INTRODUCTION: Achieving margin-negative complete resection in locally recurrent rectal cancer often requires en bloc resection involving adjacent structures such as the sacrum. However, sacrectomy is technically demanding and poses a high risk of significant intraoperative bleeding and postoperative pelvic sepsis due to the dead space created after resection. We developed a minimally invasive surgical technique to address these challenges. TECHNIQUE: We used a laparoscopic approach to sacrectomy as part of en bloc resection for posterior locally recurrent rectal cancer. In this technique, the anterior and lateral dissection of the sacrum was performed laparoscopically, whereas the final sacral transection was performed under direct vision in the prone position. Preoperative imaging was used to identify the planned sacral transection line, which was reproduced intraoperatively using a premeasured vascular tape. Anterior and lateral dissection of the sacrum was performed laparoscopically to allow secure vascular control. Final sacral transection was performed under direct vision in the prone position. A pedicled omental flap and a dead-space-filling nonfunctional anastomosis were used to fill the pelvic cavity and prevent postoperative sepsis. A double-barreled stoma was created to facilitate fecal diversion. RESULTS: Laparoscopic sacrectomy was successfully performed in 43 patients with locally recurrent rectal cancer. The margin-negative complete resection rate was 86%, which is notably high for this challenging population. The 5-year overall survival rate was approximately 59%. No cases of major intraoperative bleeding or early complications related to the dead-space-filling nonfunctional anastomosis were observed. CONCLUSIONS: This laparoscopic technique offers a safe and feasible option for selected patients with posterior locally recurrent rectal cancer. Combined dead-space management may further help reduce postoperative complications while preserving oncological validity.
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