World Journal of Surgery

, Volume 41, Issue 2, pp 590–595 | Cite as

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors

  • Ajit Pai
  • Saleh Mohamed EftaihaEmail author
  • George Melich
  • John J. Park
  • Pey-yi Kevin Lin
  • Leela M. Prasad
  • Slawomir J. Marecik
Original Scientific Report with Video



Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity.


Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed.


All procedures were successfully completed without conversion. Average body mass index was 32 kg/m2. The mean operative time and blood loss were 370 min and 130 ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14 months, all patients remain disease-free.


Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.


Abdominoperineal Resection Circumferential Resection Margin Perineal Herniation Tumor Perforation Perineal Wind 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Drs. Ajit Pai and George Melich would like to thank the Foundation for Surgical Fellowships for providing the opportunity to undergo fellowship training in the institution of affiliation.

Compliance with ethical standards

Conflict of interest

There was no source of funding for this paper. Ajit Pai, Saleh M. Eftaiha, George Melich, John J Park, Pey-yi Kevin Lin, Leela M Prasad, and Slawomir J Marecik have no conflict of interest or financial ties to disclose.

Supplementary material

Supplementary material 1 (MP4 20508 kb)

Supplementary material 2 (MP4 20402 kb)

Supplementary material 3 (MP4 19043 kb)


  1. 1.
    Marecik SJ, Zawadzki M, Desouza AL et al (2011) Robotic cylindrical abdominoperineal resection with transabdominal levator transection. Dis Colon Rectum 54:1320–1325CrossRefPubMedGoogle Scholar
  2. 2.
    Miles WE (1908) A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2:1812–1813CrossRefGoogle Scholar
  3. 3.
    Stelzner S, Koehler C, Stelzer J et al (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Int J Colorectal Dis 26:1227–1240CrossRefPubMedGoogle Scholar
  4. 4.
    West NP, Finan PJ, Anderin C et al (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26:3517–3522CrossRefPubMedGoogle Scholar
  5. 5.
    Han JG, Wang ZJ, Wei GH et al (2012) Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 204:274–282CrossRefPubMedGoogle Scholar
  6. 6.
    Bülow S, Christensen IJ, Iversen LH et al (2011) Danish Colorectal Cancer Group. Intra-operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer. Colorectal Dis 13:1256–1264CrossRefPubMedGoogle Scholar
  7. 7.
    den Dulk M, Putter H, Collette L et al (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer 45:1175–1183CrossRefGoogle Scholar
  8. 8.
    Welsch T, Mategakis V, Contin P et al (2013) Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications. Int J Colorectal Dis 28:503–510CrossRefPubMedGoogle Scholar
  9. 9.
    Holm T, Ljung A, Häggmark T et al (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238CrossRefPubMedGoogle Scholar
  10. 10.
    Luca F, Valvo M, Ghezzi TL et al (2013) Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer. Ann Surg 257:672–678CrossRefPubMedGoogle Scholar
  11. 11.
    Chi P, Chen ZF, Lin HM et al (2013) Laparoscopic extralevator abdominoperineal resection for rectal carcinoma with transabdominal levator transection. Ann Surg Oncol 20:1560–1566CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Ajit Pai
    • 1
    • 2
  • Saleh Mohamed Eftaiha
    • 2
    Email author
  • George Melich
    • 1
    • 4
  • John J. Park
    • 1
  • Pey-yi Kevin Lin
    • 1
  • Leela M. Prasad
    • 1
    • 3
  • Slawomir J. Marecik
    • 1
    • 3
  1. 1.Division of Colon and Rectal SurgeryAdvocate Lutheran General HospitalPark RidgeUSA
  2. 2.Department of Surgical OncologyApollo HospitalsChennaiIndia
  3. 3.Division of Colon and Rectal SurgeryUniversity of Illinois at ChicagoChicagoUSA
  4. 4.Department of General Surgery, Royal Columbian HospitalUniversity of British ColumbiaNew WestministerCanada

Personalised recommendations