CYLINDRICAL  APR<br />PETER HEWETT<br />
		DOORS OF DUBLIN<br />
DOORS OF ZANZIBAR<br />
	RECTUMS OF EUROPE<br />British Journal of Surgery<br />Volume 97, Issue 4, pages 588–599, April 2010<br />
Local recurrence has not improved to the same degree as seen with anterior resection after the introduction of TME.<br />S...
Cylindrical AP Resection<br />Mobilisation of the mesorectum down to the origins of the levator muscles.<br />Stoma format...
Extended Perineal resection<br />Excision of the sphincter complex<br />Follows the inferior surface of the levators to a ...
Advantages (literature)<br />Reduced rate of perforation<br />Reduced rate of CRM<br />70% more tissue outside the interna...
J ClinOncol. 2008 Jul 20;26(21):3517-22. Epub 2008 Jun 9.<br />Evidence of the oncologic superiority of cylindrical abdomi...
ExtralevatorAPR removed more tissue from outside the smooth muscle layer per slice (median area 2120 versus 1259 mm2; P < ...
Multicentre experience with extralevatorabdominoperineal excision for low rectal cancer†<br />N. P. West1,*, <br />C. Ande...
Advantages<br />Good  visualisation anterior structures with plane easily seen and dissected<br />Easy control of bleeders...
Disadvantages<br />Learning curve as to how far to dissect into the pelvis<br />Unaccustomed plane<br />Coccygeal division...
Tips<br />If the excised sigmoid colon is very fatty amputate it so that the rectum can be delivered easily.<br />If there...
Tips<br />
FIGURE 1.<br />Pelvic Floor Reconstruction Using Human Acellular Dermal Matrix After Cylindrical Abdominoperineal Resectio...
Cylindrical APR
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Cylindrical APR

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Cylindrical APR

  1. 1. CYLINDRICAL APR<br />PETER HEWETT<br />
  2. 2. DOORS OF DUBLIN<br />
  3. 3. DOORS OF ZANZIBAR<br />
  4. 4. RECTUMS OF EUROPE<br />British Journal of Surgery<br />Volume 97, Issue 4, pages 588–599, April 2010<br />
  5. 5. Local recurrence has not improved to the same degree as seen with anterior resection after the introduction of TME.<br />Significant reduction in tissue volume around the tumour in APR specimens compared with Anterior resection specimens<br />Greater CRM positivity<br />Greater local recurrence<br />Poorer 5 year cancer specific survival<br />
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  11. 11. Cylindrical AP Resection<br />Mobilisation of the mesorectum down to the origins of the levator muscles.<br />Stoma formation and closure<br />Patient is rotated into the prone position<br />Extended perineal resection<br />
  12. 12. Extended Perineal resection<br />Excision of the sphincter complex<br />Follows the inferior surface of the levators to a point laterally where they originate from the pelvic sidewall<br />The point should be just inferior to the level where the abdominal procedure was terminated<br />Coccyx can be removed in continuity with the main specimen<br />Repair of defect with a gluteal flap.<br />
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  20. 20. Advantages (literature)<br />Reduced rate of perforation<br />Reduced rate of CRM<br />70% more tissue outside the internal sphincter / muscularispropria at the tumour<br />14.5mm extra tissue posteriorly and 4mm at anterior and lateral margins at the tumour.<br />
  21. 21. J ClinOncol. 2008 Jul 20;26(21):3517-22. Epub 2008 Jun 9.<br />Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer.<br />West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P.<br />Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, United Kingdom. Karolinska University Hospital, Stockholm, Sweden <br />
  22. 22. ExtralevatorAPR removed more tissue from outside the smooth muscle layer per slice (median area 2120 versus 1259 mm2; P < 0·001) leading to a reduction in CRM involvement (from 49·6 to 20·3 per cent; P < 0·001) and IOP (from 28·2 to 8·2 per cent; P < 0·001) compared with standard surgery. However, extralevator surgery was associated with an increase in perineal wound complications (from 20 to 38·0 per cent; P = 0·019).<br />
  23. 23. Multicentre experience with extralevatorabdominoperineal excision for low rectal cancer†<br />N. P. West1,*, <br />C. Anderin3, <br />K. J. E. Smith2, <br />T. Holm3, <br />P. Quirke1<br />British Journal of Surgery<br />Volume 97, Issue 4, pages 588–599, April 2010<br />
  24. 24. Advantages<br />Good visualisation anterior structures with plane easily seen and dissected<br />Easy control of bleeders<br />Decreased perforation rate<br />One surgeon<br />Easy to teach<br />Easy to assist<br />Perineal operator does not get wet<br />Possibly less blood loss<br />
  25. 25. Disadvantages<br />Learning curve as to how far to dissect into the pelvis<br />Unaccustomed plane<br />Coccygeal division leaves bare bone in a potentially contaminated field.<br />No further access to abdomen during the perineal dissection<br />No difference in postoperative recovery<br />Perineal wound complications<br />
  26. 26. Tips<br />If the excised sigmoid colon is very fatty amputate it so that the rectum can be delivered easily.<br />If there is anterior attachment of the tumour take care in reflecting the rectum.<br />If possible mobilise an omental pedicle to place in the pelvis.<br />Remember the drain!<br />
  27. 27. Tips<br />
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  29. 29. FIGURE 1.<br />Pelvic Floor Reconstruction Using Human Acellular Dermal Matrix After Cylindrical Abdominoperineal Resection.<br />Han, Jia; Wang, Zhen; Gao, Zhi; Xu, Hui; Yang, Zeng; Jin, Mu<br />Diseases of the Colon & Rectum. 53(2):219-223, February 2010.<br />DOI: 10.1007/DCR.0b013e3181b715b5<br />FIGURE 1. Use of human acellular dermal matrix for reconstruction of pelvic floor.<br />© The ASCRS 2010.<br />2<br />
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