This document discusses extralevator abdominoperineal excision (ELAPE) for rectal cancer. It describes how ELAPE aims to improve on conventional abdominoperineal resection (APR) by removing a larger volume of tissue, including the levator muscles, to obtain clear margins. Meta-analyses have found ELAPE results in lower rates of circumferential resection margin involvement, local recurrence, and involved nodes compared to APR. However, ELAPE also increases morbidity risks and requires perineal wound reconstruction. While ELAPE shows potential oncological benefits, more high-quality studies are still needed to prove its superiority over selective approaches.

1. EXTRALEVATOR ABDOMINO-
PERINEAL RESECTION
Dr Harsh Shah
MS, FMAS, DNB, MCh (GI)
Kaizen Hospital
Ahmedabad

2. Evolution of rectal cancer
surgery
■ APR – Miles (1908)
■ Invention of circular stapler (1970)
■ TME by Heald (1982)
■ TEMS Gerhard Buess(1983)
■ Extralevator APR – T. Holm (2007)

3. Principles of rectal cancer
surgery
■ Neoadjuvant CTRT
■ High ligation of IMA
■ Circumferential resection margin
– Total mesorectal excision
– Sharp dissection of mesorectal fascia
– Autonomic nerve preservation
– Distal margin - 0.5 to 1cm

4. Classification of lower rectal tumours (Rulier
et al)

5. Indications of APR
■ Carcinoma rectum with involvement of external
sphincter or levators
■ Carcinoma rectum with poor sphincter function
■ Carcinoma anal canal (failed neo-adjuvant CTRT)

6. Standard APR

7. Problems with conventional
APR
■ High local recurrence rate (10-25%)
– Positive CRM at lower border of mesorectum
– Risk of inadvertent bowel perforation
■ Perineal wound related morbidity (15-55%)
– Infection, dehiscence, hernia
Law WL, Chu KW. Abdominoperineal resection is associated with poor
oncological outcome. Br J Surg 2004;91:1493—9.

8. APR vs AR/LAR

9. Why results of APR are poor
?■ Tumour related factors
– Higher T stage
– Poor tumour biology
■ Anatomical factor
– Mesorectum is very thin in lower rectum
■ Technical factors
– Poor visibility during deep rectal mobilization
– Poor perineal exposure (62% of rectal perforations)
– Too economical resection (preserving levators for closure)

10. Extralevator APR

11. ANATOMY OF LEVATOR
ANI MUSCLES

12. Pelvic floor muscles – Superior view
Puborectalis
Rectum
Pubococcygeus
Iliococcygeus
Tendinous arch
Coccygeus
Sacrococcygeal ligament

13. Pelvic floor muscles – Inferior
view
Puborectalis
Rectum
Pubococcygeus
Iliococcygeus

14. Ischiorectal Fossa

15. Anatomy of fascia

16. Pre-op preparation
■ Antibiotic prophylaxis
■ Mechanical bowel preparation
■ Thromboprophylaxis
■ Marking of stoma site

17. Technique- T. Holm (2007)
■ Abdominal part
– Mesorectum not dissected off levators
– Mobilization is stopped
■ Upper border of coccyx posteriorly
■ Just below autonomic nerves laterally
■ Just below seminal vesicles(males) &
cervix(females) anteriorly
– Divided sigmoid brought out as stoma

18. Perineal part- Prone jack-knife
position with legs apart

19. Perineal part- Technique
■ Anus closed with double
purse string suture
■ Tear drop incision
extended cranially to
lower part of sacrum
■ Dissection continues just
outside s/c portion of
external anal sphincter
■ Levators exposed
circumferentially
upto insertion

20. Prone position Tear drop incision

21. Technique- cont.
■ Coccyx disarticulated
from sacrum
■ Higher up division of
presacral fascia
■ Entry into pelvis
1. Presacral fascia 2. fascia propria 3. Waldeyer
Fascia. Blue line- abdominal dissection, Red line
Perineal dissection

22. Incision Coccyx disarticulaton

23. Division of levator muscles

24. Technique- cont.
■ Levator muscles divided
■ Specimen brought out &
dissected off
prostate/posterior
vaginal wall
1. Fascia propria 2. Denonvillier’s fascia

25. Cylindrical specimen with
the cuff of levator muscles
Wide perineal defect

26. Need for Perineal wound reconstruction
■ Wider defect created
■ Skin & ischio-rectal fat left for closure
■ Neoadjuvant RT
Advantages
■ Fills the dead space
■ Obtain skin healing
■ Allows rapid discharge

27. Perineal wound reconstruction
■ Flaps
– Gluteus maximus MCF
■ Unilateral
■ Bilateral
– Rectus abdominis MCF
■ Inferior epigastric artery
■ Need change of posture
– Gracilis flap
■ Medial circumflex femoral artery
■ Disadvantages
– Donor site morbidity
– Longer operating time
– Need for plastic surgeon

28. Perineal wound
reconstruction
■ Mesh
– Biological – acellular collagen (porcine, human)
– Shorter operating time
– Can be performed by colorectal surgeon
– No donor site morbidity
■ Disadvantages:
– Seroma
– Chronic pelvic pain

29. Advantages of ELAPE
■ Larger amount of tissue removed around the
tumour
– Fat
– Muscle
– Lymphatics
■ Prone position gives better visualization of
anatomy
■ Rate of tumour perforation are lower

30. ELAPE VS
CONVENTIONAL APR

31. Meta-analysis
■ Huang et al – 2014
■ Yu et al – 2014
■ Zhou et al – 2015
■ De Nardi - 2015
■ Negoi et al - 2016

32. Oncological superiority of extralevator abdomino
perineal resection over conventional
abdominoperineal
resection: a meta-analysis: Huang et al: Int J
Colorectal Dis (2014)
Six studies with a total of 881 patients
1 RCT, 1 Prospective study, 4 restrospective study
8.2 % 2

33. Oncological superiority of extralevator abdomino perineal
resection over conventional abdominoperineal
resection: a meta-analysis: Huang et al: Int J Colorectal
Dis (2014)
ELAP compared to APR
■ lower CRM involvement (OR, 0.36; 95%CI, 0.23–0.58; P <0.0001)
■ Lower IOP (OR, 0.31; 95%CI, 0.12–0.80; P =0.02)
■ lower LR rate (OR, 0.27; 95%CI, 0.08–0.95; P = 0.04)
■ Increased post-op morbidity in ELAP (p=0.67)
■ Subgroup analysis(Neoadjuvant CTRT) also revealed the same
results
■ Conclusions : ELAP achieved oncologically superior results as
compared to APR

34. Negoi et al AJS 2016
Studies ELAPE/APR OR p valu

35. Negoi et al AJS 2016
Studies ELAPE/APR OR p value

36. Limitations of ELAP
■ Need to change of posture
■ Longer operative time
■ Need for perineal wound reconstruction
■ Perineal wound related complication
■ Anterior CRM not affected
■ Chronic pelvic pain
■ Sexual dysfunction

37. Effect of Neo-adjuvant CTRT

38. Limitations of present studies
■ Only one RCT, with low sample size
■ Heterogeneous pre-operative treatment
– Neoadjuvant therapy
– Dose/duration
■ Selection bias
■ Extent of levator resection
■ Type reconstruction
■ Learning curve for ELAP
■ Quadrant oriented interpretation of CRM not available

39. Mesh vs flaps
Reconstruction of the perineum following extralevator
abdomino-perineal excision for carcinoma of the lower
rectum: a systematic review: Foster et al : colorectal dis
2012
■ 11 cohort studies
■ 255 patients - flap repair and 85 - biological mesh repair
■ no significant difference in the rates of perineal wound
complications or perineal hernia formation
■ Increased trend towards use of flaps for neo-adjuvant CTRT
group

40. MRI

41. Partial ELAP
■ Partial right or left ELAP can be performed
– Can improve perineal wound healing
■ Anteriorly located tumours
– Resection of posterior vaginal wall, partial
prostatectomy/Anterior exenteration can be planned

42. Summary- ELAPE
■ Levators resected en block with specimen
■ Avoids waist formation in specimen
■ Need for perineal wound reconstruction
■ Flaps or mesh gives equally good results

43. Take Home Message
■ Superiority to APR not proven
■ Need for high quality studies
■ Selective use of ELAPE/asymmetrical ELAPE is
recommended
■ Pre-operative MRI should be performed
■ Anteriorly located tumours need special attention

44. THANK YOU