Skip to main content

Open Abdominoperineal Resection

  • 2022 Accesses


Low-lying cancers of the rectum and anal canal may require abdominoperineal resection (APR) to clear disease. Although APR may be performed with the patient in supine or prone position, we favor the supine lithotomy approach. Since this procedure may be associated with significant morbidity, preoperative screening and patient selection are important. In this chapter, we review the step-by-step procedure to perform open lithotomy APR.


  • Rectal cancer
  • Open technique
  • Lithotomy position
  • Abdominoperineal resection

This is a preview of subscription content, access via your institution.

Buying options

USD   29.95
Price excludes VAT (USA)
  • DOI: 10.1007/978-1-4939-1893-5_24
  • Chapter length: 12 pages
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
USD   99.00
Price excludes VAT (USA)
  • ISBN: 978-1-4939-1893-5
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
Softcover Book
USD   129.00
Price excludes VAT (USA)
Fig. 24.1
Fig. 24.2
Fig. 24.3
Fig. 24.4
Fig. 24.5


  1. Lange MM, Rutten HJ, van de Velde CJ. One hundred years of curative surgery for rectal cancer: 1908–2008. Eur J Surg Oncol. 2009;35(5):456–63. doi:10.1016/j.ejso.2008.09.012.

    CAS  PubMed  CrossRef  Google Scholar 

  2. Lefevre JH, Corte H, Tiret E, Boccara D, Chaouat M, Touboul E, et al. Abdominoperineal resection for squamous cell anal carcinoma: survival and risk factors for recurrence. Ann Surg Oncol. 2012;19(13):4186–92. doi:10.1245/s10434-012-2485-1.

    PubMed  CrossRef  Google Scholar 

  3. Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242(1):74–82.

    PubMed Central  PubMed  CrossRef  Google Scholar 

  4. Watanabe T, Kazama S, Nagawa H. A 1cm distal bowel margin is safe for rectal cancer after preoperative radiotherapy. Hepatogastroenterology. 2012;59(116):1068–74.

    CAS  PubMed  Google Scholar 

  5. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94(2):232–8. doi:10.1002/bjs.5489.

    CAS  PubMed  CrossRef  Google Scholar 

  6. Guo M, Gao C, Li D, Guo W, Shafik AA, Zbar AP, et al. MRI anatomy of the anal region. Dis Colon Rectum. 2010;53(11):1542–8. doi:10.1007/DCR.0b013e3181f05256.

    PubMed  CrossRef  Google Scholar 

  7. Shihab OC, How P, West N, George C, Patel U, Quirke P, et al. Can a novel MRI staging system for low rectal cancer aid surgical planning? Dis Colon Rectum. 2011;54(10):1260–4. doi:10.1097/DCR.0b013e31822abd78.

    PubMed  CrossRef  Google Scholar 

  8. Bretagnol F, Panis Y, Rullier E, Rouanet P, Berdah S, Dousset B, et al. Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial. Ann Surg. 2010;252(5):863–8. doi:10.1097/SLA.0b013e3181fd8ea9.

    PubMed  CrossRef  Google Scholar 

  9. Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H. Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer–a systematic overview. Int J Colorectal Dis. 2011;26(10):1227–40.

    PubMed  CrossRef  Google Scholar 

  10. West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26(21):3517–22. doi:10.1200/JCO.2007.14.5961.

    PubMed  CrossRef  Google Scholar 

  11. de Campos-Lobato LF, Stocchi L, Dietz DW, Lavery IC, Fazio VW, Kalady MF. Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum. 2011;54(8):939–46. doi:10.1097/DCR.0b013e318221eb64.

    PubMed  CrossRef  Google Scholar 

  12. Keller DS, Lawrence JK, Delaney CP. Prone jackknife position is not necessary to achieve a cylindrical abdominoperineal resection: demonstration of the lithotomy position. Dis Colon Rectum. 2014;57(2):251. doi:10.1097/DCR.0000000000000047.

    PubMed  CrossRef  Google Scholar 

  13. Tayyab M, Sharma A, Ragg JL, Macdonald AW, Gunn J, Hartley JE, et al. Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal excision of the rectum. Dis Colon Rectum. 2012;55(3):316–21. doi:10.1097/DCR.0b013e31823e2424.

    PubMed  CrossRef  Google Scholar 

  14. Shihab OC, Heald RJ, Holm T, How PD, Brown G, Quirke P, et al. A pictorial description of extralevator abdominoperineal excision for low rectal cancer. Colorectal Dis. 2012. doi:10.1111/j.1463-1318.2012.03181.x.

    PubMed  Google Scholar 

  15. Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg. 2012;204(3):274–82. doi:10.1016/j.amjsurg.2012.05.001.

    PubMed  CrossRef  Google Scholar 

  16. Holm T. Controversies in abdominoperineal excision. Surg Oncol Clin N Am. 2014;23(1):93–111. doi:10.1016/j.soc.2013.09.005.

    PubMed  CrossRef  Google Scholar 

  17. Ramsay G, Parnaby C, Mackay C, Hanlon P, Ong S, Loudon M. Analysis of outcome using a levator sparing technique of abdominoperineal excision of rectum and anus. Cylindrical ELAPE is not necessary in all patients. Eur J Surg Oncol. 2013;39(11):1219–24. doi:10.1016/j.ejso.2013.08.004.

    CAS  PubMed  CrossRef  Google Scholar 

  18. Campos FG, Habr-Gama A, Nahas SC, Perez RO. Abdominoperineal excision: evolution of a centenary operation. Dis Colon Rectum. 2012;55(8):844–53. doi:10.1097/DCR.0b013e31825ab0f7.

    PubMed  CrossRef  Google Scholar 

  19. Finan P, Haboubi N. The Miles operation—extralevator abdominoperineal excision. Colorectal Dis. 2012;14(10):1171–2. doi:10.1111/j.1463-1318.2012.03191.x.

    PubMed  CrossRef  Google Scholar 

  20. Han JG, Wang ZJ, Gao ZG, Yang Y, Du YF. Human acellular dermal matrix for pelvic floor reconstruction after cylindrical abdominoperineal resection. Hepatogastroenterology. 2011;58(109):1205–7. doi:10.5754/hge10809.

    PubMed  CrossRef  Google Scholar 

  21. Bebenek M, Wojnar A. Infralevator lymphatic drainage of low-rectal cancers: preliminary results. Ann Surg Oncol. 2009;16(4):887–92. doi:10.1245/s10434-009-0324-9.

    PubMed  CrossRef  Google Scholar 

  22. Ngamprasertwong P, Phupong V, Uerpairojkit K. Brachial plexus injury related to improper positioning during general anesthesia. J Anesth. 2004;18(2):132–4. doi:10.1007/s00540-003-0220-6.

    PubMed  CrossRef  Google Scholar 

  23. Ikeya E, Taguchi J, Ohta K, Miyazaki Y, Hashimoto O, Yagi K, et al. Compartment syndrome of bilateral lower extremities following laparoscopic surgery of rectal cancer in lithotomy position: report of a case. Surg Today. 2006;36(12):1122–5. doi:10.1007/s00595-006-3313-7.

    PubMed  CrossRef  Google Scholar 

  24. Lange MM, Buunen M, van de Velde CJ, Lange JF. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review. Dis Colon Rectum. 2008;51(7):1139–45. doi:10.1007/s10350-008-9328-y.

    PubMed Central  PubMed  CrossRef  Google Scholar 

  25. Clinical Practice Guidlines of rectal cancer 2014. v2. Available at

  26. Barabouti DG, Wong WD. Current management of rectal cancer: total mesorectal excision (nerve sparing) technique and clinical outcome. Surg Oncol Clin N Am. 2005;14(2):137–55. doi:10.1016/j.soc.2004.11.003.

    PubMed  CrossRef  Google Scholar 

  27. Heald RJ, Moran BJ, Brown G, Daniels IR. Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers’ fascia. Br J Surg. 2004;91(1):121–3. doi:10.1002/bjs.4386.

    CAS  PubMed  CrossRef  Google Scholar 

  28. Chi P, Chen ZF, Lin HM, Lu XR, Huang Y. Laparoscopic extralevator abdominoperineal resection for rectal carcinoma with transabdominal levator transection. Ann Surg Oncol. 2013;20(5):1560–6. doi:10.1245/s10434-012-2675-x.

    PubMed  CrossRef  Google Scholar 

  29. Simunovic M, Pinthus J, Coates AJ, DeNardi F. Anterior-entry abdominoperineal resection: a variation in the method of perineal dissection. Ann Surg Oncol. 2012;19(3):794–800. doi:10.1245/s10434-011-2016-5.

    PubMed  CrossRef  Google Scholar 

  30. Fingerhut A, Hay JM, Delalande JP, Paquet JC. Passive vs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma. A multicenter, controlled trial. The French Association for Surgical Research. Dis Colon Rectum. 1995;38(9):926–32.

    CAS  PubMed  CrossRef  Google Scholar 

  31. Komori K, Hirai T, Kanemitsu Y, Shimizu Y, Sano T, Ito S, et al. Pathology studies of combined radical resection of seminal vesicle in the treatment of rectal cancer. Int Surg. 2011;96(1):51–5.

    PubMed  CrossRef  Google Scholar 

  32. How P, West NP, Brown G. An MRI-based assessment of standard and extralevator abdominoperineal excision specimens: time for a patient tailored approach? Ann Surg Oncol. 2013;21(3):822–8. doi:10.1245/s10434-013-3378-7.

    PubMed  CrossRef  Google Scholar 

  33. Ruo L, Paty PB, Minsky BD, Wong WD, Cohen AM, Guillem JG. Results after rectal cancer resection with in-continuity partial vaginectomy and total mesorectal excision. Ann Surg Oncol. 2003;10(6):664–8.

    CAS  PubMed  CrossRef  Google Scholar 

  34. 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(2):313–5.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Philip Paty M.D. .

Editor information

Editors and Affiliations

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

In this video, the surgeon demonstrates his approach to open lithotomy abdominoperineal resection. (MP4 823439 kb)

Key Operative Steps

  1. 1.

    The patient is placed in lithotomy position.

  2. 2.

    The abdomen is opened and explored to rule out metastatic disease.

  3. 3.

    The sigmoid colon is mobilized and the left ureter and gonadal vessels are identified and preserved.

  4. 4.

    Incise the right lateral peritoneum from the sacral promontory to the origin of the IMA.

  5. 5.

    Perform low ligation of the IMA including the superior rectal vessels and the first trunk of sigmoid vessels.

  6. 6.

    Divide the sigmoid colon with a linear stapler ensuring adequate mobilization for tension-free, well-vascularized colostomy.

  7. 7.

    Retract sigmoid and rectum anteriorly for posterior dissection and proceed with anterior and lateral dissection.

  8. 8.

    Establish plane of extralevator resection and complete levator dissection.

  9. 9.

    Begin perineal phase with an elliptical incision around the anus.

  10. 10.

    The incision is carried anteriorly to the perineal body and laterally and posteriorly through the ischiorectal fossa until the anococcygeal ligament and the posterior/lateral levator muscles are exposed.

  11. 11.

    Proceed with dissection circumferentially around the rectum until it is completely free.

  12. 12.

    Remove the specimen transanally and close the perineal defect. Drain the pelvis and perineal space.

  13. 13.

    Create and mature an end colostomy.

Rights and permissions

Reprints and Permissions

Copyright information

© 2015 Springer Science+Business Media New York

About this chapter

Cite this chapter

Wang, L., Gu, J., Paty, P. (2015). Open Abdominoperineal Resection. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY.

Download citation

  • DOI:

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-1892-8

  • Online ISBN: 978-1-4939-1893-5

  • eBook Packages: MedicineMedicine (R0)