A Novel Laparoscopic Technique With a Bladder Peritoneum Flap Closure for Pelvic Cavity for Patients With Rigid Pelvic Peritoneum After Neoadjuvant Radiotherapy in Laparoscopic Extralevator Abdominoperineal Excision

BACKGROUND: In laparoscopic extralevator abdominoperineal excision, reconstruction of the pelvic peritoneum helps to prevent the small intestine from adhering to pelvic wall tissues, thus avoiding small-bowel obstruction and perineal complications. However, there are difficulties in pelvic peritoneum closure if the patient has received preoperative radiotherapy and has a rigid pelvis. We report a novel laparoscopic method for pelvic peritoneum reconstruction using the bladder peritoneum flap in laparoscopic extralevator abdominoperineal excision after neoadjuvant radiotherapy. TECHNIQUE: After transection of the rectum, if the patient had a rigid pelvis, we chose to perform the novel technique for the pelvic peritoneum closure in a 3-step approach. The flap has an arch shape with the bottom at the anterior wall of the pelvic cavity entrance. The height of the arched flap is equal to the distance from the bladder to the sacral promontory. The peritoneum was incised with electrocautery at the planned level and peeled off the bladder. The bladder peritoneum flap was then rotated to cover the entrance of the pelvic cavity and sutured to the brim of the pelvis. RESULTS: Acceptable postoperative short-term and long-term outcomes (5- to 22-month follow-ups) were achieved in 3 patients who underwent bladder peritoneum flap closure. CONCLUSIONS: The bladder peritoneum flap appears to be safe and feasible for intracorporeal closure of the pelvic cavity in laparoscopic extralevator abdominoperineal excision after neoadjuvant radiotherapy. The procedure provides a novel option for patients with severe fibrosis of the pelvis when another peritoneum reconstruction method is not feasible.