A 73-Year-Old Woman Treated for Rheumatoid Arthritis with Lower Rectal Carcinoma Who Underwent Abdominoperineal Resection, Lateral Regional Lymph Node Resection, and Partial Hepatectomy by Hand-Assisted Laparoscopic Surgery (HALS): A Case Report

Abstract

BACKGROUND This report describes the case of a 73-year-old woman treated for rheumatoid arthritis with lower rectal carcinoma who underwent abdominoperineal resection, lateral regional lymph node resection, and partial hepatectomy by hand-assisted laparoscopic surgery (HALS). More recently, HALS has proven to be useful in multiple organ resections. CASE REPORT A 73-year-old woman who presented with hematochezia was diagnosed with lower rectal cancer and referred to our hospital. The patient had a history of rheumatoid arthritis and was taking oral nonsteroidal anti-inflammatory drugs. After further evaluation, the patient was diagnosed with stage IV rectal cancer with a metastatic liver lesion and a right lateral lymph node metastasis. All lesions were resected using HALS. A 50-mm longitudinal umbilical incision was created for use as a hand access site, and 3 ports with a diameter of 5 mm each were inserted into the lower abdomen to perform right lateral lymph node dissection and abdominoperineal resection. HALS was performed in the upper abdomen, where the liver was used to partially resect segment S6. The patient was discharged without complications 13 days after the operation. CONCLUSIONS In this complex case of advanced rectal carcinoma with liver metastases, use of the HALS surgical method was shown to be possible. Immunomodulatory treatment for rheumatoid arthritis may have influenced the outcome for this patient.

Figure 1.

Preoperative imaging of rectal cancer and lymph node metastasis. (A) Barium enema imaging revealed a 7-cm, type 2, circumscribed lesion extending from the lower rectum through the anal canal (arrow). (B) A contrast-enhanced computed tomography scan of the pelvic area showed rectal cancer located mainly on the posterior wall, with metastasis present at the right lymph node (white arrowhead).

Figure 2.

Preoperative imaging of metastatic liver lesion. Contrast-enhanced computed tomography scan of the upper abdomen showed a 3-cm metastatic tumor of the liver (segment 6 of the liver; arrow). (This finding was similar to the ultrasound and magnetic resonance imaging findings).

Figure 3.

Diagram of location of ports and incision used in resecting the primary lesion. Arrows indicate the surgeon’s line of sight for arranging ports from the lower abdomen to the pelvic floor for the hand-assisted laparoscopic surgery procedure.

Figure 4.

Upper abdominal surgery for partial resection of the liver (segment 6 of liver). (A) Diagram of port arrangement, with arrows indicating the surgeon’s line of sight. (B) A 3-cm metastatic tumor in the liver (segment 6 of liver) was confirmed by intraoperative ultrasound and palpation. The intraprocedural photograph shows partial hepatic resection performed with an ultrasonic coagulator.

Figure 5.

Photograph of the postoperative abdomen. A drain was placed by using the port insertion sites in the upper right (under the right diaphragm) and lower right (pouch of Douglas) abdominal areas. A permanent artificial anus was constructed in the lower left abdomen.

Figure 6.

Resected specimens. (A) On rectal biopsy, a resected recto-anal specimen showed a type 2 lesion with a diameter of 80×70 mm; (B) A cut surface image of a specimen from the partially resected liver (segment 6 of the liver) showing an adenocarcinoma that was identical to the main lesion was detected and diagnosed as metastatic liver cancer