Laparoscopic abdominoperineal resection with partial vaginectomy for T4b rectal cancer

This video demonstrates landmark advances in the minimally invasive management of low rectal cancer with adjacent organ invasion. Laparoscopy allows superior pelvic visualization, enabling precise dissection between the rectum and vagina even after neoadjuvant chemoradiotherapy. The combined approach of oncologic resection and immediate gracilis flap reconstruction reflects modern standards in treating locally advanced low rectal tumors with vaginal involvement.

The procedure was indicated for low rectal adenocarcinoma with confirmed invasion of the posterior vaginal wall following multidisciplinary evaluation, where sphincter preservation was not feasible and an oncologically complete en bloc abdominoperineal resection with partial vaginectomy was required.

Contraindications include medically unstable patients unable to tolerate major pelvic surgery or general anesthesia; extensive tumor invasion into structures not amenable to curative resection (e.g., pelvic sidewall, iliac vessels, sacrum above S3); distant metastatic disease where curative intent is not appropriate; and severe cardiopulmonary disease preventing safe creation of pneumoperitoneum for laparoscopic access.

A high-definition laparoscopic tower with a 30° laparoscope was used. Instrumentation included standard atraumatic laparoscopic graspers, a combined hook and bipolar energy device (LigaSure™ technology, Medtronic), and a linear laparoscopic stapler (Signia™ Stapling System, Medtronic) for rectal and colonic transection. Suction–irrigation was performed with standard laparoscopic equipment.
Perineal dissection was aided by the Lone Star® Retractor System, and conventional instruments were used for harvesting the gracilis flap.

The patient was positioned in modified lithotomy with steep Trendelenburg to optimize pelvic exposure. Four laparoscopic ports were placed in a standard colorectal configuration, ensuring ergonomic access to the deep pelvis. The operating room setup allowed a smooth transition between the abdominal and perineal phases. During the perineal step, circumferential exposure of the anal canal and posterior vaginal wall was established to facilitate precise dissection and the partial vaginectomy.

Preoperative evaluation included colonoscopy with biopsy confirming adenocarcinoma, CT scan of the chest–abdomen–pelvis, and pelvic MRI for local staging, which demonstrated low rectal cancer with suspected vaginal invasion and mesorectal nodes. The case was discussed in a multidisciplinary tumor board, and the patient underwent neoadjuvant chemoradiotherapy before surgery. Standard anesthetic, medical, and nutritional assessments were completed.

Key anatomical landmarks include the inferior mesenteric artery (IMA) and vein (IMV) for high vascular ligation, the mesorectal fascia, levator ani complex, anal canal, rectovaginal septum, and posterior vaginal wall. When anatomy is altered by tumor invasion or post-radiotherapy fibrosis, dissection follows the true avascular planes, keeping close to the mesorectal fascia to ensure an R0 resection. In cases with posterior vaginal wall involvement, an en bloc partial vaginectomy is performed. If more extensive anterior or lateral involvement is found, wider vaginal resection or pelvic exenteration may be required to obtain negative margins.

Abdominal phase: Risk of bleeding at IMA/IMV, ureteral injury, and bowel injury; managed with clear visualization, careful vessel control, and immediate repair if needed.
Pelvic phase: Risk of nerve, ureteral, or unintended vaginal injury, especially in fibrotic planes; prevented by following mesorectal fascia and rectovaginal septum.
Perineal phase: Risk of bleeding and injury to adjacent organs; controlled via stepwise dissection and meticulous hemostasis.
Reconstruction: Risk of flap ischemia and wound complications; addressed with proper flap positioning and close postoperative monitoring.

The authors declare no conflicts of interest, financial or otherwise. No financial, consultant, institutional, or other relationships influenced the conduct of this work.

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- Thiele JR, Weber J, Neeff HP, et al. Reconstruction of perineal defects: a comparison of the myocutaneous gracilis and the gluteal fold flap in interdisciplinary anorectal tumor resection. Front Oncol. 2020;10:668.