abdomino-perineal resection

1. Presenter: Dr. Mohammad Masoom Parwez
Moderator: Prof. Dr. Pradeep Saxena

3.  Historical Background
 Indications
 Preoperative Planning
 Surgical Technique
 Post operative care
 Management of complications
 Outcomes

5.  W. Ernest Miles, 1908 : credited with describing modern APR
 Single stage surgery incorporating both abdominal and perineal procedure
 Creation of abdominal colostomy
 Removal of entire pelvic colon and meso colon below the common iliac artery
 Lymph node at the bifurcation of common iliac artery
 Levator muscles at their origin, ischiorectal fat and anus
 O.V Lloyd Davis popularized synchronous two team approach with patient in
lithotomy position
 Bill Heald, 1982: revolutionized the technique of entire mesorectum excision via
precise and meticulous dissection

9.  Adenocarcinoma lower rectum – for negative circumferential resection margin
(not distal margin)
 Anal SCC – that persists or recurs after chemoRT
 Anal melanoma
 Anal sarcoma
 GIST
 Extended APR – vulvar, vaginal or prostate ca involving distal rectum/anal
spinchter
 Benign – as a part of total proctocolectomy in FAP or IBD

10. Intersphincteric
Extralevator
Ischioanal

11.  Creates narrowest perineal wound
 For patients without levator
involvement, but incontinent
 Patients at high risk for anastomotic
leak – poor wound healing, inadequate
physiological reserve

12.  ELAPE – Extralevator abdominoperineal
excision
 Levator muscles are removed en bloc with
the specimen
 Tumor within a cm from the dentate line
 Low rectal tumor with threatened CRM
 Where a sphincter saving procedure is
oncologically impossible

13.  Levator muscles are incised at their
lateral insertions
 Dissection outside the fat pad of
ischioanal fossa and along fascia of
obturator internus muscle
 Widest of perineal dissection approach
 Tumor involving perianal skin,
ischioanal fat, levator muscles with
direct tumor invasion, perforation,
abscess, fistula

15.  Significant morbidity
 Medical clearance
 Marking of stoma site
 Counselling by stoma therapist
 Bowel cleansing/enema (original Nichols and Condon oral antibiotic regime, 1970
of Neomycin and Erythromycin base)

16. Extent of resection:
 Physical examination and review of imaging
 Multidisciplinary approach with specialists
 Anterior structures – prostate, post wall of vagina
 Posterior structures - sacrum
 Pelvic sidewall lymphadenopathy – extended lymphadenectomy
 Dr. Solomon – extended resections and pelvic exenteration

18. Stoma marking:
 Outer third of rectus abdominis
 Abdomen characteristics: Protuberant abdomen, folds, scars, costal margin and
iliac crest, pendulous breasts an hernias
 Patient characteristics: mobility (wheelchair bound), posture (kyphosis), dexterity,
vision
 Patient preference for location (belt line)
 Surgical considerations: type of stoma (loop vs end), segment of intestine, need for
both urinary and fecal stoma, continence

19. Workup:
 History - baseline urinary and sexual function, continence
 DRE – relationship of tumor to surrounding structures
 Staging workup – CT scan of chest, abdomen and pelvis, baseline CEA, endorectal
US, MRI of pelvis (T and N stage)
 MERCURY Trial – 91% accuracy of MRI in predicting negative resection margin
in patients going for primary surgery and 77% accuracy among [patients who have
received NACT
 Rectal MRI – invasion of levator muscle and sphincter complex relation

20. Abdominal dissection
Perineal dissection

21.  Lloyd Davis position – both procedures can be performed without repositioning
the patient
 Prone jack knife position
 Lithotomy position

22. Abdominal dissection:
 Lower midline or low transverse laparotomy
 Thorough examination of abdomen and pelvis
 Sigmoid colon is mobilized by dividing the attachments and adhesions to lateral
abdominal and pelvic sidewall
 Incision is extended cephalad upto splenic flexure and distally towards pelvis
 Mesentery is lifted from RP attachment exposing the left gonadal vessels and left
ureter
 Stay in retromesocolic plane. Deeper dissection – damage to left ureter and
gonadal vessels

24.  Sigmoid colon is retracted anteriorly
and laterally exposing the root of the
sigmoid mesentery
 Incision is made to right of sigmoid
mesocolon, proximal to promontory
 Plane is developed underneath the
superior rectal vessels in the loose
areolar tissue, between the origin of
inferior mesenteric artery and
promontory

25.  Avoid injuring the superior hypogastric plexus – situated between the sup rectal
vessels and bifurcation of aorta
 Hypogastric nerves can be seen as two band like structures just lateral to the
midline, as the dissection proceeds inferior to the sacral promontory
 Identify and secure the ureter in the retroperitoneum, isolate and ligate the
superior rectal vessels between the origin of left colic and first sigmoid vessel
 Left colic artery is not routinely divided, but any enlarged LN around the
bifurcation of IMA should be dissected
 High ligation of IMA carries the risk of damaging the hypogastric plexus

26.  The mesentery of the sigmoid colon is divided at the point chosen to create the end
colostomy
 The colon itself is divided using a linear stapler after ensuring sufficient
mobilisation to ensure a tension free, well vascularized colostomy
 Areolar plane behind the fascia proper of the rectum is opened by anterior
reflection of the stump of the superior rectal vessels and the proximal rectum
away from the promontory
 Identify and protect B/L hypogastric nerves present in the lateral aspect of the
areolar space

27.  Inferior dissection is carried along the
concavity of the sacrum, till the
sacrococcygeal junction and extended
from the midline, laterally
 Distally, preserve the pelvic splanchnic
nerve coursing from the lateral pelvic
sidewall near the anterior sacral
foramina to join the pelvic plexus
 Division of the areolar connective
tissue should be done using
electrocautery or other sharp
dissection

29.  The lateral stalks are exposed and divided using electrocautery by providing
traction on the rectum to the opposite side of the pelvis
 Forceful retraction can damage the pelvic plexus
 Dissection is continued laterally until the origin of levator muscle is reached
 Finally, the peritoneum is opened anteriorly in the cul de sac
 Dissection is carried to the level of prostate in men, and halfway down the vagina
in women
 Placement of pelvic drain, closure of midline incision and maturing of stoma

34. Perineal dissection:
 Position: lithotomy or prone jack
knife
 Elliptical incision made outside the
lateral edge of external sphincter and
medial to ischial tuberosity
 Posteriorly, incision should be
midway between anus and coccyx
 Anteriorly, it should divide the
perineal body
 Can be extended

35.  The dissection is done using electrocautery, controlling the perforating vessels as
well as the inferior rectal arteries
 Palpate the coccyx and aim the posterior dissection to join with the posterior
mesorectal dissection
 Dividing the anococcygeal ligament at the tip of the coccyx provides access to the
posterior pelvis for joining the mesorectal dissection
 Once the two dissection planes have been connected posteriorly, divide the levator
muscles close to their insertion on the tendinous arch covering the obturator
internus

36.  Placing the index finger of the non dominant hand into the pelvis and hooking the
levator muscles facilitates this division
 Puborectalis should be divided anteriorly before the transverse perineal muscle is
reached

41.  The rectum is still attached anteriorly to the prostate or vagina
 At this point, it should be delivered through the wound to facilitate exposure for
anterior dissection
 This is best performed from proximal to distal following the anterior surface of the
prostate/vagina and from medial to lateral
 This approach provides better visualization of the neurovascular bundle (pelvic
plexus) and avoids injury to the urethra
 In males, palpating the urethra and the urinary catheter can help avoid injury
 In females, placing a finger in the vagina helps define the plane of the
rectovaginal septum

42.  Once the specimen is removed, the pelvic cavity is irrigated
 Pelvic drains placed previously are repositioned as required and perineal defect is
closed
 For primary closure, meticulous multi-layered closure of the ischiorectal fat with
absorbable sutures is done, and skin is approximated in a vertical mattress
pattern using nylon

43.  In patients with large perineal defects, reinforcement with a biological absorbable
mesh anchored to the coccyx, coccygeus muscle and pelvic sidewall is done to
prevent wound dehiscence and perineal hernia
 Other options
 VRAM flap
 B/L V-Y advancement gluteal flaps
 Gracilis muscle flaps

49.  ERAS –
 Early ingestion of clear liquids advancing to low residue diet as tolerated
 Limited IV fluid resuscitation
 Early ambulation
 Non narcotic pain control
 Urinary catheter at least till third post op day
 Post APR drain management
 Primary closure – remove prior to discharge
 Rectus flap – as long as 2 weeks or till output diminishes
 Restrict physical activity to protect the perineal wound

50.  For primary closure, avoid sitting for 4 – 5 weeks
 Perineal sutures to remain in place for 3-4 weeks
 For flap closure, avoid bending at the waist for 4-5 weeks

52.  Most common source of morbidity – perineal wound
 Perineal wound infection as high as 40%, high risk of evisceration
 Wound is irrigated, necrotic tissue removed, additional drain placed and wound
reclosed if possible
 Otherwise, negative pressure dressing has good success rate
 Synthetic prosthetic devices (silicone breast implants) can also fill the defect,
though not recommended in contaminated fields

53.  Genitourinary and sexual dysfunction – up to 50%
 Prevention –
 Surgical technique
 Identification and protection of pelvic nerve
 Minor dysfunction improves 12 months after surgery
 However, a significant minority of patients sustain permanent dysfunction

54.  Stoma related complication – parastomal hernia – significant long term
consequence
 Studies support the use of preperitoneal prosthetic mesh for constructing
permanent ostomies

56.  APR performed in lithotomy – risk of intraoperative bowel perforation and
positive CRM – higher recurrence rate and mortality compared to LAR
 With neoadjuvant chemoradiation, local recurrence as high as 30%
 Prone positioning for cylindrical APR – reduction in local recurrence rate to 6%
and perineal wound infection to 11%, decreased rate of positive CRM
 Patient with clinical stage 2 or 3 treated with neoadjuvant chemoradiotherapy
and optimal surgery, 5 year survival rate after APR is around 70% compared to
85% after sphincter preserving surgery

57.  Fischers Mastery of Surgery, 7th international edition (2019)
 Maingot’s Abdominal Operations, 13th edition (2019)