ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Abdominal perineal resection (APR): Open technique

Abdominal perineal resection (APR): Open technique
Literature review current through: Jan 2024.
This topic last updated: Feb 15, 2022.

INTRODUCTION — An abdominal perineal resection (APR) includes the resection of the sigmoid colon, rectum, and anus (figure 1) and the construction of a permanent end colostomy.

INDICATIONS — Benign and malignant conditions that can be treated by APR include but are not limited to:

Crohn's proctitis with anal disease

Ulcerative colitis, not a candidate or amenable to an ileal pouch anal anastomosis

Fecal incontinence, not amenable to sphincter-sparing procedures

Low-lying rectal cancer involving anal sphincter complex and/or positive distal margin

Anal cancer, failed neoadjuvant therapy

Anal cancer, recurrent

Anal melanoma

PREOPERATIVE PREPARATION

Enterostomal assessment — Preoperative counseling and education with a skilled enterostomal nurse therapist and site selection for optimal placement of the ostomy are the key components of preoperative preparation. (See "Overview of surgical ostomy for fecal diversion", section on 'Preparation and counseling'.)

Mechanical bowel preparation — A mechanical bowel preparation (MBP) is not included in preoperative preparation. A review of the evidence to omit an MBP is discussed separately. The use of MBP prior to colon and rectal surgery is controversial. (See "Overview of colon resection", section on 'Bowel preparation'.)

There is a paucity of data regarding MBP in patients with rectal cancer undergoing a low anterior resection. The benefit may depend upon the surgical procedure being performed:

A subset analysis of a multicenter randomized trial [1] including 449 patients who had a low anterior resection (48 of 449 with a diverting colostomy) found no benefit for MBP [2]. Compared with no MBP, patients undergoing an MBP had similar rates of leakage (approximately 7 percent), rate of complications, anastomotic dehiscence, intra-abdominal abscess, and mortality.

However, in patients undergoing a sphincter-saving resection for rectal cancer, MBP appears to be useful. A randomized trial of 178 patients undergoing a sphincter-saving resection found lower overall morbidity and infection rates for patients undergoing an MBP compared with no MBP (27 versus 44 percent and 16 versus 34 percent) [3].

Antibiotic prophylaxis — Prophylactic antibiotics are reviewed elsewhere. We do not use oral antibiotics or continue prophylaxis postoperatively (table 1 and table 2).

The use and timing of antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures is discussed separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Timing'.)

Venous thromboembolism prophylaxis — Patients undergoing an APR are at a high risk for developing a deep venous thrombosis (DVT) [4,5]. All patients scheduled for an APR should receive primary prophylaxis. Prevention of DVT is discussed in detail separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

OPEN SURGICAL TECHNIQUE

Patient positioning — Attention to patient positioning is integral to preventing peripheral nerve injuries, pressure sores, deep vein thrombosis, and compartment syndrome (figure 2) [6]. To lower the risk of surface pressure and subsequent peripheral nerve injury, the authors place an inflated bean bag with a soft gel layer under the patient [7], which can be moulded around the patient when the air is evacuated. Operating room safety and a review of strategies to prevent nerve injury during pelvic surgery are reviewed separately. (See "Patient safety in the operating room" and "Nerve injury associated with pelvic surgery".)

The patient is placed in the modified dorsal lithotomy position, and:

Intermittent pneumatic compression pumps are applied to both legs.

The legs are raised simultaneously and secured in boots.

The legs should be at the same height with the hips and knees flexed at 45 to 60°.

Adequate padding should be placed around the posterolateral aspect of the lower legs to prevent a common peroneal nerve injury.

The buttocks should be extended slightly over the end of the operating table so that the sacrum is supported on the bean bag surface, even with the lower break of the procedure bed [8].

The patient's arms should either be padded and secured by the side of the patient or secured on padded arm boards and extended no more than 90º [9].

For the patient with severe obesity, special operating tables with side extensions are used for added support [10]. The shoulders should be padded to prevent pressure sores from the bean bag.

Exploration for resectability — Prior to initiating the resection, the abdomen is thoroughly examined for resectability of the sigmoid colon and rectum.

For patients with cancer, this evaluation includes an assessment of local, regional, and distant disease.

The abdomen is explored for evidence of anomalies and/or metastatic disease, including peritoneal implants, hepatic metastases, and distant nodal metastases.

The primary tumor is palpated to confirm its location. Local and regional resectability is determined by assessing tumor invasion into the pelvic walls or organs (eg, prostate, bladder, and uterus). The entire colon is palpated to identify synchronous colonic lesions.

Mobilization of colon — There are two approaches to mobilizing and resecting the sigmoid colon, medial to lateral (early ligation of vascular pedicle) or lateral to medial (early mobilization of the colon). The authors perform all dissections, both open and laparoscopic, in a medial to lateral fashion.

The advantages of the early division of the vascular pedicle include reduced bleeding during dissection, maximal time for sharp demarcation between ischemic and well-perfused bowel, and more efficient identification of the correct plane in the fine areolar tissue that connects the mesocolon to the mesentery. This approach helps to reduce the risk of injury to retroperitoneal structures such as the ureter.

Medial to lateral approach — The medial to lateral approach is ideal for resection of inflamed bowel and adjacent mesentery and for performing the "no-touch" approach to colon cancer resection (figure 3 and figure 4 and figure 5).

The general principles for performing a sigmoid colectomy, beginning with ligation of the mesenteric lymphovascular pedicle, include:

Apply gentle traction to the sigmoid colon while the mesentery is incised using electrocautery behind the superior rectal artery (SRA), which overlies the sacral promontory (figure 6).

Develop the avascular areolar tissue plane, located behind the SRA and anterior to the sacral promontory, laterally and diagonally over the pelvic brim.

Perform the majority of the colon dissection with a gentle sweeping technique in the avascular plane. The colon is resected in a posterior to anterior motion to avoid injury to the underlying autonomic nerves and presacral venous plexus.

Dissect in the avascular areolar tissue plane; a window is created and the ureters, gonadal, and iliac vessels are identified and preserved (figure 6). The left and right ureters are retroperitoneal and cross the iliac vasculature near the origins of the internal iliac arteries; the left ureter enters the pelvis at the apex of the sigmoid mesocolon. Dissection of the pelvic portion of the ureters should be performed medially to laterally, as the blood supply enters laterally.

Incise the mesentery cephalad over the anterior surface of the aorta; the first major branch is the inferior mesenteric artery (IMA) (figure 3).

Dissect the SRA to its origin from the IMA and ligate the SRA with a permanent tie suture (low tie method). This allows for removal of an appropriate amount of the associated lymphatics for a rectal cancer resection (figure 5). An alternative to the low tie method is the high tie method, where the IMA is ligated at its origin. The authors prefer the low tie method because it preserves the blood supply from the IMA to the left colon (left colic artery), without compromising survival for rectal cancer patients compared with the high tie method [11].

Release the left colon from its lateral attachments by retracting the sigmoid and left colon medially and incising the line of Toldt (figure 7). The dissection is continued medially to the previously developed space.

Divide the colon with a linear stapling device near the junction of the descending and sigmoid colon to facilitate distal resection and prevent bowel spillage.

Lateral to medial approach — The lateral to medial approach is the traditional technique for mobilizing the colon in an open procedure. This technique includes the same principles for identifying and preserving the ureters and gonadal and iliac vessels and ligating the SRA as described in the above section.

Although this approach is more familiar to many surgeons, the disadvantages include potentially more blood loss from the early division of the lateral attachments prior to division of the vascular pedicles and more manipulation of the colon.

The general principles for performing a left colectomy, beginning with mobilization of the left colon, include [12]:

Divide the lateral peritoneal attachments along the line of Toldt and mobilize the colon medially.

Mobilize the IMA using blunt dissection in the avascular fusion plane.

Identify the SRA as the artery passes into the pelvis at the base of the sigmoid mesentery.

Mobilize the sigmoid colon and upper rectum in the avascular plane with a gentle sweeping posterior-to-anterior motion; the SRA is mobilized with the mesocolon.

Mobilization of rectum — Mobilization of the rectum is performed in the avascular presacral space between the fascia propria (the thin layer of fascia that encases the rectum and its lymphatics) and the presacral fascia (figure 8). Attention to detail is critical to avoid avulsion of the sacral plexus veins and middle sacral artery (figure 9) [12].

The general principles for mobilizing the upper rectum include:

Gently retract the upper rectum anteriorly to facilitate identification of the avascular presacral space, using either the operator's nondominant hand or a St. Mark's deep pelvic retractor (picture 1).

Identify and preserve the iliohypogastric nerves along either side of the rectum at the level of the sacral promontory (figure 10).

Access the retrorectal space posteriorly in the midline, using electrocautery to divide the rectorectal fascia (Waldeyer's fascia) (figure 11) [13,14]. Precise dissection on the fascia propria reduces the risk of damage to the iliohypogastric nerves. Tethering from the lateral peritoneal reflexion is incised and divided. The lateral ligaments that contain the middle hemorrhoidal vascular pedicles are divided with electrocautery (figure 12 and figure 13). Circumferential dissection is completed by incising the peritoneum at the base of the cul-de-sac. Proceed with the dissection to the level of the pelvic diaphragm.

Avoid injury to the posteriorly located parasympathetic fibers by using electrocautery judiciously when dissecting the posterior plane.

Technical considerations when operating in the male pelvis (figure 14):

Incise the peritoneum approximately 5 mm anterior to the fold of the cul-de-sac, exposing the seminal vesicles that are cleared by sharp dissection with electrocautery.

Continue the plane of dissection anteriorly to encompass Denonvilliers' fascia [15], until reaching the junction with the prostate capsule. For rectal cancers located anteriorly, Denonvilliers' fascia is separated from the prostate capsule to provide a clear margin. For rectal cancers located posteriorly, the dissection is performed in the plane closer to the anterior surface of the rectum, leaving Denonvilliers' fascia intact to preserve the nerves.

Terminate the mobilization anteriorly below the level of the seminal vesicles and posteriorly at the upper border of the coccyx.

Technical considerations when operating in the female pelvis (figure 15):

Retract the uterus superiorly using a St. Mark's retractor (picture 1) or by securing the uterus to the abdominal wall with a suture.

-Incise the peritoneum at the peritoneal reflection with electrocautery and dissect along the rectovaginal septum in the areolar tissue plane.

Remove the vaginal segment en bloc if the tumor is tethered to the posterior wall of the vagina; the vaginal segment should be removed en bloc with the rectal specimen. The posterior vagina is reconstructed with absorbable sutures during the perineal portion of the procedure (figure 16).

-Avoid bearing in or coning the specimen during the circumferential dissection as this will compromise the circumferential resection margin.

Terminate the mobilization anteriorly below the cervix uteri and posteriorly at the upper border of the coccyx (figure 17).

Do not mobilize the mesorectum from the levator muscle at this time (figure 17). However, the bowel is divided at a level to permit at least a 5 cm margin proximal to the malignancy.

The colostomy is constructed prior to performing the perineal resection.

Colostomy construction — The surgical principles of construction of an end colostomy, including technical insights and use of prophylactic mesh, are reviewed in detail separately. (See "Overview of surgical ostomy for fecal diversion".)

Omental flap — In patients who require adjuvant radiotherapy after surgery, an omental flap can be created by detaching the greater omentum from the transverse colon while keeping its vascular pedicle connected to the stomach. Once secured in the pelvic hollow with sutures, it serves to shield the small intestines and genitourinary organs from radiation damage [16].

Omental flaps were theorized to reduce perineal wound morbidity and aid in primary healing of the perineum. However, a systematic review and meta-analysis of 14 studies revealed no beneficial effect of omentoplasty on presacral abscess formation and perineal wound healing after APR, while it increased the likelihood of developing a perineal hernia [17].

Repositioning for perineal resection — At the completion of the abdominal portion of the operation, the patient is repositioned from the modified dorsal lithotomy to the prone position for the perineal portion of the procedure. The boots are removed and the legs are slowly lowered to the operating table simultaneously. This will avoid injury to the hips from inadvertent rotation. The patient is now supine in preparation to be transferred to the prone (Kraske) jackknife position (figure 18).

Cylindrical versus conventional approach — The perineal resection of the rectum and anus and adjacent tissues (figure 19 and figure 20) was traditionally performed in the lithotomy position; however, that approach is associated with a high rate of positive circumferential resection margins (CRMs), intraoperative bowel perforation, and local recurrence [18-21].

The contemporary approach is to place the patient in the prone jackknife (Kraske) position, which facilitates a cylindrical perineal resection. A randomized trial of 67 patients undergoing an APR found that patients resected using the cylindrical approach had a lower rate of positive CRMs compared with patients undergoing the conventional (lithotomy) approach (5.7 versus 28.1 percent) [20]. Patients undergoing the cylindrical approach had a statistically similar probability of intraoperative bowel perforation (2 of 35 versus 5 of 32 patients) but a significantly higher median three- and six-month postoperative visual analogue score (VAS) for pain (VAS 4 versus 1, and 3 versus 0, respectively). In addition, a retrospective review of 109 patients with a potentially curable primary adenocarcinoma found that patients treated by the cylindrical approach (n = 10) had significantly fewer intraoperative perforations compared with patients resected in the lithotomy position (3.7 versus 22.8 percent) [18]. Patients undergoing the cylindrical approach also had fewer positive CRMs (14.8 versus 40.6 percent). A meta-analysis of six studies with a total of 881 patients compared outcomes following cylindrical versus conventional APR [22]. Cylindrical APR was associated with a significantly lower positive CRM involvement (odds ratio [OR] 0.36; 95% CI 0.23-0.58) and lower intraoperative perforation rate (OR 0.31; 95% CI 0.12-0.80, p <0.02) compared with conventional APR. Among four studies, cylindrical APR was also associated with a significantly lower local recurrence rate (OR 0.27; 95% CI 0.08-0.95) [22].

Rationale for the improved results with the cylindrical approach to a perineal resection includes more tissue excised [23] and that the surgeon is more likely to perform the resection in the appropriate tissue plane [19]. The disadvantages of the prone jackknife position include anesthetic-related complications (eg, displacement of the endotracheal tube, decreased cardiac index) and direct pressure injuries (eg, skin necrosis, peripheral nerve injury).

Perineal resection

The general principles for performing the perineal resection include:

Tape the buttocks apart and close the anus with a silk pursestring suture.

Make an incision around the anus, extending to the lower edge of the sacrum.

Dissect through the subcutaneous adipose tissue just outside the plane of the external sphincter (figure 17 and figure 21), using electrocautery and a self-retaining retractor (eg, Lone Star retractor system) to optimize exposure and access.

Identify the levator muscle and dissect to the point of insertion of the muscle on the pelvic sidewall (figure 22).

The general principles for closure of the perineal wound after resection include:

The perineal wound is closed in layers with a series of 2-0 absorbable sutures used to approximate the subcutaneous adipose tissue.

An absorbable subcuticular suture is used to close the skin. In the majority of cases, we close the skin primarily.

For defects too large for a primary closure, the perineal defect may require reconstruction with a biological mesh or a myocutaneous flap, such as a pedicled gluteus maximus, gracilis, or rectus abdominal flap [24-26].

In a randomized trial of 104 patients who underwent pelvic radiation followed by extralevator APR, standard sutured closure of the perineal defect and closure with a porcine acellular dermal mesh sutured to the pelvic floor remnants resulted in uncomplicated perineal wound healing at 30 days in similar percentages of patients (66 versus 63 percent). At one year, fewer patients with mesh closure had perineal hernias (73 versus 87 percent) [27].

There is no consensus for the optimal flap for immediate repair of the pelvic defect. In a retrospective review of 133 patients undergoing an APR or pelvic exenteration for cancer resection, patients with a perineal defect closed with a vertical rectus abdominis myocutaneous flap (VRAM; n = 114) had significantly fewer major complications compared with closure with a gracilis flap (15 versus 42 percent) [28]. Patients with a VRAM closure also had fewer rates of donor cellulitis (6 versus 26 percent), pelvic abscesses (6 versus 32 percent), and wound dehiscence (5 versus 21 percent). Harvesting VRAM flaps did not increase early abdominal wall complications. The decision on the type of flap formation will be influenced by patient factors (current smoker, lifestyle factors), tumor factors (neoadjuvant therapy, size of defect to be repaired), and operative expertise in the unit offering the surgery.

The authors do not drain the perineum; however, other surgeons may opt to use closed suction drains. Definitive evidence from high-quality randomized trials is not available. (See "Management of perineal complications following an abdominal perineal resection", section on 'Prevention'.)

INTRAOPERATIVE CHALLENGES — Resection of the rectum is associated with several technical challenges, including preservation of the ureters and urethra, sacral venous plexus, and pelvic autonomic nerves.

Ureter and urethra — The ureter is at risk for transection or injury during the lateral mobilization of the colon and ligation of the superior rectal artery during the abdominal portion of the operation, while the urethra is at risk when performing the anterior portion of the perineal resection [29].

The following key points and maneuvers help identify and preserve the ureters [30]:

The ureter never branches.

The ureter shows evidence of peristalsis or vermiculation when manipulated.

If the ureter cannot be identified distally due to inflammation or tumor, identify a more proximal portion and dissect distally.

Avoid excessive dissection of the ureter to preserve blood supply and avert ischemic necrosis.

Place ureteral stents prior to resection, particularly in settings of large cancers or previous pelvic surgery or inflammation [31].

Identify all structures prior to division and ligation. Vascular ligation (eg, superior rectal artery) should not be performed prior to identification of the ureters.

Palpate the indwelling urinary catheter to define the plane between the prostate and the rectum. The urethra is at risk of injury with anterior rectal tumors that require the resection of the prostate gland. If a urethral injury has occurred, then the catheter is typically visible.

The management of transection or other injury to the ureters is reviewed separately. (See "Surgical repair of an iatrogenic ureteral injury" and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Pelvic and genitourinary injuries'.)

Hemorrhage — Life-threatening hemorrhage can be encountered during the pelvic dissection and typically arises from injury to the presacral plexus or internal iliac vessels (figure 23). In the setting of bleeding from the presacral plexus, the first step is to apply pressure to the area and advise the anesthesiologist so blood products can be administered. Titanium thumbtacks can be used to directly compress the bleeding vein [32]. If local control measures fail, the pelvis is packed with laparotomy sponges, the procedure is terminated, and resuscitation is continued in the intensive care unit [33,34]. The pH, intravascular volume, and clotting status must be optimized prior to returning to the operating room, typically in 24 to 48 hours, to remove the packs and complete the planned procedure. (See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults", section on 'Treatment'.)

If bleeding is from the internal iliac vessels, the first step is to obtain control by direct pressure proximally and distally and determine the source of the bleeding [35]. It is prudent to consult a vascular surgeon, if available. If a repair is unfeasible, or if the patient is becoming unstable, both the internal iliac artery and vein can be ligated if necessary.

The management of bleeding complications following colon and rectal operations is discussed separately. (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Major vessel injury' and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Presacral bleeding'.)

Pelvic autonomic nerves — The pelvic autonomic nerves consist of sympathetic and parasympathetic components that regulate urinary and sexual function (figure 24 and figure 25).

Injury to the nerves can occur during the following steps of the operation:

The sympathetic nerves are at risk of injury at their origin from the aortic plexus during ligation of the internal mesenteric artery (IMA) and at the sacral promontory during the division of the hypogastric nerves from the hypogastric plexus.

The parasympathetic nerves are at risk of injury during the lateral dissection, especially during the division of the lateral ligaments and anterolaterally during the dissection behind the prostate and seminal vesicles.

Interlacing sympathetic and parasympathetic nerve fibers from the pelvic plexus form the inferior hypogastric nerve plexus that innervates the rectum, bladder, ureter, prostate, seminal vesicles, and corpora cavernosa and are at risk when dissecting the rectum from these structures.

Damage to these autonomic nerves can lead to bladder and sexual dysfunction and is reviewed separately. (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Genitourinary complications'.)

POSTOPERATIVE MANAGEMENT — Patients are managed by the fast-track multimodal protocol. (See "Enhanced recovery after colorectal surgery".)

Management of the colostomy is described separately. (See "Ileostomy or colostomy care and complications".)

PERINEAL WOUND COMPLICATIONS — Perineal wound complications are common. The incidence, risks, and management are discussed separately. (See "Management of perineal complications following an abdominal perineal resection".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colorectal cancer" and "Society guideline links: Colorectal surgery for cancer".)

SUMMARY AND RECOMMENDATIONS — An abdominal perineal resection (APR) includes the resection of the sigmoid colon, rectum, and anus and the construction of a permanent end colostomy.

The indications for an APR include benign conditions (eg, Crohn's proctitis) and malignancy (eg, low rectal cancers, recurrent anal cancers). (See 'Indications' above.)

Preoperative assessment includes an evaluation by an enterostomal nurse, mechanical bowel preparation at the discretion of the surgeon, prophylactic antibiotics, and deep vein thrombosis prophylaxis. (See 'Preoperative preparation' above.)

The authors mobilize the colon using the medial to lateral approach by ligating the lymphovascular pedicle prior to mobilizing the colon. (See 'Mobilization of colon' above.)

Mobilization of the rectum is performed in the avascular presacral space between the fascia propria (the thin layer of fascia that encases the rectum and its lymphatics) and the presacral fascia. Attention to detail is critical to avoid avulsion of the sacral plexus veins and middle sacral artery. (See 'Mobilization of rectum' above.)

The perineal resection should be performed in the prone (Kraske) jackknife position to facilitate the perineal resection. (See 'Perineal resection' above.)

  1. Contant CM, Hop WC, van't Sant HP, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370:2112.
  2. Van't Sant HP, Weidema WF, Hop WC, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg 2010; 251:59.
  3. Bretagnol F, Panis Y, Rullier E, et al. Rectal cancer surgery with or without bowel preparation: The French GRECCAR III multicenter single-blinded randomized trial. Ann Surg 2010; 252:863.
  4. Holm T, Singnomklao T, Rutqvist LE, Cedermark B. Adjuvant preoperative radiotherapy in patients with rectal carcinoma. Adverse effects during long term follow-up of two randomized trials. Cancer 1996; 78:968.
  5. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:381S.
  6. O'Connell MP. Positioning impact on the surgical patient. Nurs Clin North Am 2006; 41:173.
  7. Stephenson LL, Webb NA, Smithers CJ, et al. Lateral femoral cutaneous neuropathy following lateral positioning on a bean bag. J Clin Anesth 2009; 21:383.
  8. Recommended practices for positioning the patient in the perioperative setting. Perioperative Standards and Recommended Practices. AORN J 2008; :497.
  9. Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000; 55:980.
  10. Dybec RB. Intraoperative positioning and care of the obese patient. Plast Surg Nurs 2004; 24:118.
  11. Titu LV, Tweedle E, Rooney PS. High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: a systematic review. Dig Surg 2008; 25:148.
  12. Chapter 83. Abdominoperineal resection, Low anterior resection. In: Operative Anatomy, 3rd ed, Scott-Conner CE, Dawson DL (Eds), Wolters Kluwer, Lippincott, Williams & Wilkins, Philadelphia 2009. p.569.
  13. Jin ZM, Peng JY, Zhu QC, Yin L. Waldeyer's fascia: anatomical location and relationship to neighboring fasciae in retrorectal space. Surg Radiol Anat 2011; 33:851.
  14. García-Armengol J, García-Botello S, Martinez-Soriano F, et al. Review of the anatomic concepts in relation to the retrorectal space and endopelvic fascia: Waldeyer's fascia and the rectosacral fascia. Colorectal Dis 2008; 10:298.
  15. Lindsey I, Guy RJ, Warren BF, Mortensen NJ. Anatomy of Denonvilliers' fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg 2000; 87:1288.
  16. Killeen S, Devaney A, Mannion M, et al. Omental pedicle flaps following proctectomy: a systematic review. Colorectal Dis 2013; 15:e634.
  17. Blok RD, Hagemans JAW, Klaver CEL, et al. A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer. Ann Surg 2020; 271:654.
  18. West NP, Finan PJ, Anderin C, et al. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 2008; 26:3517.
  19. Nagtegaal ID, van de Velde CJ, Marijnen CA, et al. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 2005; 23:9257.
  20. Han JG, Wang ZJ, Wei GH, et al. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 2012; 204:274.
  21. Bernstein TE, Endreseth BH, Romundstad P, et al. Circumferential resection margin as a prognostic factor in rectal cancer. Br J Surg 2009; 96:1348.
  22. Huang A, Zhao H, Ling T, et al. Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 2014; 29:321.
  23. Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 2005; 242:74.
  24. Holm T, Ljung A, Häggmark T, et al. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 2007; 94:232.
  25. Galandiuk S, Jorden J, Mahid S, et al. The use of tissue flaps as an adjunct to pelvic surgery. Am J Surg 2005; 190:186.
  26. Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 1999; 6:33.
  27. Musters GD, Klaver CE, Bosker RJ, et al. Biological Mesh Closure of the Pelvic Floor After Extralevator Abdominoperineal Resection for Rectal Cancer: A Multicenter Randomized Controlled Trial (the BIOPEX-study). Ann Surg 2016.
  28. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg 2009; 123:175.
  29. Elliott SP, McAninch JW. Ureteral injuries: external and iatrogenic. Urol Clin North Am 2006; 33:55.
  30. Fry DE, Milholen L, Harbrecht PJ. Iatrogenic ureteral injury. Options in management. Arch Surg 1983; 118:454.
  31. Redan JA, McCarus SD. Protect the ureters. JSLS 2009; 13:139.
  32. Timmons MC, Kohler MF, Addison WA. Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application. Obstet Gynecol 1991; 78:313.
  33. Loveland JA, Boffard KD. Damage control in the abdomen and beyond. Br J Surg 2004; 91:1095.
  34. McPartland KJ, Hyman NH. Damage control: what is its role in colorectal surgery? Dis Colon Rectum 2003; 46:981.
  35. Oderich GS, Panneton JM, Hofer J, et al. Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication. J Vasc Surg 2004; 39:931.
Topic 14995 Version 17.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟