Abdominoperineal excision (APE), also known as abdominoperineal resection (APR), is a major surgical procedure used to remove the rectum, anus, and sigmoid colon, along with the associated mesorectum and surrounding tissues. This procedure is typically performed for cancers of the lower rectum and anal canal that cannot be managed with sphincter-preserving surgery. After the excision, a permanent colostomy is created to divert waste through an opening in the abdominal wall.
Indications for Abdominoperineal Excision (APE)
- Rectal Cancer: Especially tumors located within 5 cm of the anal verge that involve the anal sphincter complex.
- Anal Cancer: Advanced tumors or recurrent disease.
- Recurrent Pelvic Tumors: When less invasive surgeries are not feasible.
- Inflammatory Bowel Disease: In rare cases, for complications related to Crohn’s disease or ulcerative colitis.
- Non-Healing Anorectal Fistulas or Abscesses: Intractable or recurrent infections.
Procedure Overview
The abdominoperineal excision (APE) consists of two surgical phases:
Abdominal Phase
- An incision is made in the abdomen.
- The sigmoid colon and rectum are mobilized.
- The mesorectum, containing lymph nodes and surrounding fat, is excised.
Perineal Phase
- An incision is made around the anus.
- The anal canal, sphincters, and surrounding tissues are removed.
- The perineal wound is closed or managed with additional flaps if necessary.
A colostomy is then created by bringing the end of the colon to the surface of the abdominal wall.
Clinical Considerations
- Total Mesorectal Excision (TME): This technique ensures that all cancerous tissue and associated lymph nodes are removed, which reduces local recurrence.
- Neoadjuvant Therapy: Patients may receive preoperative chemotherapy and/or radiotherapy to shrink tumors and reduce the risk of recurrence.
- Colostomy: Following the procedure, patients live with a permanent colostomy.
Postoperative Care and Recovery
- Wound Care: Perineal wounds require careful management to prevent infection.
- Colostomy Care: Patients receive education on managing the colostomy, including skin care and appliance usage.
- Physical Rehabilitation: Aimed at regaining mobility and preventing complications such as deep vein thrombosis (DVT).
- Psychological Support: Patients may need emotional and mental health support to adapt to lifestyle changes associated with a permanent colostomy.
Complications of Abdominoperineal Excision
- Perineal Wound Infection: One of the most common complications due to the high risk of contamination.
- Hernia: Parastomal hernias (bulging around the colostomy site) can develop.
- Phantom Rectal Sensation: Some patients may continue to feel as if they need to defecate.
- Sexual and Urinary Dysfunction: Possible due to nerve damage during the procedure.
Advantages and Disadvantages
- Advantages: Provides effective treatment for low rectal cancer with a high risk of recurrence.
- Disadvantages: Involves a permanent colostomy, which can significantly impact the patient’s quality of life.
Recent Advances
- Minimally Invasive Techniques: Laparoscopic and robotic-assisted APE are becoming more common to reduce postoperative recovery time and pain.
- Extralevator Abdominoperineal Excision (ELAPE): A modified approach that extends the resection to include more tissue, potentially reducing recurrence rates in advanced cancers.