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.