VM66 - Laparoscopic APR with Posterior Vaginectomy and Colonic Flap Reconstruction for Locally Advanced Rectal Cancer

Purpose/Background: Strategies for curatively managing locally advanced rectal cancer were multimodality treatment. Still, Surgery is the mainstay of curative treatment, which is technically a challenge in those with invasive disease. To achieve R0 resection and the best oncological outcome, extensive procedure may be required, and complex reconstruction is needed with the least complication.
This video demonstrates the laparoscopic approach of abdominoperineal resection with posterior vaginectomy and colonic flap reconstruction for locally advanced rectal cancer with posterior vaginal involvement.

Methods/Interventions: A 69-year-old woman came with mucous-bloody stool and a change in bowel habits. On examination, we found a rectal mass involving the posterior wall of the vagina. Pathological confirmed adenocarcinoma of the rectum. Diverting left-side transverse colostomy was performed, and definite surgery was performed 10 weeks after completion of neoadjuvant concurrent chemoradiation. The descending colon distal to the stoma was planned to use as colonic flap vaginal reconstruction.
The laparoscopic approach surgery was started with medial to lateral sigmoid mobilization. Skeletonized the IMA root for the lymph node harvested, and low ligation of IMA was performed, preserving the left colic and sigmoidal branch. Rectal mobilization was performed respecting the TME plane on the posterior and both lateral sides—cautious dissection on the anterior rectal dissection at the cervix level. Tumor involvement was identified, and posterior vaginal dissection was performed above the level of invasion. The descending colon segment, which supply by the sigmoidal artery, was divided from the stoma and rectosigmoid colon. Indocyanin Green was injected to confirm the good perfusion to the colonic segment.
The perineal phase starts with an elliptical perianal incision, including the perineal body and posterior vaginal opening. Ischiorectal tissue and levator were dissected until connected with previously laparoscopic dissection at the posterior and lateral sides. Exposed the posterior vaginal wall and connected the vaginal dissection from laparoscopy, the gross margin of vaginal involvement was visualized. The colonic reconstruction was performed. First, we extract the prepared colonic segment through the perineal defect, and partially colotomy with longitudinal fashion. Suture the colonic wall to the remnant vaginal wall starting with the angular stitch, which will act as the distal part of the neo-vaginal canal. The perineal defect was repaired layer by layer, from the levator muscle to the perineal skin. Lastly, ICG-enhanced fluorescence imaging was performed to ensure good perfusion to the neo-vagina.

Results/Outcomes: The postoperative was uneventful, and the patient was discharged on postoperative day 7. Pathological results show rectal adenocarcinoma invading vaginal epithelium (ypT4b) with free all resection margins. There was no recurrence of the disease detected in 1-year follow-up.

Conclusion/Discussion: Extensive and complex reconstructions for locally advanced rectal cancer are feasible with promising oncological results. Combining Indocyanin Green-enhanced fluorescence imaging with the complex reconstruction may reassure surgical results. Long-term oncological outcomes and the functioning of neo-vaginal reconstruction should be observed.