Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta‐analysis

Abstract

Background and Objectives This study is a systematic review with meta‐analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack‐knife position (P‐APR) vs the classic lithotomy position (C‐APR). Methods We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random‐effect model. Results The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P‐APR was associated with decreased operative time (OT) (DM, −43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5‐year LR (OR, 1.00; P = 0.99). Conclusion The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.

Human factors in pelvic surgery

“…In a randomized trial of 30 patients undergoing anorectal surgery in the prone jackknife or lithotomy position, surgeons reported less mental and physical stress and better exposure in prone jackknife [50]. Proponents of the prone position hypothesized that the exposure and ergonomics were sufficiently superior to also improve oncologic outcomes; however, a meta-analysis pooling nonrandomized studies comparing prone versus lithotomy positioning for abdominoperineal resection in rectal cancer did not show an oncologic advantage [51]. Studies to date have not measured surgeon strain, body position, or discomfort.…”

Lithotomy versus prone position for perianal surgery: a randomized controlled trial

“…Despite several advantages of jackknife prone position over the lithotomy, acceptance of jackknife prone position for perianal procedures is extremely low, at least in our center. Researchers have compared the operation time, blood loss, rectal perforation rate, circumferential resection margin, and oncological outcome of APR, in lithotomy and jackknife prone position, with several advantages in the later [2][3][4][5]. However, we could not find any study comparing these 2 positions regarding the ergonomics, comfort of the surgical team, and position-related complications.…”

“…In contrast, the surgeon comfortably operated on the patient by standing between the patient's legs and lying in a jackknife prone position. Constant soiling of the field by blood and inadequate exposure of the operative field in the lithotomy position, as reflected by the exposure scale [1][2][3][4][5], led to mental discomfort. The SMEQ score used to measure the mental stress level showed a statistically significant difference favoring the jackknife prone position.…”

“…Besides, blood tends to pool to the operating site, and lighting is often challenging [2]. Studies have shown lesser esti-mated blood loss and operative time while performing abdominoperineal resection (APR) in jackknife prone position [2][3][4][5]. The rates of perforation and positive circumferential resection margin, too, are found to be lower in this position [4].…”

Selection and Outcomes in Abdominoperineal Resection

“…Along the lines of outcomes, some have postulated that perhaps the position may influence overall oncologic outcomes. Although the data regarding the oncological success of the traditional lithotomy vs. prone positions are mixed, there is consensus that the prone position is a less cumbersome operation for the surgeon and associated with decreased blood loss and operative time, recent studies have failed to demonstrate a formidable difference with regards to intraoperative specimen perforation or circumferential radial margin positivity (34).…”