Abdominal perineal resection (APR): Open technique
- John RT Monson, MD, FRCS, FACS
John RT Monson, MD, FRCS, FACS
- Professor of Surgery
- University of Central Florida, College of Medicine
- Fergal Fleming, MD, FRCS
Fergal Fleming, MD, FRCS
- Assistant Professor of Surgery and Oncology
- Division of Colorectal Surgery
- University of Rochester Medical Center
An abdominal perineal resection (APR) includes the resection of the sigmoid colon, rectum, and anus (figure 1), and the construction of a permanent end colostomy.
Benign and malignant conditions that can be treated by APR include, but are not limited to:
●Crohn’s proctitis with anal disease
●Ulcerative colitis, not a candidate or amenable to an ileal pouch anal anastomosis
●Fecal incontinence, not amenable to sphincter sparing procedures
- Contant CM, Hop WC, van't Sant HP, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112.
- Van't Sant HP, Weidema WF, Hop WC, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg 2010; 251:59.
- Bretagnol F, Panis Y, Rullier E, et al. Rectal cancer surgery without boewl preparation. The French GRECAR III multicenter, single-blinded, randomized trial. Presented at ASCRS 2011, Vancouver, British Columbia.
- Holm T, Singnomklao T, Rutqvist LE, Cedermark B. Adjuvant preoperative radiotherapy in patients with rectal carcinoma. Adverse effects during long term follow-up of two randomized trials. Cancer 1996; 78:968.
- Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:381S.
- O'Connell MP. Positioning impact on the surgical patient. Nurs Clin North Am 2006; 41:173.
- Stephenson LL, Webb NA, Smithers CJ, et al. Lateral femoral cutaneous neuropathy following lateral positioning on a bean bag. J Clin Anesth 2009; 21:383.
- Recommended practices for positioning the patient in the perioperative setting. Perioperative Standards and Recommended Practices. AORN J 2008; :497.
- Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000; 55:980.
- Dybec RB. Intraoperative positioning and care of the obese patient. Plast Surg Nurs 2004; 24:118.
- Sonoda T, Milsom JW. Section 5: Gastrointestinal tract and abdomen. Chapter 34: Segmental colon resection.ACS Surgery: Principles and Practice http://www.acssurgery.com/acs/chapters/ch0534.htm (Accessed on November 07, 2011).
- Titu LV, Tweedle E, Rooney PS. High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: a systematic review. Dig Surg 2008; 25:148.
- Chapter 83. Abdominoperineal resection, Low anterior resection. In: Operative anatomy, Third, Scott-Conner CE, Dawson DL. (Eds), Wolters Kluwer, Lippincott, Williams & Wilkins, Philadelphia 2009. p.569.
- Jin ZM, Peng JY, Zhu QC, Yin L. Waldeyer's fascia: anatomical location and relationship to neighboring fasciae in retrorectal space. Surg Radiol Anat 2011; 33:851.
- García-Armengol J, García-Botello S, Martinez-Soriano F, et al. Review of the anatomic concepts in relation to the retrorectal space and endopelvic fascia: Waldeyer's fascia and the rectosacral fascia. Colorectal Dis 2008; 10:298.
- Lindsey I, Guy RJ, Warren BF, Mortensen NJ. Anatomy of Denonvilliers' fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg 2000; 87:1288.
- Killeen S, Devaney A, Mannion M, et al. Omental pedicle flaps following proctectomy: a systematic review. Colorectal Dis 2013; 15:e634.
- West NP, Finan PJ, Anderin C, et al. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 2008; 26:3517.
- Nagtegaal ID, van de Velde CJ, Marijnen CA, et al. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 2005; 23:9257.
- Han JG, Wang ZJ, Wei GH, et al. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 2012; 204:274.
- Bernstein TE, Endreseth BH, Romundstad P, et al. Circumferential resection margin as a prognostic factor in rectal cancer. Br J Surg 2009; 96:1348.
- Huang A, Zhao H, Ling T, et al. Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 2014; 29:321.
- Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 2005; 242:74.
- Holm T, Ljung A, Häggmark T, et al. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 2007; 94:232.
- Galandiuk S, Jorden J, Mahid S, et al. The use of tissue flaps as an adjunct to pelvic surgery. Am J Surg 2005; 190:186.
- Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 1999; 6:33.
- Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg 2009; 123:175.
- Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am 2006; 33:55.
- Fry DE, Milholen L, Harbrecht PJ. Iatrogenic ureteral injury. Options in management. Arch Surg 1983; 118:454.
- Redan JA, McCarus SD. Protect the ureters. JSLS 2009; 13:139.
- Timmons MC, Kohler MF, Addison WA. Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application. Obstet Gynecol 1991; 78:313.
- Loveland JA, Boffard KD. Damage control in the abdomen and beyond. Br J Surg 2004; 91:1095.
- McPartland KJ, Hyman NH. Damage control: what is its role in colorectal surgery? Dis Colon Rectum 2003; 46:981.
- Oderich GS, Panneton JM, Hofer J, et al. Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication. J Vasc Surg 2004; 39:931.
- PREOPERATIVE PREPARATION
- Enterostomal assessment
- Mechanical bowel preparation
- Antibiotic prophylaxis
- Venous thromboembolism prophylaxis
- OPEN SURGICAL TECHNIQUE
- Patient positioning
- Exploration for resectability
- Mobilization of colon
- - Medial to lateral approach
- - Lateral to medial approach
- Mobilization of rectum
- Colostomy construction
- Omental flap
- Repositioning for perineal resection
- - Cylindrical versus conventional approach
- Perineal resection
- INTRA-OPERATIVE CHALLENGES
- Ureter and urethra
- Pelvic autonomic nerves
- POSTOPERATIVE MANAGEMENT
- PERINEAL WOUND COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS