Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

Background The descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach. Methods Patients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO). Results Of the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p =0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p =0.034). Multivariable analysis showed that no-CPP ( p =0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space. Conclusion CPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.