Abdominal perineal resection

Abdominoperineal resection (APR) for many years was the treatment of choice for most patients with rectal cancer.

Recent advances in surgical technique and other treatment modalities have led to a marked increase in the rate of sphincter-sparing operations, with a concomitant decrease in APR.

APR completely removes the distal colon, rectum, and anal sphincter complex using both anterior abdominal and perineal incisions, resulting in a permanent colostomy.

Recent advances have included total mesorectal excision in patients undergoing APR and the addition of methods to enhance perineal wound healing.

Minimally invasive techniques are also being applied to APR, with good initial results.

Patients are given a mechanical bowel preparation the day before surgery, and parenteral antibiotics are given in the perioperative period.

The colostomy site is positioned to avoid the midline incision, bony prominences, scars and skin folds. In the presence of a large rectal mass, perirectal tissue invasion, or ureteral involvement, ureteral stents should be placed.

Laparoscopic abdominoperineal resection can be performed safely and with reduced hospital stay, and since the specimen is removed through the perineum, no large abdominal incisions are required and that significantly reduces postoperative pain.

Preoperative preparation and patient positioning are identical to the open procedure, as are the principles of the operation.

Conversion rates for laparoscopic abdominoperineal resection vary from 1.4 to 48% due to bleeding, inability to obtain exposure, large tumor size, adhesions, inguinal hernia, and radiation fibrosis.

Complication rates between open procedure and laparoscopic surgery are similar and there is no significant difference is oncologic outcomes.

Choice of technique should be based on patient selection and surgeon experience.

Cardiac and pulmonary complications account for most of the 3% operative mortality.

The most common immediate complication is intraabdominal or pelvic abscess.

Abscesses account for one third of early complications.

Complications may arise from nerve injury, urologic injury, the perineal wound, and the ostomy.

APR sequelae include perineal wound complications that may cause pressure and pain and skin breakdown along with evisceration.

Permanent sexual or urinary dysfunction occurs in about 60% of patients treated with APR.

Peroneal nerve injury from incorrect stirrup use and brachial plexus injury from steep Trendelenburg positioning may occur.

Autonomic nerves that affect both sexual and urinary function may be injured at during pelvic dissection, and postoperative sexual or urinary dysfunction can range from 10 to 60%.

Associated with bleeding in 4% of patients, 11-16% have wound infection and 14-24% have wound dehiscence.

Dissection may injure the hypogastric nerves, and the autonomic plexus is at risk.

Autonomic injury to the bladder may result in bladder dystonia, and sexual dysfunction in men.

Perineal wound complications are common.

The perineal wound is closed primarily or with a myocutaneous flap.

The membranous urethra may be injured by the perineal surgery.

Perineal herniation is an extremely rare complication.

Falling prevalence due to improved surgical techniques have decreased the number of patients who require this procedure, and the use of neoadjuvant therapy has eliminated a subset of patients who in past years would have undergone abdominoperineal resection.

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