Abstract
The prognosis of rectal cancer has significantly improved over the last decades since the introduction of the total mesorectal excision (TME) surgery. However, the outcome of lower rectal cancer has not improved to the same degree despite the increased use of neoadjuvant treatment. Large multicentre studies have shown that abdominoperineal resection (APR) for low rectal cancer is associated with increased intraoperative perforation and circumferential resection margin (CRM) involvement and subsequent worse prognosis compared to similar stage of rectal cancer resected with a low anterior restorative procedure [1–3]. For this reason, the surgical technique of the standard APR is under debate. Because of anatomical coning of the mesorectum at the level of the pelvic floor, there is less margin for error resulting in increased rates of R1 or incomplete resections (Fig. 45.1a). A more extensive resection by extralevator dissection with a cylindrical specimen is associated with decreased intraoperative perforation rates, CRM involvement and subsequently less recurrence and better survival in several studies [4]. Although forms of bias in these publications are present and other reports have shown good outcome after standard APR, the extralevator abdominoperineal resection (ELAPR) has clear advantages for treatment of more advanced lower rectal cancers [5].
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Similar content being viewed by others
References
Heald RJ, Smedh RK, Kald A, Sexton R, Moran BJ. Abdominoperineal excision of the rectum–an endangered operation. Norman Nigro Lectureship. Dis Colon Rectum. 1997;40:747–51.
Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol Off J Am Soc Clini Oncol. 2005;23:9257–64. doi:10.1200/jco.2005.02.9231.
Chambers W, et al. Changes in the management and outcome of rectal cancer over a 10-year period in Oxford. Colorectal Dis Off J Asso Coloproctol Great Br Ireland. 2011;13:1004–8. doi:10.1111/j.1463-1318.2010.02360.x.
West NP, et al. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol Off J Am Soc Clini Oncol. 2008;26:3517–22. doi:10.1200/jco.2007.14.5961.
Morris EJ, et al. Low abdominoperineal excision rates are associated with high-workload surgeons and lower tumour height. Is further specialization needed? Colorectal Dis Off J Asso Coloproctol Great Br Ireland. 2011;13:755–61. doi:10.1111/j.1463-1318.2010.02263.x.
Bach SP, et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009;96:280–90. doi:10.1002/bjs.6456.
Pachler J, Wille-Jorgensen P. Quality of life after rectal resection for cancer, with or without permanent colostomy. Cochrane Database Syst Rev (Online). 2005;(2):CD004323. doi: 10.1002/14651858.CD004323.pub3.
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;51:1139–45. doi:10.1007/s10350-008-9328-y.
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993;341:457–60.
Lindsey I, Warren BF, Mortensen NJ. Denonvilliers’ fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum. 2005;48:37–42.
de Campos-Lobato LF, et al. Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum. 2011;54:939–46. doi:10.1097/DCR.0b013e318221eb64.
Nilsson PJ. Omentoplasty in abdominoperineal resection: a review of the literature using a systematic approach. Dis Colon Rectum. 2006;49:1354–61. doi:10.1007/s10350-006-0643-x.
de Bruin AF, Gosselink MP, van der Harst E, Rutten HJ. Local application of gentamicin collagen implants in the prophylaxis of surgical site infections following gastrointestinal surgery: a review of clinical experience. Tech Coloproctol. 2010;14:301–10. doi:10.1007/s10151-010-0593-0.
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;94:232–8. doi:10.1002/bjs.5489.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer-Verlag Berlin Heidelberg
About this chapter
Cite this chapter
Tuynman, J.B., Mortensen, N.J. (2017). Surgical Technique and Difficult Situations from Neil Mortensen (Laparoscopic). In: Korenkov, M., Germer, CT., Lang, H. (eds) Gastrointestinal Operations and Technical Variations. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-49878-1_45
Download citation
DOI: https://doi.org/10.1007/978-3-662-49878-1_45
Published:
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-662-49876-7
Online ISBN: 978-3-662-49878-1
eBook Packages: MedicineMedicine (R0)