Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

Abstract

Background: Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

Discussion: Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Fig. 1

Appropriate planes for total mesorectal excision. a Anterior view demonstrating dissection plane between visceral mesorectal fascia and parietal fascia. b Lateral view of appropriate TME plane in the male. c Lateral view of TME dissection plane in the female

Fig. 2

Total mesorectal excision specimen. a, b Gross view with intact mesorectum without “waisting” of the specimen. c Full thickness cross sections following fixation demonstrate a negative circumferential resection margin. Final pathology demonstrates a 1.5-cm T1 adenocarcinoma arising in a 5.5-cm tubulovillous adenoma

Fig. 3

Total mesorectal excision. a Anterior dissection behind the seminal vesicles. b Anterior dissection in a female. c Dissection in the “holy plane” evidenced by an intact, shiny mesorectum

Fig. 4

Appropriate planes for intersphincteric resection—TME plane created from above intersects intersphincteric plane. a Partial ISR; b complete ISR

Fig. 5

Complete intersphincteric resection. a Dissection begins at the dentate line. b The rectum is eviscerated through the anus after joining of the abdominal and perineal dissection planes. c Handsewn coloanal anastomosis

Fig. 6

Perineal dissection in the APPEAR technique. a Perineal incision. b Evisceration of the specimen through the perineal wound after connection of abdominal and perineal dissection planes

Fig. 7

Transanal TME. a Dissection begins following the placement of a purse string distal to the tumor. b The posterior mesorectum. c Dissection posterior to the vagina

Fig. 8

Full thickness local excision of a rectal neoplasm using TEM. a Dissection begins with rectal lesion seen at the right. b Dissection encompassing half the circumference of the rectum, nearly completed. c Closure of the defect. d Resected specimen, adenoma with a 2-mm focus of T1 adenocarcinoma

Fig. 9

Abdominoperineal resection. a Anterior view demonstrating abdominal dissection in TME plane with perineal specimen including sphincter complex for a very low rectal tumor. b Lateral view of resection planes in the male. c Lateral view of resection planes in the female