Prone Compared With Lithotomy for Abdominoperineal Resection: A Systematic Review and Meta-analysis

Abstract

Background: Abdominoperineal resection (APR) is the primary surgical approach to low rectal cancers. Both prone and lithotomy patient positioning during the perineal dissection are currently acceptable approaches. There is no consensus on whether patient positioning has an impact on operative and oncologic outcomes. The aim of this review was to compare the perioperative and long-term oncologic outcomes between prone and lithotomy patient positioning. Materials and methods: Search of Medline, Embase, Web of Science, CENTRAL, PubMed, and ClinicalTrials.gov databases was performed. Articles were eligible for inclusion if they compared prone and lithotomy positioning for the perineal portion of APR for rectal cancer in one of the primary outcomes. Quality of included studies was assessed using Newcastle eOttawa Scale and Cochrane Risk of Bias Tool. Results: Nine studies with 888 patients in the prone group and 897 in the lithotomy group were included. Compared with lithotomy position, prone position had a significantly lower perforation rate (risk ratio: 0.50, 95% confidence interval [CI]: 0.32 to 0.79, P ¼ 0.003) and rates of positive circumferential resection margin involvement (risk ratio: 0.66, 95% CI: 0.44 to 1.00, P ¼ 0.05). Prone position also had a significantly shorter operative time than lithotomy position (mean difference: À45.20 min, 95% CI: À63.03 to-27.36, P < 0.00001). Positioning did not affect 5-y overall survival or local and distal recurrence. Conclusions: Prone positioning may lead to lower rates of perforation and circumferential resection margin involvement in APR. In addition, it may lead to shorter operative time. Larger randomized studies are required to confirm the results of this review and examine the difference in long-term outcomes.

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].…”

“…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]. Although researchers unanimously agree that ergonomics in lithotomy position is unsatisfactory for both the surgeon and the assistant, no attempt has been made to compare these positions concerning ergonomics.…”