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Abdominoperineal Resection
Abdominoperineal Resection
Abdominoperineal Resection
ver the past few decades there have been significant possibility that the bowel may not easily reach the pre-
O advances in adjuvant therapy for malignant condi-
tions of the anus and low rectum, as well as medical
ferred location and an alternative site should be marked.
In preparation for an abdominoperineal resection, pa-
therapy for inflammatory bowel disease involving the rec- tients undergo a standard bowel preparation with me-
tum and anal canal. Many of these advances have allowed chanical evacuation of the large bowel often using a
sphincter-sparing operations and in some cases, the pos- balanced electrolyte solution (GoLytely威, Braintree Lab-
sibility to delay or avoid surgery. In 2003, it is predicted oratories, Braintree, MA) along with an antibiotic prophy-
that there will be 42,000 new cases of rectal cancer and laxis. We use a combination of neomycin 1 g and metro-
4000 cases of anal cancer.1 Although the possibility of nidazole 1 g at 1 PM, 2 PM, and 9 PM the evening before
sphincter sparing surgery following neoadjuvant therapy surgery. Bowel preparation is performed at home and the
either with a low double stapled anastomosis or an inter- patients arrive to the hospital before their planned oper-
sphincteric dissection and hand sewn coloanal anastomo- ative procedure. Before the start of the operation, addi-
sis may be possible in many patients with cancer of the tional antibiotic prophylaxis is given intravenously. Al-
low rectum, when the sphincter complex is involved, though many antibiotic regimens are appropriate, we use
sphincter sparing operations are not possible. In addition, Cefotetan威 (Astra-Zeneca, Wilmington, DE) 2 g before sur-
despite significant advances in medical therapy for in- gery and 1 g at 12 and 24 hours later. After the perioperative
flammatory bowel disease, abdominoperineal excision is dosing of antibiotics, further antibiotics are not used.
required for most patients undergoing surgery for Crohn’s In the operative room the patient is positioned in a
proctitis and is occasionally selected as the operative proce- modified lithotomy position (Fig 1). The rectum is pre-
dure of choice by a few patients with ulcerative colitis. pared by insertion of a 32 French Malecot catheter fol-
Indications for abdominoperineal resection include lowed by lavage with normal saline solution. Once clear,
those patients with a malignancy involving the sphincter full strength Betadine solution is instilled within the rec-
complex,2 patients with Crohn’s proctitis and anal dis- tum for its tumorocidal properties. The Malecot catheter
ease,3 patients with ulcerative colitis preferring to have a may be left as a drainage tube for evacuation of residual
stoma or those patients with any of the above conditions colonic contents during the operation and to prevent ac-
cumulation of residual stool in the rectum during the
who already suffer with incontinence and would be debil-
pelvic or perineal dissection. Alternatively, some sur-
itated by a low anterior, coloanal, or ileal pouch anal
geons prefer to encircle the anal canal with a suture such as
anastomosis. These patients have a superior quality of life
a #1 Prolene to occlude the anal orifice. If the procedure is
with their stool evacuation from either an ileostomy or a
performed for anal cancer, this often is not possible.
colostomy into a contained bag allowing them the free-
Most commonly, a midline incision is created and
dom to live a normal life.
curves around the umbilicus opposite the side of the
Preoperative preparation and education of the patient
planned stoma. If a colostomy is planned the incision will
is important before creating a stoma. An Enterostomal
curve to the right of the umbilicus and if an ileostomy
Therapist (ET) should visit with the patient and discuss were planned it would then curve to the left. The fascia is
what a stoma is and what appliances are available and divided along the linea alba and the peritoneal cavity is
how they would function. The ET nurse will then perform entered. On entering the peritoneal cavity exploration
preoperative stoma siting. The stoma should be sited should be performed. In patients with malignant disease,
away from creases and in a location that the patient can careful palpation of the liver is important and intraoper-
see. It is preferable to mark more than one location in the ative ultrasonography can be performed. The upper ab-
dominal contents should be gently palpated and then the
intestines inspected. After palpating the stomach and du-
From the University of Texas Southwestern Medical Center at Dallas, Dallas,
TX. odenum, the small bowel should be palpated and in-
Address reprint requests to Clifford L. Simmang, MD, MS, FACS, FASCRS, spected from the ligament of Treitz to the ileocecal valve.
5323 Harry Hines Blvd., Dallas, TX 75390-9156. This is to identify concomitant pathology that may need
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0504-0006$30.00/0 attention at the time of this operation. The colon is then
doi:10.1053/joptechgensurg.2003.10.005 palpated throughout, as are the retroperitoneal structures.
1 Lithotomy positioning. The operative position for a synchronous abdominoperineal resection is low lithotomy. This is most
often accomplished with the use of adjustable stirrups to allow for a gentle flex at the knees and elevation of the lower extremities.
Elevation of the lower extremities assists in promoting venous drainage, which may reduce the incidence of venous thrombosis.
Sequential compression devices are also used for prophylaxis not only for venous thromboembolism, but also as an additional
cushion to prevent nerve injury. The patient’s position must be inspected for appropriate padding. A soft roll, which may be a sheet
or a blanket, may be placed underneath the patient’s buttocks to aid in elevation and exposure for the perineal portion of the
operation. Once in position, the anal canal may be closed with a heavy suture to prevent perineal contamination.
242 Clifford L. Simmang
higher incidence of rectal perforation because of the ad- ues circumferentially on either side. At times a finger can
herence of Waldeyer’s fascia. Sharp dissection and divi- be placed through this opening and the surgeon can cau-
sion will decrease this complication. Circumferential dis- terize through the levators onto his finger on the perito-
section is now performed by incising the peritoneum at neal pelvic side (Fig 11B). This division is continued on
the base of the cul-de-sac. For a low rectal cancer, espe- both sides leaving the anterior dissection yet to complete.
cially if this is in an anterior location, the anterior dissec- If the plane of dissection is clearly defined, the anterior
tion should be performed on the prostate side of Denon- dissection is completed (Fig 11C). However, if there is
villiers’ fascia (Fig 6). If the tumor is posterior, and then adherence or the operative planes are difficult, exposure
the anterior dissection in men may be on the rectal side of can be improved by passing the proximal end of the sig-
Denonvilliers’ fascia, which will decrease the likelihood moid colon out the posterior opening of the levators (Fig
of nerve injury. This circumferential dissection is contin- 10). This allows traction from both the proximal and distal
ued until a complete mesorectal dissection is performed aspects of the rectum and can aid in helping define the plane
and the rectum has coned down to the narrow muscular required for transection to achieve a grossly clear margin.
tube as it enters into the anal canal. In women, the ante- There are special considerations when performing APR
rior dissection begins at the depth of the cul-de-sac (Fig for anal cancer or IBD. For patients with IBD where this
7) and proceeds through the avascular plane in the recto- operation is being performed for an inflammatory condi-
vaginal septum. If adherence is noted during this dissec- tion of the rectum, an intersphincteric proctectomy is
tion, especially anteriorly, it may be prudent to wait for preferred.4 This achieves resection of all diseased bowel
the perineal operator to begin and approach the most while limiting the size of the perineal wound and increas-
tethered area simultaneously abdominally and perineally. ing the likelihood for primary healing. However, for those
If the tumor is tethered to the posterior vaginal wall, a patients with anal cancer, especially if there is a significant
posterior vaginectomy should be performed (Fig 8). The component onto the anal margin, a wide perineal skin exci-
perineal approach begins with a standard posterior inci- sion will be required. This wound cannot be closed primarily
sion, however the anterior incision proceeds to incorpo- and must then be repaired with a flap. A very difficult wound
rate an ellipse of the posterior vagina (Fig 9). Once the may be treated with wound care or even a wound vac to
specimen is delivered, the posterior vagina and the peri- promote healing or allow the addition of a flap.
neal body can be reconstructed with absorbable sutures The perineal wound is closed in layers. I use a series of
(Fig 10). The proximal end of the colon can be passed 2-0 figure of eight absorbable sutures and attempt to ap-
posteriorly to better visualize the last anterior attach- proximate the levators, if possible. If this has been a very
ments (Fig 10). In men, if the tumor appears tethered to wide excision, there will be little left and all that can be
Denonvilliers’ fascia, a superficial layer of the prostate approximated is the subcutaneous ischiorectal fat. There are
capsule can be encorporated. However, if there is invasion sufficient fibrous septae running through this fat to allow for
within the prostate, a combined en bloc proctectomy with closure. The skin is closed with subcuticular sutures. One or
cystoprostatectomy (anterior exenteration) is required. two pelvic drains are placed abdominally and are brought
This possibility should have been detected, discussed, out through separate abdominal stab incisions. I believe that
and planned for preoperatively and a surprise in this lo- transabdominal drainage is preferable to perineal drainage,
cation should not occur. as this is as effective and much more comfortable for the
The perineal dissection is most often performed syn- patient. Some surgeons omit drainage all together.
chronously with the completion of the pelvic dissection. The colostomy is fashioned by excising a quarter-
An elliptical incision is made centering on the perineal sized disc of skin and core of subcutaneous fat (Fig 12).
body anteriorly and the mid point between the anal canal The anterior rectus sheath is identified and incised
and the coccyx posteriorly (Fig 11A). The skin is incised longitudinally. The skin and fascia are kept in align-
and the incision is carried into the ischiorectal fat. This ment by the use of Kocher clamps to assure that after
dissection is performed circumferentially by continually the colostomy is brought straight through and when
going from one location and one side to another to the skin is later closed, that the angle does not change.
achieve length and advance the dissection. The dissection The abdominal wall is then elevated as a curved Mayo
should be in the ischiorectal fat outside of the sphincter scissors is passed between the fibers of the rectus mus-
complex. The neurovascular bundle to the anus enters in cle and the tips are opened to allow a longitudinal
the posterolateral location and caution should be exer- incision of the posterior rectus sheath to be made. The
cised with dissection in this area and anticipate the pos- passage through the rectus is then maintained and di-
sible need for hemostatic control. I prefer to enter the lated to allow two fingers to easily pass through. The
peritoneal cavity in the posterior location. A malleable end of the colon is then brought up through this open-
retractor can be inserted deep into the pelvis and easily ing and will be allowed to remain there until the abdo-
palpated by the perineal surgeon. Using cautery, the inci- men is closed (Fig 13). It is matured as the last step to
sion can be carried directly onto this retractor. Once entry avoid contamination of the incision. It is not necessary
into the peritoneal cavity is gained, the dissection contin- to tack the colostomy to the posterior fascia. The mid-
Abdominoperineal Resection 243
line incision is closed and the staple line excised from turing ileostomies, colostomies can be matured with a
the distal end of the colon. The colostomy is matured full thickness of skin. Some surgeons will also encor-
by performing interrupted sutures in the colon begin- porate a three-point suture fixation everting the colos-
ning at the mucoserosal junction with about 1 cm of tomy much like a Brooke ileostomy is performed. Al-
distal colon within this suture and then placing the though this is not necessary for a colostomy, it will help
suture through the skin about 5 mm from the edge. prevent retraction. A stoma appliance it then placed around
Although subcuticular sutures are preferable when ma- the stoma and a dressing placed over the incision.
2 Left colon mobilization. After entry into the abdominal cavity and thorough exploration, the operation is begun by mobiliza-
tion of the left colon. Although some surgeons will begin with a high ligation of the IMA, performing the “no touch” technique by
ligating the vascular pedicle before colonic manipulation, most surgeons begin with lateral mobilization. The peritoneal reflection
is incised with electrocautery. This incision lies just inside the white line of Toldt. As the colon is elevated a second retroperioneal
fusion plane is identified and dissection progresses in the avascular areolar tissue plane. As this progresses medially, the first set of
tubular structures to be encountered will be the gonadal vessels. Key to avoiding injury to the ureter is to recognize that inferior to
the IMA, the ureter lies medial to the gonadal vessels. The ureter is identified next and the colon is mobilized proximally. This
proximal mobilization is carried superiorly and around the splenic flexure to provide adequate mobility of the left colon, as needed.
Following mobilization of the left colon a plane is developed underneath the superior hemorrhoidal artery.
244 Clifford L. Simmang
3 High ligation of the inferior mesenteric artery. A window is created on the right, medial side of the sigmoid colon mesentery
underneath the superior hemorrhoidal artery. The peritoneum is then incised just inferior to the superior hemorrhoidal artery and
this window is enlarged until the inferior mesenteric artery is encountered. The inferior mesenteric artery is then divided between
clamps and ligated. This division defines the mesenteric dissection leading to the site on the colon, which will represent the
proximal margin that was defined by division of its vascular mesentery. The colon is divided with a linear cutting stapling device.
Abdominoperineal Resection 245
5 Division of lateral ligaments. A fibrous condensation containing the middle hemorrhoidal vascular pedicle makes up the lateral
ligaments. Traction on the rectum to the opposite side will allow this structure to be identified as a curtain of tissue. Often, this
vascular pedicle is not prominent and can be divided by cautery, especially if the patient has undergone neoadjuvant therapy. If a
prominent vascular pedicle is present, it may be divided between ties, clips, with an ultrasonic device (Autosonics威 US Surgical
Corporation, Harmonic Scalpel威 Ethicon Endosurgery) or using a vascular endoscopic stapler (US Surgical Corporation, Ethicon
Endosurgery).
Abdominoperineal Resection 247
6 Anterior dissection in men. Following the posterior dissection the lateral peritoneum is incised. An incision is made 5 mm
anterior to the fold of the cul-de-sac. The seminal vesicles are exposed and using sharp dissection most commonly with cautery, the
seminal vesicles are cleared. The plane of dissection continues anterior to encompass Denonvilliers’ fascia until the junction with
the prostatic capsule. Further distal dissection is between the mesorectal fat and the prostatic capsule, staying as wide as possible.
For a tumor in the anterior location Denonvilliers’ fascia should be separated from the prostatic capsule as needed to provide a clear
and free radial margin from the tumor.
248 Clifford L. Simmang
11 (continued) (C) The remaining anterior attachments are now divided. This is often performed last to minimize the risk of
injury to the urethra and prostate in males which lie directly anterior to this dissection (at times this can be facilitated by delivery
of the proximal rectum through the posterior wound helping to define the remaining anterior attachments).
254 Clifford L. Simmang
12 Construction of an end colostomy. Selection of stoma location. A quarter-sized disc of skin is excised at the colostomy site
previously marked. The anterior rectus sheath is split longitudinally. The rectus muscles are separated and the peritoneum is incised
longitudinally as well. The skin and fascia should remain at the same level to provide for a straight tunnel or opening through the
rectus that does not change at the end of the operation when the skin is closed.
Abdominoperineal Resection 255
scopic surgeons. Despite advances in surgical 4. Zeitels J, Fiddian-Green R, Dent T: Intersphincteric proctatec-
technique along with improvements in neoadjuvant tomy. Surgery 96(4):617-623, 1984
5. Rullier E, Laurent C, Carles J, et al: Local recurrence of low rectal
and adjuvant therapy, the surgical treatment of rectal cancer after abdominoperineal and anterior resection. Br J Surg
cancer involving the pelvic floor and sphincter com- 84:525-528, 1997
plex remains complicated. Strict attention to the tech- 6. Nissan A, Guillem J, Paty P, et al: Abdominoperineal resection for
nical details of this operation are required to achieve an rectal cancer at a specialty center. Dis Colon Rectum 44:27-35,
optimal surgical outcome. 2001
7. Tschmelitsch J, Kranberger P, Prommegger R, et al: Survival
and local recurrence after anterior resection and abdomino-
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