit of his rectal resections he noted a local recurrance rate of over 95 within 1ndash3 years
bull He described ldquothree zones of local spreadrdquo from rectal cancers
-Downward to perianal skin
-Lateral along levator ani and internal iliac nodes
-Upward corresponding with proximal lymphatic drainage to the mesocolon
bull When performing the operation the abdominal phase is performed first with the patient in lsquoan exaggerated Trendelenburg posturersquo
bull Once a laparotomy has been performed via a median incision a loop colostomy is fashioned in the left iliac fossawith the apex of the sigmoid colon
bull The sigmoid colon is then divided about 2 inches distal to the stoma site (thus creating a loop sigmoid colostomy with a blind ending distal portion)
bull The lsquopelvic colonrsquo (sigmoid colon) is then mobilized and the inferior mesenteric artery is divided below the sigmoid branches
bull Attention then turns to the rectal mobilization and lsquothe remainder of the operation is now practically bloodless and should be rapidly proceeded withrsquo
bull The anterior and posterior rectal mobilization is done bluntly whereas the lsquolateral ligaments of the rectum are divided with scissorrsquo
bull The rectal mobilization continues lsquodown to the upper surface of the levatores anirsquo
bull The abdominal cavity is then lavaged with saline and closed
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
ELAPE- HISTORY
bull First successful rectal excision by Jacques Lisfranc ndash 1826 ndashperineal approach
bull Next 70 ndash 80 yrs rectal cancer treated through perinealapproach with high morbidity and local recurrance
bull 1908 ndash Earnest Miles described Abdomino perinealexcision(APE)
MILES CONCEPT
bull After a decade-long audit of his rectal resections he noted a local recurrance rate of over 95 within 1ndash3 years
bull He described ldquothree zones of local spreadrdquo from rectal cancers
-Downward to perianal skin
-Lateral along levator ani and internal iliac nodes
-Upward corresponding with proximal lymphatic drainage to the mesocolon
bull When performing the operation the abdominal phase is performed first with the patient in lsquoan exaggerated Trendelenburg posturersquo
bull Once a laparotomy has been performed via a median incision a loop colostomy is fashioned in the left iliac fossawith the apex of the sigmoid colon
bull The sigmoid colon is then divided about 2 inches distal to the stoma site (thus creating a loop sigmoid colostomy with a blind ending distal portion)
bull The lsquopelvic colonrsquo (sigmoid colon) is then mobilized and the inferior mesenteric artery is divided below the sigmoid branches
bull Attention then turns to the rectal mobilization and lsquothe remainder of the operation is now practically bloodless and should be rapidly proceeded withrsquo
bull The anterior and posterior rectal mobilization is done bluntly whereas the lsquolateral ligaments of the rectum are divided with scissorrsquo
bull The rectal mobilization continues lsquodown to the upper surface of the levatores anirsquo
bull The abdominal cavity is then lavaged with saline and closed
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
MILES CONCEPT
bull After a decade-long audit of his rectal resections he noted a local recurrance rate of over 95 within 1ndash3 years
bull He described ldquothree zones of local spreadrdquo from rectal cancers
-Downward to perianal skin
-Lateral along levator ani and internal iliac nodes
-Upward corresponding with proximal lymphatic drainage to the mesocolon
bull When performing the operation the abdominal phase is performed first with the patient in lsquoan exaggerated Trendelenburg posturersquo
bull Once a laparotomy has been performed via a median incision a loop colostomy is fashioned in the left iliac fossawith the apex of the sigmoid colon
bull The sigmoid colon is then divided about 2 inches distal to the stoma site (thus creating a loop sigmoid colostomy with a blind ending distal portion)
bull The lsquopelvic colonrsquo (sigmoid colon) is then mobilized and the inferior mesenteric artery is divided below the sigmoid branches
bull Attention then turns to the rectal mobilization and lsquothe remainder of the operation is now practically bloodless and should be rapidly proceeded withrsquo
bull The anterior and posterior rectal mobilization is done bluntly whereas the lsquolateral ligaments of the rectum are divided with scissorrsquo
bull The rectal mobilization continues lsquodown to the upper surface of the levatores anirsquo
bull The abdominal cavity is then lavaged with saline and closed
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull When performing the operation the abdominal phase is performed first with the patient in lsquoan exaggerated Trendelenburg posturersquo
bull Once a laparotomy has been performed via a median incision a loop colostomy is fashioned in the left iliac fossawith the apex of the sigmoid colon
bull The sigmoid colon is then divided about 2 inches distal to the stoma site (thus creating a loop sigmoid colostomy with a blind ending distal portion)
bull The lsquopelvic colonrsquo (sigmoid colon) is then mobilized and the inferior mesenteric artery is divided below the sigmoid branches
bull Attention then turns to the rectal mobilization and lsquothe remainder of the operation is now practically bloodless and should be rapidly proceeded withrsquo
bull The anterior and posterior rectal mobilization is done bluntly whereas the lsquolateral ligaments of the rectum are divided with scissorrsquo
bull The rectal mobilization continues lsquodown to the upper surface of the levatores anirsquo
bull The abdominal cavity is then lavaged with saline and closed
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull Attention then turns to the rectal mobilization and lsquothe remainder of the operation is now practically bloodless and should be rapidly proceeded withrsquo
bull The anterior and posterior rectal mobilization is done bluntly whereas the lsquolateral ligaments of the rectum are divided with scissorrsquo
bull The rectal mobilization continues lsquodown to the upper surface of the levatores anirsquo
bull The abdominal cavity is then lavaged with saline and closed
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull The patient is now placed in the right lateral position lsquoso that the perineal portion of the operation can be proceeded withrsquo
bull An incision is made from the sacro-coccygeal joint to within an inch of the anus
bull A semicircular incision is then made around the anus in such a manner as to take a wide area of skin and fat
bull The coccyx is removed and the levatores lsquodivided as far outward as their origin from the white linersquo
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull Any residual attachments of the rectum to the sacrum or vaginaprostate are divided and the specimen is removed
bull The lsquochasmrsquo is then irrigated with saline and the skin closed over two drains
bull The patient is then placed in the supine position and lsquoa small opening is made into the extruded bowel to allow of the escape of flatusrsquordquo
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis
bull For a large part of the rest of the century Milesrsquo APE with or without lithotomy positioning remained the gold standard
bull Local recurrance rate around 15
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
TME CONCEPT
bull Based on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence
Encompasses
bull Excision of complete mesorectum in mid and lower third cancers ndash down to the pelvic floor
bull Complete CRM clearance by sharp dissection
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
Heald RJ Husband EM Ryall RDH The mesorectum in rectal cancer surgery the clue to pelvic recurrence Br J Surg
198269613-616
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm Martling et al Lancet 2000
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
21 st Century
bull The use of mechanical stapling devices
bull Increasing knowledge of patterns of spread with acceptance of smaller distal margins
bull Development of neoadjuvant therapies and
bull Application of local excision and transanal endoscopic microsurgery have led to
bull Sphincter-sparing surgery becoming a priority after oncologicalsafety for most rectal cancers
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull APR is performed in less than 15 of cases
bull INDICATION
Invasion of external sphincter
Low AR cannot be done
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE
bull APE is associated with higher rates of circumferential resection margin involvement local recurrence and reduced cancer specific survival
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
Problem with lower rectal cancer
bull Absence of mesorectal margin ldquocushionrdquo
bull Difficult technical dissection due to lack of planes
bull High positive radial margin rate (~36) for distal third rectal location
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull Universal Problem ndash Distal Third Location Dutch TME trial
AR APR
bull Positive margins 107 304
bull Perforations 25 137
bull Survival 576 385
bull Nagtegaal et al J Clin Oncol 2005 239257
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
ELAPE ndash the Solution
Br J Surg 2007 Feb94(2)232-8
bull Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer
bull Holm T1 Ljung A Haumlggmark T Jurell G Lagergren J
bull Abstractbull BACKGROUNDbull Intraoperative tumour perforation positive tumour margins wound complications and local
recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients
bull Between 2001 and 2005 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital
bull CONCLUSIONbull The extended posterior perineal approach with gluteus maximus flap reconstruction in APR
has a low risk of bowel perforation CRM involvement and local perineal wound complications The rate of local recurrence may be lower than with conventional APR
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
SURGICAL TECHNIQUE
-Principle
-Abdominal phase
-Perineal phase
-Reconstruction
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
PRINCIPLES OF SURGERYbull Extend of resection is that of described by Miles but by
employing TME principles
bull Levator muscles are excised enbloc with mesorectumlower rectum amp anus
bull Thereby avoiding lsquo waist of the specimenrsquo seen in conventional APR
bull Purpose To reduce bowel perforation and
CRM(circumferential margin positivity)
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
AELAPE(Cylindrical APR)
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
APR ELAPE
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
ABDOMINAL PHASE
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull In APR mesorectum is mobilised upto the pelvic floor
bull In ELAPE mesorectal mobilisation is limited
Dorsally sacrococcygeal junction
Ventrally seminal vesicles(male)cervix(female)
Laterally lateral ligament
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
PERINEAL PHASE
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
Prone Jack knife vs Supine lithotomy
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
Prone position preferred
bull Pros Improved visibility easier retraction by assistantreduced perforationreduced CRM positivity
bull Cons long operative time as patient position needs to be changed
Unable to perform rectus or gracilis transfer
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
PERINEAL PHASE
bull Anus closed with purse string suture
bull Tear drop incision made encircling anus unto tip of cocyx
bull External sphincter identified and dissection continued outside levator muscle
bull Levator muscles are followed until their origin in pelvic sidewall (white line)
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
INCISION
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
bull Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx
bull Pelvic floor is divided (levator)
bull Dissection continues anteriorly onto the prostate vagina
bull Cylindrical specimen is excised
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
ELAPE in supine position
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
RECONSTRUCTION
bull Primary closure +- omentoplasty
bull Rotation advancement flaps
Gluteus gracilis rectus
bull Free flaps
bull MeshProlene PTFE (Goretex)Biologic
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
GLUTEUS FLAP
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
GRACILIS FLAP
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
RECTUS ABDOMINUS FLAP
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
BIOLOGICAL MESH
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
MERITS
bull Good visualisation anterior structures with plane easily seen and dissected
bull Easy control of bleeders
bull Decreased perforation rate
bull One surgeon
bull Easy to teach
bull Easy to assist
bull Perineal operator does not get wet
bull Possibly less blood loss
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
DEMERITS
bull Learning curve as to how far to dissect into the pelvis
bull Unaccustomed plane
bull Coccygeal division leaves bare bone in a potentially contaminated field
bull No further access to abdomen during the perineal dissection
bull No difference in anteriorposterior margin only lateral margin clearance is increased
bull Perineal wound complications
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
EVIDENCE BASED MEDICINE
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
APR ELAPE
POSITION SUPINE SUPINE +- PRONE
ABDOMINAL PHASE TME UPTO PELVIC FLOOR
TME SHORT OF PELVIC FLOOR
PERINEAL PHASE EXTERNAL SPHINCTERREMOVED
LEVATOR ANI REMOVED COMPLETELY
WOUND COMPLCATION
LESS HIGH
CRM POSITIVITY HIGH LESS
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
CONCLUSION
bull Technique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer
bull Decision to perform ELAPE is taken preoperatively not intraoperatively
bull Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incision
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U
CONCLUSION
bull Accepted and practised mainly in Europe still not accepted in USA
bull Initial studies have shown promosing results
bull Large scale RCT needed to accept ELAPE as the gold standard
THANK U helliphellipVIDEO TO FOLLOW
THANK U