An abdominoperineal resection (abbreviated as AP resection, APR, or APER), formally known as an abdominoperineal resection of the rectum or an abdominoperineal excision of the rectum, is a surgical procedure performed to treat

rectal cancer Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel ...

anal cancer Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. A ...

. This operation involves the removal of the distal colon,

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

, and

anus In mammals, invertebrates and most fish, the anus (: anuses or ani; from Latin, 'ring' or 'circle') is the external body orifice at the ''exit'' end of the digestive tract (bowel), i.e. the opposite end from the mouth. Its function is to facil ...

, resulting in the creation of a permanent

colostomy A colostomy is an opening (stoma) in the large intestine (colon), or the surgical procedure that creates one. The opening is formed by drawing the healthy end of the colon through an incision in the anterior abdominal wall and suturing it int ...

. It is typically indicated for tumors located in the lower rectum or anal canal that cannot be adequately removed while preserving sphincter function. The procedure is performed via both an abdominal and a perineal approach, requiring the excision of affected tissues along with adjacent lymph nodes to ensure complete tumor removal and reduce the risk of recurrence.

Indication and description

See image on National Cancer Institute website
The principal indication for AP resection is a rectal carcinoma situated in the distal (lower) one-third of the rectum. Other indications include recurrent or residual anal carcinoma (

squamous cell carcinoma Squamous-cell carcinoma (SCC), also known as epidermoid carcinoma, comprises a number of different types of cancer that begin in squamous cells. These cells form on the surface of the skin, on the lining of hollow organs in the body, and on the ...

) following initial, usually definitive combination chemoradiotherapy. APRs involves removal of the

, the

and part of the

sigmoid colon The sigmoid colon (or pelvic colon) is the part of the large intestine that is closest to the rectum and anus. It forms a loop that averages about in length. The loop is typically shaped like a Greek letter sigma (ς) or Latin letter S (thus ''s ...

along with the associated (regional)

lymph nodes A lymph node, or lymph gland, is a kidney-shaped Organ (anatomy), organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphoc ...

, through incisions made in the

abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

and

perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...

. The end of the remaining

is brought out permanently as an opening, called a

stoma In botany, a stoma (: stomata, from Greek language, Greek ''στόμα'', "mouth"), also called a stomate (: stomates), is a pore found in the Epidermis (botany), epidermis of leaves, stems, and other organs, that controls the rate of gas exc ...

, which is used by the patient in conjunction with a

pouch, on the surface of the abdomen. The perineal part of the operation may be performed with intersphincteric dissection, leaving the external sphincter and levator muscles in-situ. This results in a smaller defect in the perineum and may be preferable when a margin to healthy tissue is not an issue, e.g. in IBD surgery.

Centralisation of rectal surgery

This operation is one of the less commonly performed by

general surgeon In medicine, a surgeon is a medical doctor who performs surgery. Even though there are different traditions in different times and places, a modern surgeon is a licensed physician and received the same medical training as physicians before spec ...

s, although they are specifically trained to perform this operation. As low case volumes in rectal surgery have been found to be associated with higher complication rates, it is often centralised in larger centres, where case volumes are higher.

Laparoscopic approach

There are several advantages in terms of outcomes if the surgery can be performed laparoscopically

Relation to low anterior resection (LAR)

An APR, generally, results in a worse

quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...

than the less invasive lower anterior resection (LAR). Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible.

History

William Ernest Miles (1869–1947), an English surgeon first performed the surgery of removing the rectum in 1907. He assumed that the rectal cancer can spread in both upwards and downward directions, thus necessitating the removal of the entire rectum together with the anal sphincters, resulting in a permanent stoma by connecting the proximal end of the descending colon to the skin. Mile's operation became the gold standard for treating rectal cancer because his technique successfully reduced the rate of cancer recurrence. To reduce the incidence of death and suffering of the patients associated with the APR procedure,

Henri Albert Hartmann Henri Albert Hartmann (16 June 1860 – 1 January 1952) was a French surgeon. He wrote numerous papers on a wide variety of subjects, ranging from war injuries to shoulder dislocations to gastrointestinal cancer. Hartmann is best known for Hartma ...

introduced the anterior resection of the rectum by preserving the distal rectum and anal sphincters, while producing end-sigmoid colostomy. There were attempts to restore bowel continuity by joining the proximal colon with the rectum, but the high incidence of leakage from the anastomotic site caused an increased risk of death to patients. It was only in 1948, Claude Dixon successfully connected the proximal bowel to the rectum, thus allowing patients to have a 64% 5-year survival rate.

References

External links

Laparoscopic Abdominoperineal Resection: Basic Surgical Steps
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Cleveland Clinic Cleveland Clinic is an American Nonprofit organization, nonprofit Academic health science center, academic Medical centers in the United States, medical center based in Cleveland, Ohio. Owned and operated by the Cleveland Clinic Foundation, an O ...

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