Abdominoperineal Resection (APR)

Procedure Snapshot

• Indication/urgency: Low rectal cancer involving sphincters; recurrent disease; selected Crohn or trauma cases.
• Expected duration: ___ (see contemporary series; PMID 31372214).
• Special instruments: Energy device, staplers, self-retaining retractors, pelvic pack, end colostomy supplies.

Step Workflow

1. Lithotomy with careful padding; secure legs to prevent neuropathy.
2. Midline laparotomy or lap/robotic access; explore abdomen.
3. Mobilize sigmoid and rectum circumferentially to pelvic floor (Total Mesorectal Excision).
4. Identify and protect ureters; ligate inferior mesenteric artery/vein.
5. Transect sigmoid proximally; close distal rectum.
6. Perineal phase: elliptical incision around anus; dissect through ischiorectal fossa.
7. Join abdominal and perineal planes; remove specimen en bloc.
8. Close pelvic floor; place drain.
9. Mature permanent end colostomy.

Key Pimp Questions

• Q: Why choose APR over low anterior resection?
  A: Tumor involves sphincters or very distal margin precluding anastomosis.
• Q: What is TME and why is it critical?
  A: Total Mesorectal Excision ensures intact mesorectal fascia, minimizing local recurrence (Heald 1982).
• Q: Common nerve injuries?
  A: Hypogastric and pelvic splanchnic nerves → bladder/sexual dysfunction.

Critical Anatomy

• Landmarks: Levator ani, pelvic floor, mesorectal fascia, ureters, hypogastric nerves.
• Danger zones: Lateral pelvic wall, presacral venous plexus, autonomic plexus.

Informed Consent Highlights

• Benefits: Oncologic cure or palliation.
• Alternatives: Non-operative therapy, local excision, or low anterior resection if feasible.
• Risks:
  • Bleeding ___ (PMID 30259430)
  • Wound/perineal infection ___ (PMID 31629917)
  • Urinary/sexual dysfunction ___ (PMID 31903701)
  • Stoma complications (retraction, hernia) ___ (PMID 28745847)
  • Pelvic abscess or chronic sinus ___ (PMID 30199978)

Post-op Considerations

• Foley until POD 3–5.
• Early ambulation and DVT prophylaxis.
• Multimodal analgesia.
• Stoma teaching before discharge.

References

• Chassin’s Operative Strategy, 5th ed., Ch. 86.
• Clinical Scenarios in Surgery, 2nd ed., colorectal section.
• Heald 1982; Björk 2018 (PMID 30377156).