Prone Versus Supine Position in Abdominoperineal Resection: Outcomes in the Laparoscopic Era

Background: It is unclear whether the supine or prone approach for abdominoperineal resection (APR) influences outcomes. Methods: In a retrospective study of patients with rectal cancer who underwent curative laparoscopic APR from 2005 to 2018, we compared perioperative data, postoperative outcomes, oncological outcomes, and survival between the two approaches. Results: We recruited 123 patients (58 for the supine group and 65 for the prone group), with a median age of 72 (41-93) years. Mean follow-up was 67.4-45.7 months (28-169) in the supine group and 47.8-30.9 months (13-158) in the prone group (P=.026). Duration of surgery was longer in the prone group at 23752.3 minutes versus 210 +/- 56.6 minutes in the supine group (P=.007). The incidence of tumor perforation during surgery was 9% in the supine group versus 3% in the prone group (P=.208). The incidence of perineal wound infection did not differ significantly between groups (supine 22% versus prone 20%, P=.93). The mesorectum was incomplete in 25% cases in the supine group and 14% cases in the prone group (P=.175). Circumferential resection margin positivity was 21% in the supine group and 14% in the prone group (P=.374). Local and distant recurrence was higher in patients with adenocarcinoma in the supine group at 10% and 31% versus 4% and 17% in the prone group (P=.177). Overall survival was higher in the prone group: 4% of patients died due to disease progression compared with 24% in the supine group (P=.034). Conclusions: Our results suggest that morbidity is similar with both laparoscopic techniques, but long-term outcomes seem better with the prone approach.