64
EXTRALEVATOR ABDOMINOPERINEAL RESECTION(ELAPE) Dr.A.Joseph Stalin M.Ch PG PROF.DR.R.RAJARAMAN’S UNIT CENTRE FOR ONCOLOGY GOVT ROYAPETTAH HOSPITAL CHENNAI

Extralevator abdominoperineal resection(elape)

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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

THANK U helliphellipVIDEO TO FOLLOW

THANK U

THANK U