The major pathological indication for APR is adenocarcinoma of the lower rectum, especially where the tumor invades into the anal sphincter complex or levator muscles of the pelvic floor. However, other indications include malignant and benign conditions affecting the perianal region (Box 6.1).

Low rectal cancer requires careful clinical and radiological assessment, followed by discussion among a multidisciplinary team (MDT) . The decision for APR rather than a sphincter-preserving procedure should be an outcome of this MDT process and ideally planned prior to surgery. Rectal cancer with a distal extent greater than around 6 cm from the anal verge can generally be treated with sphincter-preserving surgery, regardless of whether or not the surgeon elects to perform an anastomosis. For tumors sited at around 5 cm from the anal verge, careful consideration is needed of the most appropriate surgical procedure. While sphincter-preserving ultra-low anterior resection may be feasible for a low cancer, the potential for poor function following such surgery (especially where neoadjuvant radiotherapy has been used) means that patient selection is essential. For more locally advanced tumors that lie close to the tapering mesorectal surface in this region, and for very distal tumors at the level of the sphincter complex, APR is usually indicated. Where the pathology extends to involve the perianal skin, for instance, local fistulation or suppuration, a more extensive ischio-anal excision may be required during the perineal phase of the procedure; however, the resection is otherwise the same as for APR.

The choice of a laparoscopic approach requires consideration of the surgeon’s technical capabilities in addition to patient and tumor factors. Laparoscopic APR should be performed by surgeons who routinely perform laparoscopic total mesorectal excision (TME). While it is acknowledged that all laparoscopic rectal resection surgery is technically challenging with a longer learning curve compared with laparoscopic colonic resection [18], centers with extensive experience in these techniques can achieve operating times for laparoscopic that are similar to those for open APR [19].

APR is a major surgical undertaking, and careful case selection is essential. Contraindications to APR may relate to situations where alternative surgery is more appropriate (Box 6.2). Where other organs, such as the prostate, are involved in the disease process more extensive surgery may need to be considered to ensure that a clear resection margin can be achieved. There are also instances where any resection may be inappropriate, for instance, where significant comorbidity or poor quality of life are encountered.

Due to the technical complexity of laparoscopic APR surgery, relative contraindications include morbid obesity and multiple previous abdominal surgeries. In these situations, an open approach may be considered more appropriate, although with increasing technical experience of the surgeon these relative factors may be less pertinent.

Given the potential complexity of this surgery, general anesthesia with neuromuscular blockade should be performed by an experienced anesthesiologist. The role of epidural anesthesia for postoperative pain relief has been questioned for laparoscopic colorectal procedures [20]; however, the perineal wound following APR can be very painful, and this remains the one laparoscopic colorectal procedure for which we would still advocate routine epidural anesthesia. Additional regional block for the perineum may be beneficial for reducing perineal pain. The physiological stress of the operation should be minimized through the intraoperative use of short-acting anesthetics and goal-directed fluid therapy. Antibiotic prophylaxis is administered at the time of induction.

The patient should be carefully positioned supine on the operating table, supported to allow safe head-down angulation of the table during a potentially long procedure. The legs are elevated in a Lloyd-Davies position. Careful attention should be paid to reducing the risk of nerve injury both from pressure on the legs and also on the brachial plexus.

Given the importance of the location for the permanent stoma, efforts should be taken to ensure that the site marked so carefully by the ostomy therapist prior to surgery is not wiped away when the surgical antimicrobial solution is applied at the start of the procedure. Methods employed include remarking the site immediately following cleansing, placing a suture or staple at the marked site, or covering the ink marking with a sterile transparent dressing prior to preparing the abdomen.

The abdominal phase of laparoscopic APR uses the same approaches as laparoscopic anterior resection. The laparoscopy stack is best placed toward the patient’s feet on their left side. Pneumoperitoneum is established using a standard open technique, and trocars are inserted under direct visualization. Four access ports are generally required. Whenever possible the marked stoma site should be used for the left lower quadrant port, as the precise location of this port will not significantly impact upon the procedure. We tend to alternate the laparoscopic camera between a midline and a right lateral port to optimize visualization during the procedure. Additionally, a right iliac fossa port is used, which will be the one used for the dissecting instrument for the mesorectal dissection. Before the procedure can be commenced, adhesions to the abdominal wall should be divided and diagnostic laparoscopy performed to evaluate for occult peritoneal or hepatic metastases.

We adopt a medial-to-lateral approach, with identification and high ligation of the inferior mesenteric artery pedicle. The inferior mesenteric vein is ligated at this level also, as more proximal ligation is rarely required for APR.

The left ureter is usually identified prior to medial-to-lateral mobilization of the descending colon mesentery as per laparoscopic TME. Splenic flexure mobilization is not usually required in APR.

Entry into TME “Holy plane” [21] is usually performed in posterior midline after defining the mesorectal fascia and loose areolar tissue plane. Dissection then proceeds on a broad front to develop this plane posteriorly with care taken to avoid injury of the hypogastric nerves.

Once the posterior dissection is completed (at the level of the coccyx), the anterior peritoneal reflection is divided at approximately 1 cm anterior to the apex of the fold. The lateral plane is then approached to join the anterior and posterior dissection planes.

Laparoscopic APR dissection should stop at:

Dissection may need to be tailored depending upon the tumor location. The abdominal phase completed with division of mesentery and descending colon at an appropriate level and formation of an end colostomy at the marked stoma site.