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possibility that the bowel may not easily reach the preferred location and an alternative site should be marked.
In preparation for an abdominoperineal resection, patients undergo a standard bowel preparation with mechanical evacuation of the large bowel often using a
balanced electrolyte solution (GoLytely, Braintree Laboratories, Braintree, MA) along with an antibiotic prophylaxis. We use a combination of neomycin 1 g and metronidazole 1 g at 1 PM, 2 PM, and 9 PM the evening before
surgery. Bowel preparation is performed at home and the
patients arrive to the hospital before their planned operative procedure. Before the start of the operation, additional antibiotic prophylaxis is given intravenously. Although many antibiotic regimens are appropriate, we use
Cefotetan (Astra-Zeneca, Wilmington, DE) 2 g before surgery and 1 g at 12 and 24 hours later. After the perioperative
dosing of antibiotics, further antibiotics are not used.
In the operative room the patient is positioned in a
modified lithotomy position (Fig 1). The rectum is prepared by insertion of a 32 French Malecot catheter followed by lavage with normal saline solution. Once clear,
full strength Betadine solution is instilled within the rectum for its tumorocidal properties. The Malecot catheter
may be left as a drainage tube for evacuation of residual
colonic contents during the operation and to prevent accumulation of residual stool in the rectum during the
pelvic or perineal dissection. Alternatively, some surgeons prefer to encircle the anal canal with a suture such as
a #1 Prolene to occlude the anal orifice. If the procedure is
performed for anal cancer, this often is not possible.
Most commonly, a midline incision is created and
curves around the umbilicus opposite the side of the
planned stoma. If a colostomy is planned the incision will
curve to the right of the umbilicus and if an ileostomy
were planned it would then curve to the left. The fascia is
divided along the linea alba and the peritoneal cavity is
entered. On entering the peritoneal cavity exploration
should be performed. In patients with malignant disease,
careful palpation of the liver is important and intraoperative ultrasonography can be performed. The upper abdominal contents should be gently palpated and then the
intestines inspected. After palpating the stomach and duodenum, the small bowel should be palpated and inspected from the ligament of Treitz to the ileocecal valve.
This is to identify concomitant pathology that may need
attention at the time of this operation. The colon is then
palpated throughout, as are the retroperitoneal structures.
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Once the major arterial trunk is divided this defines the
proximal margin of resection. The mesentery is divided to
the colon, which will be near the junction of the descending
and sigmoid colon. The colon is then divided with a linear
cutting stapling device, which allows separation and prevents spillage or contamination of colonic contents (Fig 3).
Once the colon is divided, attention is directed toward
the pelvic dissection. This is begun in the posterior plane.
Continuing to mobilize the rectum in the avascular embryonic fusion plane will allow a total mesorectal excision
to be performed using a nerve sparing technique as the
hypogastric nerves can be readily identified during this
dissection (Fig 4). There will be branches given off as the
nerves traverse the pelvis, but the main trunk should be
identified and preserved during the main dissection (Fig
4). A deep pelvic St. Marks type retractor is very useful
for getting lift on the rectum and allowing this areolar
tissue plane to become readily visible. Dissection of the
rectum should be performed sharply under vision. I prefer to use electrocautery as it does aid in hemostasis especially in the area of the lateral stalks (Fig 5). As progress
dissecting the posterior rectum continues and tethering is
noted from the lateral peritoneal reflection, this should be
incised and divided. This will allow for further mobility
with the rectum. Sharp dissection will allow sharp division of Waldeyers fascia. Blunt pelvic dissection by sliding the operators hand behind the rectum has led to a
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 patients position must be inspected for appropriate padding. A soft roll, which may be a sheet
or a blanket, may be placed underneath the patients 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.
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higher incidence of rectal perforation because of the adherence of Waldeyers fascia. Sharp dissection and division will decrease this complication. Circumferential dissection is now performed by incising the peritoneum at
the base of the cul-de-sac. For a low rectal cancer, especially if this is in an anterior location, the anterior dissection should be performed on the prostate side of Denonvilliers fascia (Fig 6). If the tumor is posterior, and then
the anterior dissection in men may be on the rectal side of
Denonvilliers fascia, which will decrease the likelihood
of nerve injury. This circumferential dissection is continued until a complete mesorectal dissection is performed
and the rectum has coned down to the narrow muscular
tube as it enters into the anal canal. In women, the anterior dissection begins at the depth of the cul-de-sac (Fig
7) and proceeds through the avascular plane in the rectovaginal septum. If adherence is noted during this dissection, especially anteriorly, it may be prudent to wait for
the perineal operator to begin and approach the most
tethered area simultaneously abdominally and perineally.
If the tumor is tethered to the posterior vaginal wall, a
posterior vaginectomy should be performed (Fig 8). The
perineal approach begins with a standard posterior incision, however the anterior incision proceeds to incorporate an ellipse of the posterior vagina (Fig 9). Once the
specimen is delivered, the posterior vagina and the perineal body can be reconstructed with absorbable sutures
(Fig 10). The proximal end of the colon can be passed
posteriorly to better visualize the last anterior attachments (Fig 10). In men, if the tumor appears tethered to
Denonvilliers fascia, a superficial layer of the prostate
capsule can be encorporated. However, if there is invasion
within the prostate, a combined en bloc proctectomy with
cystoprostatectomy (anterior exenteration) is required.
This possibility should have been detected, discussed,
and planned for preoperatively and a surprise in this location should not occur.
The perineal dissection is most often performed synchronously with the completion of the pelvic dissection.
An elliptical incision is made centering on the perineal
body anteriorly and the mid point between the anal canal
and the coccyx posteriorly (Fig 11A). The skin is incised
and the incision is carried into the ischiorectal fat. This
dissection is performed circumferentially by continually
going from one location and one side to another to
achieve length and advance the dissection. The dissection
should be in the ischiorectal fat outside of the sphincter
complex. The neurovascular bundle to the anus enters in
the posterolateral location and caution should be exercised with dissection in this area and anticipate the possible need for hemostatic control. I prefer to enter the
peritoneal cavity in the posterior location. A malleable
retractor can be inserted deep into the pelvis and easily
palpated by the perineal surgeon. Using cautery, the incision can be carried directly onto this retractor. Once entry
into the peritoneal cavity is gained, the dissection contin-
Clifford L. Simmang
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turing ileostomies, colostomies can be matured with a
full thickness of skin. Some surgeons will also encorporate a three-point suture fixation everting the colostomy much like a Brooke ileostomy is performed. Although this is not necessary for a colostomy, it will help
prevent retraction. A stoma appliance it then placed around
the stoma and a dressing placed over the incision.
Left colon mobilization. After entry into the abdominal cavity and thorough exploration, the operation is begun by mobilization 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.
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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.
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Autonomic nervous plexus and innervation of the pelvic structures. The most common
sites for potential nerve injury can be seen.
Sympathetic injury may occur at the aortic
plexus near the origin of the IMA or over the
sacral promontory at the division of the hypogastric nerves from the hypogastric plexus. In
addition to sympathetic injury, parasympathetic injury may occur during lateral dissection, especially when there is division of the
lateral ligaments or anterolaterally during dissection behind the seminal vesicles and prostate.
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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 US Surgical
Corporation, Harmonic Scalpel Ethicon Endosurgery) or using a vascular endoscopic stapler (US Surgical Corporation, Ethicon
Endosurgery).
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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.
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Abdominoperineal Resection
Anterior rectal cancer involving the rectovaginal septum requiring posterior vaginectomy.
This dissection may be performed either by a synchronous team in the lithotomy position or a single operative team approach where the abdominal
portion has been completed and the operation is
now performed in prone position as demonstrated
here. Lines for transection are shown encorporating the colon, sphincter complex and posterior
vagina next to where the rectal lesion is located.
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(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).
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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.
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13
POSTOPERATIVE CARE
Postoperatively, a Foley catheter is left for urinary drainage for 4 to 5 days. Men, especially, may have difficulty
with voiding. After pelvic dissection, there is some laxity
of the anterior support as well as swelling and edema from
the procedure, which may lead to voiding difficulties in
the first few days. The pelvic drains are left until they
produce less than 50 mL of drainage per day or have been
in for 5 to 7 days and the patient is preparing for discharge. I remove pelvic drains before the patient goes
home.
RESULTS
Operating within the confined space of the pelvis increases the difficulty and complexity of surgery for rectal
cancer. Difficulty in achieving circumferential and radial
margin has been associated with a much higher local
recurrence rate in patients with rectal cancer than patients with colon cancer. Recurrence rates of 31%5 to
53%2 have been reported. However, results from other
centers have reported recurrence rates as low as 6%6 to
10%.7 These centers have used a combination of neoadjuvant, intraoperative, and postoperative adjuvant therapy to reduce local recurrence. Most centers have reported no significant difference in the local recurrence
between patients undergoing an anterior resection and an
abdominoperineal resection.
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REFERENCES
1. Jemal A, Murray T, Samuels A, et al: Cancer statistics, 2003. CA
Cancer J Clin 53:5-26, 2003
2. Fegiz G, Indinnimea M, Gozzo P, et al: Low rectal cancerwhat is
the choice? Dis Colon Rectum 37:535-541, 1994
3. Regimbeau J, Panis Y, Marteaus P, et al: Crohns disease: Can
abdominoperineal resection be predicted? J Am Coll Surg 189:
171-176, 1999