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J. G. Guillem and J. Garcia-Aguilar
less advantageous, as the ap contains no skin and
is rather small in size. In general, we reconstruct
the perineum when the patient has any of the following: a large skin defect from a wide perineal
resection, a residual large pelvic space from an
exenteration; prior radiation therapy (more than
6months before the procedure), poor nutritional
status, or other comorbidities that signicantly
increase the risk of perineal wound infections.
In addition to a ventral rectus abdominus muscle ap and gracilis reconstruction, bilateral V–Y
advancement gluteal aps are a good alternative,
especially if there is concern about retaining the
integrity of the abdominal wall. These aps provide for excellent tissue coverage and facilitate a
posterior vaginal reconstruction. The strategy
should be individualized based on each patient’s
needs, comorbidities, muscle mass, and functional limitations. The involvement of plastic surgeons early in the preoperative assessment and
planning is essential.
Surgical Technique
Anatomic Relationships
andConsiderations
The key to a successful rectal cancer operation is
an in-depth understanding of the anatomy of the
left colon, the rectum and anus, as well as the
vessels and nerves of the pelvis, the pelvic oor
musculature, and the ischiorectal fossa. The pelvic oor, also known as the pelvic diaphragm,
comprises the levator ani and coccygeus muscles.
The levator ani muscle is composed of several
smaller muscles (puborectalis, pubococcygeus,
and iliococcygeus) that insert in the inner wall of
the pelvis and unite with the muscle of the opposite side to form part of the funnel-shaped pelvic
diaphragm. These muscles are divided during an
APR.The coccygeus muscle, located in the same
plane as the levator ani muscles but more posterior, is usually not divided.
The mesorectum is the visceral mesentery
containing the terminal branches of the superior
rectal vessels and the lymphatic drainage of the
rectum. The upper third of the rectum is usually
covered with peritoneum in the front and on both
sides and has a posterior mesorectum attached to
the concavity of the sacrum, which is a continuation of the mesentery of the sigmoid colon. Below
the peritoneal reection, the rectum is completely
extraperitoneal. The mesorectum here is thick
posteriorly and, when removed with an intact
capsule, has a characteristic bilobar appearance.
As the rectum funnels down toward the anorectal
ring, the mesorectum also tapers off distally. At
this very distal aspect, just above the anorectal
ring, there is no appreciable mesorectum. The
longitudinal layer of the muscularis propria of
the posterolateral rectum is in direct contact with
the levator muscles. Anteriorly, the mesorectum
is either absent or reduced to a thin layer of areolar tissue in the mid- and distal rectum.
Fascial Structures andPlanes
The fascia propria of the rectum is a thin, glistening membrane surrounding the mesorectum
below the peritoneal reection. Like the mesorectum proper, it is thinner anteriorly than posteriorly. Anteriorly, a remnant of the embryologic
peritoneal cul-de-sac, known as Denonvilliers
fascia, separates the mesorectum from the urogenital structures. The anatomic appearance of
Denonvilliers fascia varies, from a barely visible
translucent membrane to a distinct, tough, brinous layer of connective tissue. Posteriorly, the
fascia propria extends from the sacral promontory to Waldeyer’s fascia, a condensation of connective tissue spanning the area from the fourth
sacral vertebra to the anorectal ring. Here the
mesorectum is separated from the presacral fascia by loose, avascular, areolar tissue. The correct
plane for dissection during a total mesorectal
excision is between the fascia propria of the rectum and the presacral fascia.
Below the peritoneal reection, the mesorectum is in intimate contact laterally with the connective tissue overlying the autonomic nerves
that pass from the pelvic plexus to the rectum.
These bilateral fusions of the endopelvic fascia,
known as lateral ligaments, connect the pelvic
sidewall with the mesorectum. In some patients,
the lateral ligaments contain accessory middle
rectal vessels. The middle rectal artery usually
runs immediately above the levator muscles.
23 Rectal Cancer: Operative Treatment Transabdominal
433
Blood Supply
The blood supply of the rectum comes primarily from the superior rectal artery, which is the
continuation of the inferior mesenteric artery
after it gives off the left colic artery (Fig.23.8).
The superior rectal artery gives several sigmoidal branches before diving into the mesorectum, where it gives multiple branches to the
rectum but usually prominent left and right
branches that run alongside the mesorectum.
The lower portion of the rectum also receives
blood supply from the internal iliac vessels.
The middle rectal artery, an inconsistent branch
of the inferior vesicle artery, is usually located
deep in the pelvis, running over the levator
muscle. The inferior rectal artery is a branch of
the pudendal artery and provides blood supply
to the anal canal and anal sphincter. The superior rectal vein has a parallel course to its homonymous artery, on its way to join the left colic
vein to form the inferior mesenteric vein draining into the splenic vein. As in other locations,
the superior, middle, and inferior rectal veins
follow the course of their arteries. While the
superior rectal vein joins the left colic vein to
form the inferior mesenteric vein and drains
into the portal system, the middle and inferior
rectal veins drain into systemic circulation
through the internal iliac veins. These anastomoses represent the potential portosystemic
communication that becomes relevant in
patients with portal hypertension.
Fig. 23.8 Vascular anatomy of the left side of the colon
Autonomic Pelvic Nervous System
The superior hypogastric plexus, located in front
of the aorta, contains preganglionic sympathetic
bers originating from the lumbar sympathetic
trunk that converge at the level of the aortic bifurcation into two well-dened hypogastric nerves,
which course laterally over the internal iliac vessels toward the lateral pelvic sidewall. There they
join the splanchnic pelvic nerves, containing
postganglionic parasympathetic bers from S3 to
S4, to form the inferior hypogastric plexus, which
is located posterolateral to the seminal vesicles in
men and in a corresponding location in women.
Branches of the inferior hypogastric plexus provide innervation to the distal ureter, vas deferens,
seminal vesicles, urinary bladder, prostate, and
even the distal rectum in some patients. The inferior hypogastric plexus also forms the urogenital
neurovascular bundles that pass anterior to
Denonvilliers fascia. The pudendal nerve, originating from the sacral plexus, contains sensory,
motor, and parasympathetic bers that provide
most of the innervation of the perineal region.
Damage to any of these nerves during an operation can result in signicant urinary, sexual, and
sensory dysfunction.
Open Abdominal Dissection
As in any other colorectal cancer procedure, this
operation begins with a thorough examination of
the abdomen and pelvis. The sigmoid colon is
mobilized by dividing the attachments and
adhesions to the lateral abdominal and pelvic
sidewall and rendered a midline structure. The
incision is carried cephalad toward the splenic
exure and distally toward the pelvis. The
mesentery of the sigmoid and descending colon
is retracted away from the retroperitoneal
attachments, exposing the left gonadal vessels
and the left ureter. It is important to remain in the
retromesocolic plane, as deeper dissection into
the retroperitoneal fat can lead to increased
bleeding and damage to the gonadal vessels and
the left ureter. The sigmoid colon is retracted
anteriorly and to the left to expose the root of the
434
J. G. Guillem and J. Garcia-Aguilar
sigmoid mesentery for the surgeon standing on
the right side of the patient. Next, an incision is
made in the peritoneum to the right side of the
base of the sigmoid mesocolon, just anterior to
the sacral promontory. A plane is developed
underneath the superior rectal vessels in the loose
areolar tissue, between the origin of the inferior
mesenteric artery and the promontory. Care
should be taken to avoid injuring the superior
hypogastric plexus (SHP), situated between the
superior rectal vessels and the bifurcation of the
aorta. The division of the SHP into the left and
right hypogastric nerves can be seen as two thick,
bandlike structures just lateral to the midline that
have the appearance of a “wishbone” when the
rectum is tented up anteriorly.
Once the ureter is identied and left in situ in
the retroperitoneum, the superior rectal vessels
are isolated between the origin of the left colic
vessels and the rst sigmoidal vessels and ligated.
We recommend a careful dissection of any
enlarged lymph node around the bifurcation of the
inferior mesenteric artery, taking great care not to
damage the SHP. The mesentery of the sigmoid
colon is then divided toward the point of the
sigmoid colon that has been chosen to create the
end sigmoid colostomy. The sigmoid colon itself
is divided by using a linear stapler. The divided
sigmoid colon and the descending colon should
be sufciently mobilized to ensure a tension-free,
well-vascularized colostomy that is not retracting
inferiorly.
The areolar space behind the fascia propria of
the rectum is visualized by anterior reection of
the stump of the superior rectal vessels and the
proximal rectum toward the ceiling and away from
the sacral promontory. In the beginning of this
dissection, it is important to identify and protect
the bilateral hypogastric nerves. The areolar tissue
is incised and the dissection continued inferiorly
along the concavity of the sacrum as far as the
sacrococcygeal junction and extending from the
midline laterally. Distally, the pelvic splanchnic
nerves are preserved, as they course from the
lateral pelvic sidewall near the anterior sacral
foramina to join the inferior hypogastric plexus.
We nd that rm and precise traction with a
St. Mark’s pelvic retractor or a Wiley renal vein
retractor—along with strong counter-traction
from the surgeon’s nondominant hand on the rectum—can help to place the areolar plane on tension and expose the proper plane for dissection.
Division of the areolar connective tissue should
be done using electrocautery or other sharp dissection. Blunt nger dissection is extremely
imprecise and can lead to a poor-quality resection
plane, which compromises the oncologic validity
of the operation. Blunt dissection may also damage the pelvic nerves and lead to impotence or
retrograde ejaculation, as well as severe pelvic
bleeding that can be difcult to control.
The dissection is continued postero-laterally
until the origin of the levator muscle is reached.
Finally, the peritoneum is opened anteriorly in
the cul-de-sac. Dissection is carried to the level
of the prostate in men and halfway down the
vagina in women. The anterior dissection can be
performed in different planes, depending on the
location of the tumor. For anteriorly located
tumors, the dissection should proceed in front of
Denonvilliers fascia to avoid dissecting into the
tumor. For other tumors, dissection can be safely
performed behind Denonvilliers fascia to preserve the nerves of the prostatic plexus.
Robotic Mobilization ofSplenic
Flexure andLeft Colon
A medial-to-lateral mobilization of the left and
sigmoid colon is preferred for the robotic
approach. The inferior mesenteric vein (IMV) is
used as the initial anatomic landmark. To expose
the IMV, the ligament of Treitz and the attachments between the proximal jejunum and the
descending mesocolon may have to be divided
sharply, so that the small bowel can be retracted
toward the right upper quadrant (Fig.23.9).
Next, the peritoneum just under the vein is
incised, and medial-to-lateral dissection begins
by separating the mesocolon from Toldt’s fascia.
Dissection proceeds toward the abdominal wall,
taking care to identify and preserve the ureter and
gonadal vessels. More distally, the IMV runs
parallel to the left colic artery (LCA). Therefore
the IMV/LCA pedicle should be followed
ab
23 Rectal Cancer: Operative Treatment Transabdominal
435
inferiorly, and freed from its posterior attachments
to the aorta, until the origin of the inferior
mesenteric artery (oIMA) is identied. The
peritoneum over the sacral promontory, just
medial to the right common iliac vessels, is
incised, entering the areolar plane posterior to the
superior rectal artery. By extending this dissection
plane to the left, the origin of the IMA is
identied; the vascular anatomy creates a characteristic T-shaped structure (Fig.23.10).
After identifying the ureter and gonadal vessels in the retroperitoneal plane, the IMA can be
divided (Fig.23.11). To obtain a full mesocolic
mobilization and facilitate a tension-free low
anastomosis, we routinely divide the artery with
multiple applications of the robotic vessel sealer
or vascular stapler in cases of a larger IMA.The
medial-to-lateral dissection is taken laterally
toward the abdominal wall. The colon is then
retracted medially; the peritoneum along the
white line of Toldt is opened, completely freeing
the descending and sigmoid colon. Next, the
splenic exure is taken down by (1) opening the
gastrocolic omentum just below the gastroepiploic
vessels, or (2) dividing the avascular coloepiploic
attachments next to the bowel wall. The
splenocolic ligament is divided. We recommend
using an energy-based vessel sealing device for
these steps. Last, the attachments of the body and
tail of the pancreas to the colonic mesentery are
Fig. 23.9 Visualization of the azygos section of the inferior mesenteric vein, close to the inferior border of the
pancreas
Fig. 23.11 View of the inferior mesenteric artery (IMA)
and its branches, the left colic artery (LCA) and the superior rectal artery (SRA)
Fig. 23.10 Opening of the areolar space behind the superior rectal vessels. (a) The landmarks are the right common iliac artery (RCIA) and the fold of the mesentery of
the sigmoid colon (MSC). (b) The areolar space is dis-
sected carefully, keeping the hypogastric plexus, left ureter, and left gonadal vessels undisturbed in the
retroperitoneum
436
Fig. 23.12 Visualization of retroperitoneum and the
lesser sac after division of the transverse colon mesentery
attachment to the inferior border of the pancreas
carefully divided to obtain a full splenic exure
release (Fig.23.12).
The mesentery of the descending colon is then
divided from the stump of the IMA towards the
colon at the point of future division of the bowel,
usually at the junction of the descending and
sigmoid colon. The mesentery can be divided
with an energy source, or with several res of a
vascular stapler. Alternatively, the mesentery can
be divided with electrocautery clipping the
mesenteric vessels. We recommend dividing the
marginal artery at this time to avoid tearing the
vessels during the extraction manoeuvres,
particularly if extraction of the specimen through
the anus is anticipated.
Robotic Total Mesorectal Excision
After completing colonic mobilization, the
robotic pelvic dissection can begin. A signicant
degree of Trendelenburg position is often
necessary to maintain the small intestine out of
the pelvis. The DaVinci® S HD, Si, or Xi can be
docked over the patient’s left hip, permitting
access to the anus and perineum during the entire
procedure.
The camera arm with a 0o telescope is rst
docked to trocar C. Next, we attach a robotic
trocar to arm 1 and “piggyback” this into the
12 mm R1 port. Arms 2 and 3 are docked to
trocars R2 and R3, respectively. For instruments
we choose scissors for arm 1, a fenestrated bipo-
J. G. Guillem and J. Garcia-Aguilar
Fig. 23.13 Trocar positioning for a robotic total mesorectal excision. ©2018, Memorial Sloan Kettering Cancer
Center
lar grasper in 2, and a “pro-grasp” grasper in 3.
The assistant remains on the right side, using
ports L1 and L2 for suctioning and retraction of
the rectum out of the pelvis. With the DaVinci Xi,
the fourth robotic arm replaces the L2
laparoscopic arm (Fig.23.13).
With the assistant elevating the rectosigmoid
junction, dissection begins posteriorly at the
sacral promontory, entering the plane between
the fascia propria of the rectum and the presacral
fascia. Care must be taken to identify and preserve
the hypogastric nerves bilaterally. The dissection
is carried out almost exclusively with monopolar
cautery, applied with the scissors in shorts bursts,
to prevent excessive smoke accumulation and
nerve injury. The TME proceeds along the areolar
plane down to the rectococcygeal ligament,
which is opened (Fig.23.14).
It is important to avoid grabbing the mesorectum with any of the robotic graspers. These
instruments have considerable strength, and can
cause bleeding as well as undesirable injuries to
the fascia propria. We prefer to use the bipolar
grasper in arm 2 chiey as a retracting device.
Anteriorly, the peritoneal reection is incised
and dissection is continued along the rectovagi-
ab
23 Rectal Cancer: Operative Treatment Transabdominal
437
nal septum in women, or the rectovesical/rectoprostatic fascia (Denonvilliers fascia) in men. Arm
3 is very useful for retracting the bladder and other
anterior structures as dissection proceeds distally
(Fig.23.15). The precise articulation of the robotic
scissor tips allows the surgeon to carry out the dissection utilizing ideal angles of attack.
Laterally, dissection proceeds along the sidewalls medial to both ureters. Care must be taken
to avoid injuring the autonomic pelvic plexus.
Dissection continues down to the pelvic oor,
separating the fatty mesorectum from the levators. In preparation for rectal division, DREs are
performed regularly to ascertain the level of the
tumour. The rectum is lifted off the levator muscle and prepared circumferentially.
Before dividing the rectum, one member of
the team performs a DRE under direct visualiza-
Fig. 23.14 Exposure of the areolar space behind the fascia propria of the rectum (top) and in front of the promontory (bottom)
tion to fully assess the distal margin. In select
cases we have tied a suture around the distal rectum to close off the rectal lumen and ensure
application of the stapler below the level of the
tumor. Thanks to the smooth articulation of the
robotic arms, this manoeuvre is not technically
challenging (Fig.23.16).
The assistant can divide the rectum while the
surgeon maintains proper exposure. Under ideal
circumstances, the 12mm R1 trocar can be used
after undocking the robotic arm, leaving the
robotic surgeon with only R2 and R3. If more
exposure is necessary, another laparoscopic
12mm trocar just lateral to R1 can be inserted as
the stapling port. Stapler cartridge length should
not exceed 45 mm; this length permits easy
application of the jaws over the bowel. Usually
two or three res are necessary, and it is important
to maintain proper alignment to avoid crossing
staple lines. Given the thickness and pliability of
the rectum, a green cartridge or the Tristaple®
(Conmed, CT) purple cartridge is indicated,
especially after neoadjuvant chemoradiation.
After division of the rectum the robotic cart
can be undocked. We routinely extract the
specimen through a 5–7 cm suprapubic
Pfannensteil mini-laparotomy covered with a
plastic wound protector. The proximal bowel is
divided and an anvil secured to the proximal
colon with a hand-sewn purse-string suture. After
closing the fascia with interrupted absorbable
sutures, the anastomosis is created with a circular
stapler under direct laparoscopic visualization
(Fig. 23.17). For cases requiring a very low
Fig. 23.15 Anterior dissection in a female patient (a) and a male patient (b)
438
ab
ab
Fig. 23.16 (a) Division of the rectum with the robotic stapler. (b) Staple line on the rectal stump after division of the
rectum
J. G. Guillem and J. Garcia-Aguilar
Fig. 23.17 (a) Creation of a colorectal anastomosis with a transrectal EEA stapler. (b) Endoscopic visualization and
testing of the colorectal anastomosis
anastomosis, a diverting loop ileostomy is indicated, especially after neoadjuvant chemoradiation therapy.
of the rectum and mesorectum. The open lumen
of rectum distal to the tumor is therefore closed
off with interrupted sutures to avoid spillage during the pelvic dissection. The robotic dissection
proceeds until the perineal dissection is met, and
Transanal Extraction Techniques
the bowel is passed through the rectal stump, covered with a wound protector, and delivered to the
In lieu of a LAR with a traditional double-stapled
anastomosis and transabdominal extraction, it is
also possible to transanally extract the specimen
and manually perform the anastomosis. This technique is indicated when the tumor is very close to
the anorectal ring and safe application of the linear
stapler can be difcult. The rectal wall is divided
transanally at the beginning of the procedure, with
a clear view of the distal margin. The transanal
dissection is then carried as far as possible outside
outside. The proximal bowel is divided outside
the anus at the point where the mesentery and the
marginal vessels have been previously divided,
and the anastomosis can then be accomplished
manually with interrupted sutures. A transanal
colonic J pouch may be created [39].
These techniques obviate the need for an
abdominal incision and the associated potential
for wound complications and incisional pain.
However, they require a higher degree of techni-
23 Rectal Cancer: Operative Treatment Transabdominal
439
cal expertise and are therefore not recommended
at the beginning of the surgeon’s learning curve.
Perineal Part oftheAPR: Prone
Position
With the patient carefully and properly positioned in
the prone position and the perineum prepped and
draped, an elliptical incision is made outside the lateral edge of the external sphincter, medial to the
ischial tuberosity. Palpating the tuberosity and placing the incision one to two ngerbreadths medially
facilitates the medial incision. Posteriorly, the incision should be placed midway between the anus and
the coccyx and can be extended if needed. Anteriorly,
the incision should divide the perineal body.
For centrally located tumors and those that do
not penetrate the anal sphincter or the levator
musculature, a narrower incision can be utilized.
If the resection is performed for more extensive
anal disease, such as recurrent anal squamous
cell cancer or adenocarcinoma arising in a stulain-ano, or Crohn’s disease, a wider resection margin can be used. In this setting, it is important to
stay in the same plane as the dissection is
extended superiorly and avoid coning in. The dissection is done using electrocautery, watching for
and controlling the perforating vessels, usually
located at 2, 4, 8 and 10 o’clock, that may bleed
profusely. A number of retractors can be helpful,
such as the Lone Star Retractor (Cooper Surgical,
Inc. Trumbull, CT) during the supercial portion
of the procedure and the self-retaining Lace
retractors and Wiley deep vein retractors during
the deeper portions of the resection.
Dividing the anococcygeal ligament at the tip
of the coccyx provides access to the posterior pelvis for joining the mesorectal dissection. Once the
two dissection planes (the abdominal mesorectal
plane and the perineal plane) have been connected
posteriorly, just anterior to the coccyx, the surgeon should divide the levator muscles beginning
at the apex of the ischiorectal fossa, close to their
insertion on the tendinous arch covering the obturator internus. We nd that placing the index nger of the nondominant hand into the pelvis and
“hooking” the levator muscles facilitates this division. The puborectalis should be divided anteri-
orly before the transverse perineal muscle is
reached. It is crucial not to violate the TME.
The rectum, which up to this point remains
attached anteriorly to the prostate or vagina, is
delivered through the wound to facilitate exposure
for the anterior dissection. The distal portion of the
anterior dissection—the separation of the distal
rectum and anal canal from the perineal body—is
best performed from proximal to distal, following
the surgically dissected and visualized anterior surface of the prostate or vagina. The perineal approach
affords better visualization of the neurovascular
bundle (the distal portion of the pelvic plexus) and
can help to avoid injury to the urethra. It is important to stay in the correct plane, and frequent bidigital and bimanual palpation can facilitate this. In
men, palpating for the urethra and urinary catheter
can help to avoid injury. In women, placing a nger
in the vagina can help to dene the plane of the
rectovaginal septum. Once the specimen is
removed, the drains previously placed in the pelvis
during the abdominal phase of the procedure are
repositioned and secured, and the perineal defect
closed. For primary closure, we approximate the
ischiorectal fat with a multilayer closure using
large absorbable sutures, and approximate the skin
with vertical mattress nylon sutures.
Perineal Part oftheAPR: Lithotomy
Position
The operation proceeds as described above for
the prone position. However, anterior dissection
may be more difcult with the patient in the
lithotomy position, especially in men. The surgeon must be in the correct plane, feeling for the
urethral catheter in men and the vagina in women.
Postoperative Care
Following an uneventful operation in an otherwise healthy, ambulatory patient, we advocate an
enhanced recovery strategy that permits early
ingestion of clear liquids and advancement to a
low-residue diet as tolerated, limited intravenous
uid resuscitation, early ambulation, and a pain
control strategy to minimize the use of narcotics.
Because of the extent of pelvic dissection and the
risk of early overow incontinence, the urinary
440
J. G. Guillem and J. Garcia-Aguilar
catheter remains in place until the second or third
postoperative day.
When a laparotomy is planned, postoperative
pain control is managed with an epidural, a transversus abdominis plane block, which is an injection
of local anesthetic into the plane where the somatic
nerves traverse, or injection of an extended duration local anesthetic (liposomal bupivacaine) [40].
To protect the perineal wound, physical
activity is restricted. If the closure was primary,
the patient should avoid prolonged sitting for
4–5 weeks following surgery, to allow the
wound to fully heal. Often, the perineal sutures
remain in place for 3–4weeks, as this area has a
high incidence of wound dehiscence and
infection. If short-duration sitting is absolutely
necessary, as is usually the case in the car ride
home from the hospital, patients should sit on a
soft pillow. They should avoid using a foam
ring, which can lead to increased pressure in the
perineum and disrupt blood ow. If a ventral
rectus abdominus ap is used, the patient should
also be instructed to avoid bending at the waist
for 3–4weeks to prevent placing undue tension
on the reconstruction.
Management ofComplications
The most signicant source of morbidity following
an APR is the perineal wound. The rate of wound
infections in the perineum, often due to the large
excision required and the necessity for preoperative
radiation, is as high as 40%. Wound infections
necessitate opening the wound. Because of the
high risk of evisceration, especially with large
defects—since there may be no fascia or muscle to
support the pelvic oor—this procedure may need
to be performed in the operating room. The wound
is irrigated, necrotic tissue is removed, and additional drains are placed as needed. Once a granulating base is established, a negative-pressure dressing
can be employed to expedite healing.
Genitourinary and sexual dysfunction following an APR may be noted in 50% of patients.
Good surgical technique, including identication
and protection of the pelvic nerves, helps to prevent such dysfunction. Fortunately, in some
patients the dysfunction is relatively minor, and
function often continues to improve for 12months
following surgery. However, a small percentage
of patients sustain permanent dysfunction, and all
patients undergoing an APR must be informed of
this possibility preoperatively.
Stoma-related complications, particularly
parastomal hernias, are a signicant long-term
consequence of APR.Because the risk of meshrelated complications is an important consideration, we avoid permanent mesh placement
during the initial surgery. However, if a symptomatic parastomal hernia occurs, placement of
permanent mesh during the repair operation
should be strongly considered, as should a possible translocation of stoma.
Watch andWait
While surgical resection remains the standard
of care for patients regardless of clinical
response to neoadjuvant therapy, ~10 to 44% of
patients will experience a complete pathologic
response (pCR) after long-course chemoradiation [41–43]. These patients have improved
outcomes and there has been interest in avoiding the morbidity and mortality associated with
radical surgery and consider a “watch and wait”
approach [44].
Habr-Gama etal., was the rst to report outcomes for the watch and wait approach [45].
Their experience and several other trials suggest
that observation after complete clinical response
is an option [46–48]. One of the signicant barriers to the watch-and-wait approach is the ascertainment of complete clinical response of the
primary tumor as well as nodal status. A combination of physical examination with endoscopic
and radiologic evaluation should be used, as the
diagnostic accuracy of each of these modalities is
low. Endoscopic ndings of complete response
include whitening of the mucosa, telangiectasia
without mucosal ulcerations, and subtle loss of
pliability of the rectal wall. Residual disease
should be highly suspected in the presence of a
palpable nodule, ulceration or irregularity.
Complete response is similarly problematic to
23 Rectal Cancer: Operative Treatment Transabdominal
441
accurately predict on radiologic imaging [49,
50]. Finally, local excision of the tumor scar may
conrm mural sterility, but is associated with signicant pain and wound complications [51, 52].
Patients who demonstrate signicant or complete mucosal response based on digital rectal
exam/proctoscopy may be considered for further
evaluation of complete response, whereas
patients with moderate to poor response should
undergo resection within 6–8weeks after completion of neoadjuvant therapy as per current
guidelines [53].
Patients who exhibit evidence of cCR should
be willing and able to undergo a strict surveillance
protocol, especially during the rst year as this is
when most recurrences occur. Based on the
approach of Habr-Gama et al. [45], patients
should undergo monthly follow-up with digital
rectal exam or proctoscopy for the rst 3months,
then every 2–3months for the remainder of the
rst year. CEA is checked every 2 months.
Radiologic evaluation using CT or MRI should be
done at the time of initial tumor assessment then
every 6months. Follow-up visits should continue
every 3 months after the rst year. Suspicious
ndings on clinical assessment or imaging should
prompt further evaluation or radical surgery.
Currently, the limited reported experience and
lack of prospective randomized trials along with
the difculty of conrming a complete response,
leads most surgeons to recommend a surgical
resection for patients that are medically operable
and willing to undergo surgery
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