Confirm that patient’s condition is satisfactory before proceeding with the perineal excision of the rectosigmoid. With significant blood loss, consider replacing volume lost with blood transfusion. Some prefer the two-team approach so that the perineal excision is carried out simultaneously with abdominal procedure. The robot is undocked.

Historically, Miles placed patient on the left side in modified Sims’ position. Some surgeons prefer to change to lithotomy position by adjusting the stirrups to lift the legs. Others prefer the patient in prone-jackknife to complete this portion. When this procedure is performed robotically, the need for dramatic repositioning is eliminated. We prefer to place the patient in steep Trendelenburg. Stabilize the patient’s vital signs after the change in position before proceeding with the perineal resection.

The anus is sewn closed with several purse-string sutures to prevent contamination. The skin is prepped again with antiseptic solution. Legs and buttocks are covered with sterile drapes. If dissection from above has been carried down far enough, perineal excision of rectum and anus should be done quickly with minimal blood loss. Outline the incision around the anus with anterior and posterior midline extension. With several Allis clamps, grasp the skin around anal orifice and incision through the skin and subcutaneous tissue at least 2 cm away from closed anal orifice. The incision starts anteriorly at the perineal body and goes laterally to the ischiorectal spines and then posteriorly at the top of the coccyx. After the skin, subcutaneous ischiorectal membrane, and fat are incised, the levators will be visualized. If not already completed during the abdominal portion, use long cautery tip to divide the anococcygeal ligament along the posterior midline near the sacrum. Once connection is established between the abdominal cavity and the perineum, hook your finger above the levator ani muscles toward the perineum and slowly divide with cautery as far from the rectum as possible. Some may prefer to divide the levators with paired clamps. Dissection starts posteriorly and then proceeds laterally and anteriorly. Often, it is best to complete the anterior dissection after the proximal portion of the specimen is everted out of the perineum. Resection should extend into the midperineum. However, in women with anterior tumor, resection should extend into the vagina, removing the posterior wall of vaginal wall. A more radical excision may be needed if the lesion is low and near the anus. After the specimen is delivered, inspect the pelvic space with direct illumination with dry sponges until the field is free of oozing. Irrigate the area.

The perineal incision is closed in at least two layers. The divided levator ani muscles are normally not closed in case of extralevator APR. A trans-abdominopelvic drain is placed. Subcutaneous and skin layers are closed with very large and widely spaced interrupted vertical mattress sutures, using number 1 nylon or silk, and tied loosely. However, if a large perineal excision is anticipated preoperatively, the surgeon may consider consulting a plastic surgeon as a myocutaneous flap reconstruction with the rectus abdominis muscle may be required. In addition, an internal barrier, such as an omental patch, may be utilized with the perineal wound left open or covered with a negative pressure therapy (i.e., wound vac). The use of V-Y flaps is also encouraged to reduce tension at the perineal flap closure.