Background: High-complexity pelvic exenteration requires extensive lateral dissection and often en bloc resection of the internal iliac vessels to secure margins. However, achieving safe, precise access to the distal pelvic sidewall through a confined operative field is technically demanding and hazardous. Impact of innovation: We developed a transperineal coccygeal muscle-guided endoscopic approach primarily to establish a reliable, anatomically guided pathway to the lateral pelvic compartments. Using the coccygeal muscle as a landmark facilitates precise identification of the distal internal iliac vessels and lumbosacral trunk, enabling safer sidewall dissection and facilitating an early distal vessel ligation strategy. Technology Materials and Methods: Following identification of the coccygeal bone, the coccygeal muscle is mobilized off the levator ani fascia. A targeted division of the levator ani at its lateral margin exposes the distal internal iliac vessels for early ligation under direct vision. This access clearly unroofs the lumbosacral trunk and sciatic nerve, permitting precise lateral pelvic sidewall dissection. Preliminary Results: In 11 consecutive patients with locally advanced or recurrent rectal cancer underwent pelvic exenteration with combined resection of the main trunk of internal iliac vein between January 2023 and December 2025, this method yielded acceptable operative time (median 918 min; 579 min until completion of resection), blood loss (median 991 ml; 374 ml until completion of resection), an R0 resection rate of 91%, and severe morbidity of 18%, comparable to published benchmarks. Conclusions and Future Directions: The transpenieal coccygeal muscle-guided route provides a practical, anatomically grounded method for accessing the distal pelvic sidewall. It represents a technically feasible strategy for managing the complex anatomy of high-complexity exenterations, though larger studies are required to confirm its impact on operative hemodynamics and long-term outcomes. See New Technology Report Video.
Ogura et al. (Tue,) studied this question.