Extent of perineal dissection during abdominoperineal resection

Ricardo T Akiba, MD, PhD, Hon, Steven D Wexner, MD, PhD, Hon. Cleveland Clinic Florida

Background: The extent of perineal dissection during abdominoperineal resection (APR) can be quite variable. The currently most accepted methods are cylindrical APR when APR is performed for rectal cancer and intersphincteric dissection when the surgical indication is benign disease.

Methods: This video shows both techniques in a side-by-side comparison. 

Results: In the cylindrical APR method, the aim is to avoid "coning" into the mesorectum during the laparoscopic abdominal phase and thus creating a "waist" during specimen extirpation. The technique includes excision of the internal and external anal sphincters and some or all of the levator ani and puborectalis muscles. However unhealed perineal wounds and perineal hernias can cause major postoperative short- and long-term morbidity. Thus in an effort to decrease this morbidity, in particular in patients with inflammatory bowel disease (IBD) who have often received steroids, biologics, and other immunosuppressives and may have also had perianal sepsis, an intersphincteric proctectomy is preferred. In this group of patients the internal sphincter is removed but the external sphincter, puborectalis, and levator ani muscles are deliberately preserved. In patients with IBD, these muscles are re-approximated to assist in perineal wound closure.

Conclusion: This cylindrical method has been associated with an improvement in the circumferential resection margin, which in turn is associated with decreased rates of local recurrence.

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