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ABDOMINOPERINEAL EXCISION

OF THE RECTUM
Dr. Putu chandra Wibawa
ANATOMI
◦ Panjang rektum 15 cm, berawal dari rectosigmoid junction, ditandai dengan
bergabungnya taeniae coli dalam lapisan otot sirkuler, sampai dengan anal canal.
◦ Bertransisi dari organ intraperitoneal menjadi ekstraperitoneal, 6–8 cm dari anus.
◦ Difiksasi di bagian posterior dan lateral oleh fascia Waldeyer.
◦ Pada laki-laki, bagian anterior rektum terfiksir ke fascia Denonvillier, sebuah lipatan dari
2 lapis peritoneum yang memisahkan rektum dari prostat posterior dan vesicula
seminalis.
◦ Pada perempuan, kavum peritoneum berlanjut menjadi kavum Douglas yang
anteriornya berbatasan dengan cervix dan posterior berbatasan dengan
pertengahan rektum.
◦ Bila dilihat dengan endoskopi, rektum mempunyai 3 valves of Houston, dimana bagian
tengahnya berhubungan dengan refleksi peritoneum anterior.
ANATOMI
◦ A. Rectalis superior  a. Meseterika inferior. memperdarahi mesorektum dan rectum
proksimal dan medial.
◦ A. Rectalis media  a.iliaca interna, hanya ditemukan pada 22% kadaver. Bila ada,
a.rectalis media ini berada dekat lateral rektum, yang sering sulit dibedakan dengan
persarafan.
◦ A. Rectalis inferior  a. Pudendalis interna berjalan posterolateral dan memperdarahi
sfingter ani dan epitelium.
Lymphatic Drainage
◦ KGB dari rektum proksimal dan medial mengalir ke KGB
mesenterium inferior.
◦ KGB dari rektum distal mengalir ke sistem mesentrium
inferior atau ke KGB sekitar a. Rectalis medial dan inferior, di
posterior a. Sacralis medial, dan di anterior melalui celah
septum retrovesical atau rectovaginal, menuju KGB iliaca
dan akhirnya menuju KGB paraaorta.
◦ Kelenjar limfe dari anal canal diatas linea dentate mengalir
ke KGB rectalis superior menuju KGB mesenterium inferior
dan ke lateral menuju KGB obturator dan iliaca interna.
◦ Dibawah linea dentata, cairan limfe mengalir ke KGB
inguinalis dan mungkin mengalir juga ke KGB rektalis inferior
atau superior
Abdominoperineal resection (APR)
◦ Completely removes the distal colon, rectum, and anal sphincter complex using both
anterior abdominal and perineal incisions, resulting in a permanent colostomy.
HISTORY
◦ In 1908, investigating the pathogenesis of rectal cancer, Miles established the role of
the lymphatic system in the spread of malignancy and emphasised the need for
synchronous removal of the rectum and its “lymphatic drainage” with the
abdominoperineal approach.
◦ Initial reports showed a high operative mortality, up to 42%.
Indications for APR
Position of
patient
◦ The patient is placed in
the lithotomy–
Trendelenburg position
with Allan stirrups and a
pad is placed under the
sacrum.
Incision
◦ A long midline incision is employed. The
incision should extend from the pubis to at
least 5 cm above the umbilicus.
Abdominal exploration and assessment
of operability
◦ The abdomen needs to be explored carefully to detect metastatic spread.
◦ The liver requires careful bimanual palpation and/or on-table ultrasound examination if
available.
◦ The whole of the peritoneal cavity should be searched for the presence of metastases
and a biopsy should be taken of any suspicious lesions.
◦ Enlarged lymph nodes are often detected during preoperative staging but should be
sought in the mesentery and lateral pelvic side walls.
◦ Evaluate the rectal tumour whether it is above or below the peritoneal reflection.
◦ The degree of mobility should be assessed, for if the lesion is fully mobile it will be
possible to remove it and provided there are no distant metastases the excision should
be radical.
◦ If the tumour is fixed to other tissues radical excision is less likely, it is mandatory to give
neoadjuvant radiotherapy with or without concomitant chemotherapy.
Abdominal exploration and assessment of operability.
◦ In particular the liver requires careful bimanual palpation and on-table ultrasound
examination if available.
◦ Any suspicious areas should be biopsied and sent for histological examination.
Abdominal phase
Mobilisation of colon :
◦ The small bowel has to be
removed from the pelvis  Loops
of bowel can be packed away in
the upper abdomen and
prevented from emerging into the
operative field by insertion of the
third blade of the self-retaining
retractor.
◦ The iliac portion of the colon is
then mobilised by incising the
congenital peritoneal folds
attached to the lateral aspect of
its mesentery
◦ In this specific stage of the procedure it is most important to find the correct avascular
anatomical plane so as not to destroy the fascial envelope around the mesorectal fat.
◦ This is best achieved with the assistant grasping the sigmoid colon and drawing it to the
right so as to put the tissues on the stretch.
◦ After incision of the peritoneum, the underlying left ureter can be seen, distinguishable
from the more laterally lying spermatic or ovarian vessels by its characteristic vermicular
movement, best displayed by ‘pinching’ the ureter lightly with non-toothed forceps.
◦ After having identified the ureter, the perisigmoidal and perirectal fascia are identified,
and the dissection is continued under the main vessels to the rectum.
◦ It is important to avoid damage to the hypogastric nerve plexus.
◦ After this manoeuvre, the sigmoid colon is retracted to the left by the surgeon and the
peritoneum is incised to the right of the midline.
◦ This incision is extended upwards to the lower border of the third part of the duodenum.
◦ The incision is deepened with the same technique as has been done to the left side,
define the correct plane of dissection without damaging the nerves.
◦ The incision is opened up to expose the front of the right common iliac artery and the
aorta.
◦ The vascular supply of the rectum can now be approached from either side of the
mesentery.
◦ Some surgeons (Goligher, 1984) advocate tying-off the proximal colon with a stout
nylon tie prior to its mobilisation; this is in the belief that tumour cells shed intraluminally
may be viable, may seed and thus may cause anastomotic recurrence.
◦ Many surgeons usually divide the sigmoid colon with a linear staple cutter after having
mobilised it.
Ligation of vascular pedicle
◦ The vascular pedicle can be tied either ‘high’ (i.e.
flush with the aorta) or ‘low’.
◦ A high tie if the aim is a radical operation.
◦ A low tie is reserved for obviously palliative
procedures, or when the patient is a poor risk.
Division of the colon
◦ Division of the colon may take place at this
point or may be accomplished after the pelvic
dissection is complete.
◦ The sigmoid mesocolon is divided obliquely from
the point of ligation of the inferior mesenteric
vessels to the site of proposed transection of the
left colon.
The pelvic
dissection
◦ Rectal dissection in the female it is useful to suture the uterus
and fallopian tubes to the abdominal wall.
◦ This makes access to the rectum particularly the anterolateral
planes much easier.
◦ The posterior rectal dissection is commenced by continuing the
peritoneal incisions on each side of the rectum following the
well-defined plane just outside the perirectal fascia as deep as
possible.
◦ It is important not to tear the perirectal fascial envelope
◦ The rectosigmoid
region is then
displaced
anteriorly and
gentle traction is
exerted in this
direction with the
surgeon’s left
hand.
◦ The posterior dissection should continue downwards as far as the coccyx so that the
entire mesorectum can be removed with the specimen.
◦ It is important to complete the posterior rectal dissection under direct vision.
◦ Occasionally this is impossible, and if so the hand may have to be introduced into the
presacral space and the rectum gently pushed forward from the front of the presacral
fascia and the sides of the pelvis as far down as the coccyx.
◦ Provided the plane of dissection remains anterior to the presacral fascia, the
manoeuvre should be relatively bloodless.
◦ The rectum is then drawn firmly
upwards and towards the
opposite side, a manoeuvre
which puts the ‘lateral
ligaments’ under stretch.
◦ A careful dissection of this tissue
is carried out using long scissors
or, preferably, hand-held
diathermy as close to the
mesorectal envelope as possible
so as to avoid the nervi erigentes
which can be seen near the side
wall of the pelvis.
Perineal phase
◦ The anal orifice is first closed,
using one or even two thick
sutures on a hand needle.
◦ The purse-string suture is placed
in the subcutaneous tissue and
completely encircles the anal
orifice.
◦ After the knot has been tied the
ends of the suture are clipped
and left long. Traction on this
suture allows the loose perineal
skin to be put on stretch; this
makes the perineal incision
easier and assists in the
subsequent dissection.
◦ An elliptical incision is made which encircles the anal
verge; it commences midway between the anus and
the posterior fourchette or bulb of the urethra
anteriorly and extends posteriorly to the
sacrococcygeal articulation.
◦ Small lateral incisions are made on each side of the
coccyx through the fibrous attachment of the
coccygeus muscle and a finger is inserted on each
side in a forward and outward direction to separate
the levator muscles from the underlying fascia of
Waldeyer.
◦ The overlying fat in the ischiorectal fossa and the
iliococcygeus muscle are divided well out to the
lateral pelvic side wall.
◦ The anal canal and rectum
are then strongly retracted
anteriorly displaying the
fascia of Waldeyer behind
the rectum.
◦ This fascia is incised
transversely with scalpel or
scissors just in front of the
divided coccyx, extending
the incision around each
side of the rectum.
Closure of the perineal
wound
Abdominal closure and completion
of colostomy
◦ The need to close the pelvic peritoneum, if primary perineal closure is performed, is
debatable.
◦ Some surgeons prefer to leave it open in the hope that the small bowel and omentum
will prolapse into the pelvis and fill the dead space, thus reducing the chance of
haematoma formation.
◦ A modification of this technique (Ruckley et al, 1970) is to mobilise the omentum and
stitch it in place within the pelvis.
◦ Our concern has always been the fear that small intestine may become obstructed if
allowed to descend into the pelvis, and that is why we prefer to close the pelvic
peritoneum whenever possible.