• Frederic Kanso, Léon Maggiori, Clotilde Debove, Amélie Chau, Marianne Ferron, and Yves Panis.
• Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France.
• Dis. Colon Rectum. 2015 Jul 1;58(7):637-44.

BackgroundIntersphincteric resection during total mesorectal excision for low rectal cancer can be performed through a primary abdominal or a primary perineal approach.ObjectiveThe 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.DesignThis was a case-matched retrospective study from a prospectively maintained database.SettingThe study was conducted at a tertiary colorectal surgery referral center.PatientsFrom 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 MeasuresPostoperative morbidity, oncologic outcomes, and 3-year overall and disease-free survivals were measured.ResultsThe 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.LimitationsThe study was limited by its nonrandomized nature and limited sample size.ConclusionsIn 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.

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