Pre-operatively all patients are sited for an end colostomy and receive stoma education. Some surgeons favor a mechanical bowel preparation (either oral laxative solution or enema) with or without oral antibiotics. Prophylactic intravenous antibiotics are administered at induction and a urinary catheter then inserted. Care must be given to appropriately pad pressure areas and potential nerve entrapment points. Neuropraxia has been reported after prolonged lithotomy [44] positioning but this was prior to widespread use of padded boots (rather than metallic stirrups) and sequential compression devices for enhanced venous blood flow and reduction of thrombotic events. After standard skin preparation, the peritoneal cavity is accessed via a lower midline infra-umibilical incision for open surgery or direct vision blunt port access for a laparoscopic approach. The sigmoid colon is mobilized beginning laterally at Todlt’s line allowing medialization of the left colon to its embryonic midline position. Care is taken to protect the left ureter and gonadal vessels and maintain an intact mesocolic into mesorectal envelope by utilizing the natural fusion plane between the mesocolon and Toldt’s fascia. The inferior mesenteric artery is ligated or vessel sealed within 1 cm of its origin to ensure all draining lymph nodes are harvested (while preserving the sympathetic hypogastric plexus) for histological staging. Alternatively, the ‘medial to lateral’ approach is used with the same steps in reverse order. There is little advantage to this and ureteric visualization is not as efficient.

Division of the mesocolon is begun proximal to the IMA and carried laterally towards the junction of the sigmoid and descending colon. The left colic artery and inferior mesenteric vein are sequentially secured as encountered. The colon is then divided after ensuring pulsatile blood flow in the marginal artery and adequate tension free length to permit end colostomy formation.

Sharp dissection is continued posteriorly, in the areolar tissue plane between the parietal pelvic wall and the visceral endopelvic fascia of the rectum, thereby ensuring an intact mesorectal envelope. The rectosacral (Waldeyer’s) fascia is sharply divided and the dissection is continued to the level of the sacrococcygeal junction. Care is taken to maintain the correct plane and avoid potentially torrential bleeding from the presacral venous plexus. Laterally the ureters are protected on the pelvic side wall and dissection is terminated just below the nervi ergentes. The lateral stalks representing condensation of the endopelvic fascia running in a posterolateral direction are divided. The peritoneal reflection is then identified and entered. The dissection is continued posterior to Denonvilliers fascia unless the tumor is anteriorly located. Recent work has demonstrated that Denonvillier’s fascia is a distinct embryological entity representing a condensation of the parietal endopelvic fascia separate to the rectal mesocolic fascia. This serves to protect branches of the inferior hypogastric plexus passing to the pelvic urogenital tract. This anterior dissection is stopped at the uteri cervix in females or lower border of the seminal vesicles in males. The bowel is now divided at the junction between the sigmoid and descending colon. If the patient is to be turned prone for the perineal phase (or if the procedure a laparoscopic one), the end colostomy is fashioned at the marked site in a standard fashion.

The perineal dissection may be performed in the prone or lithotomy positions according to surgeon preference without detrimental consequences to oncological outcomes. The anal canal is ideally closed with a purse-string suture at the beginning of the operation prior to rectal mobilization to prevent spillage. An elliptical skin incision around the anal canal should be wide enough to include the sphincter and any local tumor – hence it is tailored to the tumor size, level, and extent (Fig. 11.4). The dissection is carried through the ischioanal fossa to the undersurface of the levator plate. The inferior rectal artery arising from the internal pudendal artery in Alcock’s canal is encountered running from lateral to medial. It’s origins from the linea terminales of the posterior obturator fascia are now circumferentially exposed. The coccyx is identified and the anococcygeal ligament is divided if necessary to facilitate coalescence of the abdominal and perineal dissections. The levator muscles are now divided laterally to join the abdominal dissection plane. The specimen is carefully exteriorized and the dissection continued anteriorly off the posterior aspect of the prostate or vagina, taking care to preserve the neurovascular bundles. This phase can be completed with the rectum in position when the specimen is too bulky to evert (Fig. 11.5). Hemostasis is secured and surgeons should be aware of an aberrant obturator artery which can cause troublesome bleeding in the small but appreciable proportion of patients who have one.

If present and mobile, the uterus can be retroflexed to facilitate pelvic closure. The authors routinely use omental pedicled flap to fill the pelvic dead space and aide primary perineal wound closure [45]. This is done in layers with 2/0 polydioxanone sulfate or equivalent. The perineal skin is closed with 3/0 or 2/0 non-absorbable interrupted vertical mattress sutures (or subcuticular absorbable suture if the wound is small, clean, and non-irradiated). A closed suction pelvic drain (placed from the abdomen or perineum) is helpful in maintaining a dry perineal wound as a seroma is a common cause of wound failure without one but they are uncomfortable for patients. It is recognized that many centers routinely use a local (buttock) or distant (rectus abdominis muscle) flap, porcine/bovine dermis graft, or even their combination for closure of the perineum.

The patient is positioned as for open surgery but with an inflatable bean bag, gel mat or “mummy wrap” used to ensure the patient remains securely fixed to the operating table for steep Trendelenburg with lateral tilt for prolonged periods. Fears regarding intraocular pressure elevations have been raised but not substantiated by adverse events. The authors technique involves the surgeon and camera person on the patient’s right side with an assistant on the patient’s left. Camera monitors are placed at the patient’s feet and left side.

The authors favor a 3 or 4 port technique (Fig. 11.6a, b) with a 5 mm camera port at or above the umbilicus. The right iliac fossa (RIF) port is a consistent operating port while the suprapubic and LIF port alternate between the surgeon and assistant. The patient is initially placed in steep Trendelenburg position and mobilization commenced lateral to medial or medial to lateral as described for open surgery. The ureter and gonadal vessels are identified and preserved. The IMA is safely sealed with an energy device unless the vessel is heavily calcified when clips or locking grips may be utilized as adjuncts or the primary tools. The lateral colonic attachments are now divided. The splenic flexure may be mobilized if there is insufficient length for a colostomy (rarely needed). At this stage the authors routinely mobilize the omentum (usually on the gastroepiploic arcade) for perineal omentoplasty later in the operation. An accessory port at the proposed stoma site is helpful in providing counter traction (a 12 mm port is used to accommodate an endostapler for colonic division). In females it may be necessary (or helpful) to hitch up the uterus using an externally tied suture though the broad ligament. The dissection is as for open surgery and the dissection is stopped above the levator plate. At this stage the colon is divided with an endostapler and a colostomy formed at the premarked site. Again, the perineal phase may be performed in the supine position or the patient may be turned prone depending on surgeon preference.

A central tenet of recently published APR operative series is prone positioning. The prone position does afford excellent visualization, particularly during the potentially hazardous anterior mobilization of the specimen from the prostate/vagina and may facilitate nerve preservation. Prone positioning is however time consuming and can pose an anesthetic challenge. Furthermore, a number of groups have demonstrated that step wise or synchronous APR in the lithotomy or modified Lloyd-Davis position is oncologicaly safe with equivalent short and long term outcomes [46, 47]. A direct comparative study from the Cleveland Clinic involving APR performed in 81 patients in the prone position and 87 patients in the supine position showed no difference in local (equivalent at 5.7 and 12.5 % for supine and prone APR respectively) or distant recurrence (equivalent at 20 % after 7 years follow up) or overall survival (62.5 and 59.4 % 5 year survival). The patient groups were equivalent for demographic profile, use of adjuvant/neoadjuvant therapy, and tumor stage [46].

Additionally, a national multi-institutional study of standardized APR performed in the supine position demonstrated a local recurrence rate of 6.0 % at 5 years. It concluded that in patients undergoing APR by appropriately trained surgeons using a standardized approach, margin positivity was dictated by tumor stage, but not by center or surgeon [47]. In our opinion, patient position is at the surgeons discretion provided the resection is performed in a standardized manner incorporating en-bloc the pelvic floor and rectum.

Short and long term perineal wound complications are common following abdominoperineal resection. Regardless of approach (open, laparoscopic, robotic, lithotomy or prone), anorectal resection produces a large fixed dead-space cavity which accumulates fluid and blood clot, promoting pelvic and perineal sepsis, abscess formation and ultimately delayed wound healing. The consequences include prolonged hospital stay, increased readmission rates, increased nursing home care requirements with resultant patient and societal financial expense [48]. Higher perineal morbidity has been described following the more radical ELAPE [26]. Primary healing rates range from 45 to 91 % depending on the study, population, concomitant use of neoadjuvant radiotherapy/chemo-radiotherapy and surgical technique. Careful management of the perineal wound and pelvic cavity post APR is thus vital [48, 49]. Historically the perineum was left open and packed following APR to promote hemostasis and drainage with subsequent healing by secondary intention. Wound healing was often delayed beyond 4 months causing considerable patient discomfort [50].

Management strategies for the pelvic and perineal defects following APR have evolved to include primary perineal wound closure, closure of the peritoneum, primary closure with closed suction drainage of the pelvis drainage and pelvic wound irrigation and active closed drainage [51, 52]. Peritoneal and perineal closure was associated with fluid accumulation and subsequent infection in the dead space collection beneath the peritoneum and this technique thus fallen out of favor. The addition of irrigation to the pelvic drainage was not shown to be beneficial in an RCT from 1991 [52].

While primary perineal wound closure and closed suction is the preferred method following APR, a variety of complex, costly and time-consuming wound management techniques incorporating tissue transfer, such as vertical rectus abdominis (VRAM) and gracilis flap construction, have been advocated to deal with the pelvic cavity dead space and aide wound apposition [53–55]. Prophylactic biological matrix insertion has also been employed in an attempt to circumvent these difficulties [56]. Not all patients undergoing APR require such radical supplemental tissue transfer techniques. A very extensive resection for locally advanced rectal neoplasms with perianal skin involvement mandates formal myocutaneous grafting [57]. However the authors favor the use of omentum after APR. The anatomical, physiological and immunological properties coupled to availability of the omentum, especially laparoscopically, make it an excellent candidate for pedicled transfer to the pelvis [45]. Such a flap has sufficient length to reach the pelvic floor and adequate mass to fill any dead space (Fig. 11.7). A recent systematic review has shown that omental flap transfer and buttressing of the primary perineal repair following APR reduces wound infections, reoperation rates and hospital length of stay with minimal additional operative time or flap-associated morbidity [58].