The ongoing evolution of surgical techniques for “higher and wider” multivisceral resections has been driven by surgeons seeking the ultimate goal of R0 resection, which is now considered the key parameter when deciding what constitutes “resectable” disease with curative intent. Essentially, the indications revolve around the ability to obtain clear resection margins.

Pelvic exenteration (PE) still remains a surgical challenge associated with high mortality and significant morbidity, especially when associated with partial or complete sacral resection. Such extensive radical surgery aims to completely resect all malignant disease to achieve an R0 resection (i.e., a clear resection margin) and resection is the most important predictor of long-term survival in patients undergoing curative surgery for recurrent rectal cancer. To accomplish this, complete or partial removal of all of the pelvic viscera, vessels, muscles, ligaments, and part of the pelvic bone (ileum, ischium, pubic rami, sacrum, or coccyx) may be required. High sacral bone involvement remains controversial and, although en bloc high sacrectomy has been shown to be safe and oncologically feasible in several specialist centers (Table 43-1), concerns remain about pelvic instability and the need for subsequent reconstruction, as well as postoperative neurologic deficits associated with sacrifice of sacral nerve roots. Nonsurgical treatments such as radiotherapy and chemotherapy
provide only temporary relief of symptoms in most cases, with continual disease progression resulting in pain, bleeding, and intestinal and urinary fistulae and obstruction. Oftentimes, patients develop a painful, malodorous, fungating mass before death.

Aggressive surgical techniques in the form of a composite abdominosacral resection allows for the en bloc resection of tumor, sacrum, and pelvic floor musculature. This operation offers the potential of symptomatic relief, prolongation of life, and cure. The procedures are technically demanding and there is a price in terms of significant morbidity and mortality. As noted, completeness of resection (no microscopic disease evident at resection margins = R0) is a major factor that significantly influences outcome.

The planned resection margins and malignant indications for radical exenteration can guide the decision to proceed, but the anatomic limitations of the pelvis as well as quality of life implications and patient choice are all important for informed consent. An understanding of outcomes both with and without exenteration including long-term survival data, operative morbidity and mortality, length of hospital stay, and time for rehabilitation as well as quality of life all need to be discussed in detail. Hospital stays average often close to 3 weeks, with recovery taking 3-6 months before a stable quality of life is achieved.

There is ongoing discussion with regard to the absolute and relative contraindications for resection but we would advise against posterior sacrectomy in the following situations: