Multiport Laparoscopic Abdominoperineal Resection

  • W. Conan Mustain
  • Conor P. Delaney


Despite advances in surgical techniques allowing for the preservation of the sphincter complex in the majority of patients with rectal cancer, en bloc resection of the rectum and anus using a combined abdominal and perineal approach is still required in some circumstances. Abdominoperineal resection (APR) can be performed through an open or laparoscopic approach, though the laparoscopic approach is associated with less blood loss, decreased postoperative pain and narcotic use, and shorter hospital stay. Multiport laparoscopic APR is performed in much the same manner as laparoscopic lower anterior resection for rectal cancer, adhering to the oncologic principles of high ligation on the inferior mesenteric artery and total mesorectal excision (TME). Key differences include the omission of splenic flexure mobilization and the conscious avoidance of distal mesorectal dissection off of the levator ani muscles to preserve the cylindrical nature of the specimen and avoid “wasting” at the proximal anal canal. Performance of the perineal dissection in lithotomy allows for excellent visualization in most circumstances, without the need for prone positioning. Postoperative recovery is managed according to established enhanced recovery pathways.


Abdominoperineal resection Laparoscopic Rectal cancer Enhanced recovery 


  1. 1.
    Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet. 1908;2:1812–3.CrossRefGoogle Scholar
  2. 2.
    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.CrossRefPubMedGoogle Scholar
  3. 3.
    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(7):747–51.CrossRefPubMedGoogle Scholar
  4. 4.
    Sackier JM, Berci G, Hiatt JR, Hartunian S. Laparoscopic abdominoperineal resection of the rectum. Br J Surg. 1992;79(11):1207–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Larach SW, Salomon MC, Williamson PR, Goldstein E. Laparoscopic assisted abdominoperineal resection. Surg Laparosc Endosc. 1993;3(2):115–8.PubMedGoogle Scholar
  6. 6.
    Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6(7):477–84. doi: 10.1016/S1470-2045(05)70221-7.CrossRefPubMedGoogle Scholar
  7. 7.
    Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW, Jr., et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg. 2007;246(4):655–62; discussion 62–4. doi: 10.1097/SLA.0b013e318155a762.
  8. 8.
    Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;372(14):1324–32. doi: 10.1056/NEJMoa1414882.CrossRefPubMedGoogle Scholar
  9. 9.
    Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 2010;11(7):637–45. doi: 10.1016/S1470-2045(10)70131-5.CrossRefPubMedGoogle Scholar
  10. 10.
    van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14(3):210–8. doi: 10.1016/S1470-2045(13)70016-0.CrossRefPubMedGoogle Scholar
  11. 11.
    Schlussel AT, Lustik MB, Johnson EK, Maykel JA, Champagne BJ, Goldberg JE, et al. A population-based comparison of open versus minimally invasive abdominoperineal resection. Am J Surg. 2015;209(5):815–23. doi: 10.1016/j.amjsurg.2014.12.021.CrossRefPubMedGoogle Scholar
  12. 12.
    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.CrossRefPubMedGoogle Scholar
  13. 13.
    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.CrossRefPubMedGoogle Scholar
  14. 14.
    Keller DS, Stulberg JJ, Lawrence JK, Delaney CP. Process control to measure process improvement in colorectal surgery: modifications to an established enhanced recovery pathway. Dis Colon Rectum. 2014;57(2):194–200. doi: 10.1097/DCR.0b013e3182a62c91.CrossRefPubMedGoogle Scholar
  15. 15.
    Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ. Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways. Am J Surg. 2012;203(3):353–355.; discussion 5-6. doi: 10.1016/j.amjsurg.2011.09.017.CrossRefPubMedGoogle Scholar
  16. 16.
    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.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Japan 2018

Authors and Affiliations

  1. 1.Division of Colon and Rectal SurgeryUniversity of Arkansas for Medical SciencesLittle RockUSA
  2. 2.Digestive Disease and Surgery InstituteCleveland ClinicClevelandUSA

Personalised recommendations