Perineal or Abdominal Approach First During Intersphincteric Resection for Low Rectal Cancer: Which Is the Best Strategy?

Background: Intersphincteric resection during total mesorectal excision for low rectal cancer can be performed through a primary abdominal or a primary perineal approach.

Objective: The purpose of this study was to compare the results of a primary perineal approach with those of a primary abdominal approach in patients undergoing laparoscopic total mesorectal excision for low rectal cancer.

Design: This was a case-matched retrospective study from a prospectively maintained database.

Setting: The study was conducted at a tertiary colorectal surgery referral center.

Patients: From 2005 to 2013, among 138 patients with low rectal cancer who underwent total mesorectal excision with intersphincteric resection, 34 patients with a primary abdominal approach (abdominal group) were matched with 51 identical patients with a primary perineal approach (6-cm perineal dissection along the mesorectal plane; perineal group), according to TNM stage, sex, BMI, and age.

Main Outcomes Measures: Postoperative morbidity, oncologic outcomes, and 3-year overall and disease-free survivals were measured.

Results: The operative time was significantly shorter in the perineal group (269 minutes in perineal vs 240 minutes in abdominal group; p = 0.01). Overall morbidity (47% vs 47%; p = 1.00), severe morbidity (16% vs 15%; p = 0.90), and clinical anastomotic leakage (24% vs 12%; p = 0.17) rates showed no differences when comparing the 2 groups. The overall R1 resection rate was similar in the 2 groups (16% vs 9%; p = 0.36), including a 10% vs 9% positive circumferential margin (p = 0.88) and a 8% vs 0% positive distal margin (p = 0.15). After a median follow-up of 39 months, 3-year overall (100% vs 93% (95% CI, 88%-98%); p = 0.26) and disease-free (63% (95% CI, 56%-71%) vs 62% (95% CI, 53%-71%); p = 0.58) survival rates showed no differences between the 2 groups.

Limitations: The study was limited by its nonrandomized nature and limited sample size.

Conclusions: In cases of laparoscopic total mesorectal excision with intersphincteric resection for low rectal cancer, the primary perineal approach appears to reduce operative time and is associated with similar short- and long-term outcomes as compared with the primary abdominal approach. The primary perineal approach should thus be considered as the standard strategy.